HCH Recertification Year Two, Three and Beyond

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1 HCH Recertification Year Two, Three and Beyond Presented by: MDH Health Care Homes Regional Nurse Planners Capacity Building, Certification and Recertification Kathleen Conboy, RN, BSN Tina Peters, RN, BSN, PHN Joan Kindt, RN-C, BSN, PHN Danette Holznagel, RN, BAN, CDE, PHN, FCN

2 Today s Workshop Agenda Welcome & Learning Objectives Recertification Timeline Resources Site Team Meeting Steps Recertification Requirements Year 2, 3, & Beyond Clinic Panel Examples / Networking Benchmark Reporting Background

3 HCH Certification Updates Certified HCH Clinics Applicants are from all over the state. Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations. All types of primary care providers are certified, family medicine, pediatrics, internal medicine, med/peds and geriatrics.

4 HCH Recertification Process Learning Objectives 1. Describe the Health Care Home legislative rule subpart criteria required at recertification year two, three and beyond. 2. Review the progression of recertification as it addresses improvement to population health. 3. Describe the requirements for statewide quality improvement reporting and measurement for certified HCH clinics.

5 Recertification Process Begins at previous year s certification Reflects the progression of the clinic s HCH journey Validates existing processes Reflects improvement through outcomes

6 Recertification Steps for the Applicant STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6: Letter of intent, the clinic will receive an automated notification from MDH one year from initial certification. Application and Certification assessment Team Meeting with MDH MDH Review and Notification Optional: Variance requests Recertification

7 Recertification Site Team Meetings The team meeting is an opportunity for the clinic or organization to share the story of progression of the Health Care Home. Applicants should include care team representation, care coordinator(s), leadership, and patient partners. 7

8 Recertification Year Two Requirements Continue to meet all initial certification and recertification requirements (.0040 Subparts 1,2,3,4,5,6,7,8,9,10). Submit documentation by exception. Address any variances and/or recommendations made at initial certification (if applicable). Updates to specific subparts are required (1A; 2; 5A; 6A,B,D; 8; 9A; 9D; 10A; 10B. At year two recertification Subpart 11, HCH Benchmark Report is added.

9 Recertification Year Two, Three and Beyond.0040 Subpart 1A, 1 Subp. 1A, 1: Services to Patients with Complex and Chronic Conditions Submit documentation of progress in identifying patients who would benefit from care coordination services. Describe new population-based screening methods for risk stratification, registries, and predictive modeling tools.

10 Recertification Year Two.0040 Subpart 2 Patient Participation Submit strategies used to encourage patients to take an active role in managing their care. Describe the clinic s progress since recertification year one: Participant s readiness for change Literacy level Barriers to learning

11 Recertification Year Two, Three and Beyond.0040 Subpart 5A Subpart 5A Care Coordination Program Expansion: Submit the number of patients receiving care coordination services and care plans. Update if there are changes to care coordination or goal setting processes. HCH audit as prescribed by MDH. The audit reflects an evaluation and an action plan.

12 Recertification Year Two.0040 Subpart 6A Shared Decision-Making Examples: Workflows to solicit patient participation & shared decision-making Policies patient and family-centered principles Job descriptions Education programs Tools: Patient Activation Measure(PAM), Ottawa Shared Decision Making tools, questionnaires or other tools TruthPoint Measurement of patient /family centered care Patient stories/chart documentation

13 Recertification Year Two.0040 Subpart 6B Community Partnerships Demonstration of on-going partnership with at least one community resource. Meeting Minutes Communication or education plan Formal referral agreements Work plan Examples of community resources Waiver or Senior services Local public health Home Health Assisted living Schools Behavioral Health

14 Recertification Year Two.0040 Subpart 6D Planning for Transitions in Care Anticipatory planning care transitions: Pediatric to adult care Transition assisted living, skilled nursing or memory care facility Transition to temporary rehabilitation Transition to palliative care or hospice

15 Recertification Year Two, Three and Beyond.0040 Subpart 8 External Care Plans All clinics must provide documentation of the number and type of care plans (comprehensive or action plans). Submit two care plans per certified clinic or a maximum of 20 care plans demonstrating integration of external care plans; OR complete an audit of 20 integrated care plans and submit a summary of findings and next steps.

16 Recertification Year Two.0040 Subpart 9A Subpart 9A The Quality Team Submit documentation that the quality improvement team is in place with meeting dates, names, roles of participants, and patient partnership activity.

17 Recertification Year Two, Three and Beyond.0040 Subpart 9D Learning Collaborative Participation Submit names, roles and dates of those who attended the HCH Learning Collaborative. Suggested attendees: One or more clinicians One or more care coordinators One or more representatives from the clinic leadership Describe how patients were encouraged to participate. Submit how learning collaborative information is shared with the rest of the HCH team.

18 Recertification Year Two, Three and Beyond.0040 Subpart 10 A Reporting & Quality Improvement Statewide Quality Reporting Patient level data: Pursuant to Minnesota Rules, chapter , and Minnesota Statutes, section 256B.0752, the applicant will submit health care homes data in the manner prescribed by the commissioner to fulfill evaluation requirements. To meet this requirement, the applicant will submit patient level data to MDH, in the manner prescribed by the commissioner. The applicant will submit data through the MDH contracted data collection vendor; the data collection vendor will provide de-identified patient-level data from the applicant to MDH for the purposes of evaluation.

19 Recertification Year Two, Three and Beyond.0040 Subpart 10 A Reporting & Quality Improvement Statewide Quality Reporting Required Measures: Diabetes Vascular Pediatric and Adult Asthma, Colorectal Cancer screening Depression Remission at 6 months Patient Experience measured through the CG-CAPHS with the PCMH additional questions New: Pediatric Preventive Care Adolescent Mental Health and/or Depression Pediatric Preventive Care Obesity/BMI and Counseling

20 Recertification Year Two.0040 Subpart 10 B Quality Improvement Planning Submit a quality improvement plan that addresses the Triple Aim of health improvement: Clinical Improvement Patient Experience Improvement Cost effectiveness of services

21 Health Reform in Minnesota Minnesota s Three Reform Goals Improve the health of the population Improve patient experience Improve the affordability of health care Institute of Medicine s Triple Aim

22 Recertification Year Two.0040 Subpart 10B Quality Measures Examples of Triple Aim Indicators : Reduced duplication of services Hospital readmissions, ER usage Poly pharmacy Patient satisfaction surveys Immunization rates Advanced directives, physician orders for life sustaining treatment (POLST) Optimal care scores

23 Health Care Homes Recertification Quality Plan Document Standard 10A: The applicant must participate in the statewide quality reporting system by submitting data on quality indicators approved by the Commissioner of Health. Annually benchmarking results are reviewed at recertification. Standard 10B: At Recertification the HCH selects at least one quality indicator from each of the following categories below ( triple aim ) and measures, analyzes and tracks those indicators throughout the year. To meet this standard the HCH submits its annual quality plan and quality reports with data that has been measured, analyzed and tracked. The quality plan may include the quality measures that are submitted to the Statewide Quality Reporting System or they may be based on other quality needs. The following is an example template of how the clinic might organize their quality plan. PDSA (Plan, Do, Study, Act) planning cycles also work well to meet this standard by demonstrating the quality work in the quality plan, or other structured QI methods. Clinic Name: Quality Plan Quality Goals in Each Category. Data Collection Methods (Measures / Tools / Methods) Action Plan (Timeline, responsible person, PDSA.) Clinical improvement in patient health Patient Experience Cost Effectiveness

24

25 Recertification Year Two, Three, and Beyond.0040 Subpart 11 A,B Shows internal improvement over time Reflects comparison of MN HCH certified clinics Follow established state or federal standards Use best practices, outcome-based measures Assures accountability at recertification Reflects the framework for statewide quality improvement

26 Recertification Requirements Year Three Continue to meet all initial certification and recertification requirements (.0040 Subparts 1,2,3,4,5,6,7,8,9,10). Submit documentation by exception. Address all variances and recommendations made from the previous year. Updates to specific subparts are required (1A; 5A; 8; 9D; 10A; 11).

27 Recertification Year Three and Beyond.0040 Subpart 11 A,B Benchmark Reporting Review and discuss HCH benchmarking data at the team meeting. Based on results the certified clinic may: Submit a variance for superior outcomes and continued progress on standards if eligible, or Continue with present improvement plan, or Submit a variance with action plan for justifiable failure to show measureable improvement.

28 HCH Benchmark Report

29 Access to Benchmarking Reports https://hch-data.org/login

30 HCH Benchmarks Benchmarking Continuum for HCH Recertification Performance Continuum for HCH 30

31 Benchmarking Approach Internal and external benchmarking using a hierarchy approach: A performance (comparison) benchmark, and An internal improvement benchmark Benchmarks are established at the clinic level. Statewide averages are the aggregate of all the optimal patients eligible to be in the measure. Health Care Home averages are the aggregate of all the optimal patients eligible for the certified health care home. 31

32 Statewide and HCH Averages The statewide average is calculated by taking the total number of optimal patients in the state (numerator) divided by the total number of eligible patients in the state (denominator). The health care home average is calculated by taking the total number of optimal patients at the HCH clinic sites (numerator) divided by the total number of eligible patients at the HCH clinic sites (denominator).

33 Improvement Benchmark If a clinic s rate is less than the statewide average then MDH will review the relative percent change from the previous year. Factors to consider when reviewing the relative percent change from the previous year are: High improvement can be considered a 10 % change or greater from the previous year. Stable performance can be considered a change in performance between (-9.9% to 9.9%) from the previous year. Reduced performance can be considered a change greater than 10 % from the previous year.

34 Performance Benchmarks 34

35 Improvement Benchmark If a clinic s rate falls into the low performance range then MDH will review the change in performance from the previous year and work directly with the clinic to determine if an action plan and variance is needed to meet the standard.

36 Benchmarking Baseline and Beyond Year one recertification benchmarking results serve as the baseline comparison. Year two recertification benchmarking results are a major component of the recertification process. Year three and beyond recertification benchmark results become the measure of clinical quality.

37 Thank you! For more information visit the Minnesota Department of Health, Health Care Home website at:

38 HCH Nurse Planners Contact Information Bonnie LaPlante, Supervisor Tina Peters Metro Area Kathleen Conboy Metro Area Joan Kindt- Southern Region Danette Holznagel Northern Region

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