Patient Centered Medical Home Questions regarding NCQA Recognition

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1 Patient Centered Medical Home Questions regarding NCQA Recognition PCMH 1: Enhance Access and Continuity Element A: Access During Office Hours Factor 1: Providing same day appointments Q On the same day appointments; is it acceptable to have open access appointments first thing in the morning and directly after lunch that are not double booked, however, the rest of the schedule is free to double book? A Yes, this is acceptable. There should be availability to reserve time for same day appointments based on patient preference or triage. There must be a documented process/policy of for staff to follow for scheduling same day appointments. The report showing compliance would consist of auditing for 5 days. A Must Pass Element the practice must achieve at least 50% score on each Must Pass element in order to achieve recognition. Factor 1 is a Critical Factor Must be met for practices to receive any score on the element. PCMH Standard 1: Enhance Access and Continuity Element A: Access During Office Hours Factor 2: Providing timely clinical advice by telephone during office hours. Q If we pull telephone calls for a 5 day period and summarize the response time on a paper chart, will that be sufficient to satisfy the report requirement? A If the paper chart in the question is a log or some type of report, then yes this would suffice. This element requires a documented process for staff to follow for providing timely clinical advice by telephone. The process must define the timeliness standard in the documented process and monitor the timeliness of the response against the practice s standard. The practice will submit a report summarizing its actual response times. The report may be system generated or may be based on using other means and covers a period of at least one week of calls. Standard 1 Element A is a Must Pass Element the practice must achieve at least 50% score on each Must

2 PCMH 1: Enhance Access and Continuity Element C: Electronic Access The practice provides the following information and services to patients and families through a secure electronic system: Factor 5. Request for appointments or prescription refills Factor 6: Request for referrals or test results Q Our patient portal allows patients to send secure electronic communications to the practice, and vice versa (Facto#4). We do not, however, have a separate process for requesting appointments or refills. Instead, patients make those requests by using the secure . Is this sufficient? Why are these separate factors? A Secure may be sufficient depending on what can be demonstrated via screen shots. Screen shots are acceptable to show compliance the practice would want to be able to show a request appointment (or require prescription refill) screen shot as well as evidence of communication back that the appointment had been scheduled. The practice would submit a screen shot of a Web page where patients request referrals or test results, demonstrating its implementation the practice. PCMH 1: Enhance Access and Continuity Element D: Continuity Factor 2: Documenting the patients/family s choice of clinician Q If a patient requests an appointment with a certain provider, we try to grant that request. Most of the time, however, patients who are new to the practice are assigned to the provider with the smallest panel, and that is appropriate for that patient s age, insurance, etc. We document the assigned rendering provider, expect and track continuity with that provider, and have a process for patients to request a change of rendering provider. Is this sufficient to answer, yes to #2 of this element? A Yes because a documented process is in place, and criteria are in place for doing so. There are 2 components to meet factor the practice will submit a screen shot showing documentation of the patient/family choice of clinician and a documented process with criteria of how a patient selects the clinician and how this process is communicated to patients.

3 PCMH Standard 2 Identify and Manage Patient Populations Element D: Use Data for Population Management The practice uses patient information, clinical data and evidence based guidelines to generate lists of patient and to proactively remind patients/families and clinicians of services needed for: Factor 1: at least three different preventive care services Factor 2: at least three different chronic care services Q We are required to show materials or examples on how patients are notified. Will a copy of the electronic letter sent to patients be sufficient? A Yes, as long as the letter is specific to the preventive care or chronic care condition identified in the lists generated. For example, if the reminder is for breast cancer screening, it must specifically state it is a reminder for a mammogram. Element D is a Must Pass Element the practice must achieve at least 50% score on each Must PCMH Standard 3: Plan and Manage Care Element C: Care Management The care team performs the following for at least 75% of the patients identified I Elements A and B. Factor 1: Conducts pre visit preparations Factor 2: Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit Factor 3: Gives the patient/family a written plan of care Factor 4: Assesses and addresses barriers when the patient has not met treatment goals Factor 5: Gives the patient/family a clinical summary at each relevant visit Factor 6: Identified patients/families who might benefit from additional care management support Factor 7: Follows up with patients/families who have not kept important appointments Q In general, how in depth does our documentation need to be on these measures? Some of them are easily documented, others not so easily. Can you explain the Record Review Notebook? A The documentation to support these factors is results of a medical record review based on 3 important conditions identified in Standard 3, Element A (3 important conditions) and Element

4 B (high risk/complex patients). The workbook requires that you pull a population list, randomly select 12 patients from each condition and show how your practice meet specific factors. Example for patients with diabetes, did we conduct a pre visit review? Where is this documented (EMR, daily schedule, etc.). Must be able to show compliance with each factor. Recommendation: Conduct a practice review. Run a report of patients with your selected conditions from PCMH 3A and 3B, pull a sample of medical records and have the team identify where to look for evidence of documentation. The Medical Record review Workbook is a part of the ISS tool. The 2011 PCMH Survey Tool information is under the Publication tab on the NCQA website, The cost of the survey tool is $80. NCQA s Customer Support department ( ) Element C is a Must Pass Element the practice must achieve at least 50% score on each Must PCMH Standard 3: Plan and Manage Care Element C: Care Management Factor 4: Assesses and addresses barriers when the patient has not met treatment goals Q Not sure the best way to identify the documentation for those patients. Is a completed social history acceptable for the documentation? No to meet the requirement, a care plan that is developed with the patient/family is expected. is expected. The Plan of Care is assessed periodically to determine reasons for limited progress toward treatment goals and to help the patient/family address the barriers identified. There should be documentation that the care team addressed the barriers with the patient/family. Element C is a Must Pass Element the practice must achieve at least 50% score on each Must PCMH Standard 4: Provide Self Care Support and Community Resources Element A: Support Self Care Process The practice conducts activities to support patients/families in self care management Factor 3: Develops and documents self management plans and goals in collaboration with at least 50% of patients/families. Q Can we specify the age group to satisfy the 50% requirement? For example, can we choose, children 2 17 years of age, and we have the Bright Future developmental handout which gives the parents guidance.

5 A No the population is already defined in Standard 3 Elements A and B. NCQA expects the practice to have documentation that it provides written self care plans to patients, families or caregivers. One example for pediatric practices is an asthma action plan. Element A is a Must Pass Element the practice must achieve at least 50% score on each Must PCMH 4A: Factor 6 Q Will a report that shows educational materials were given for smoking cessation, physical exercise, diet, etc. be sufficient? A If documentation demonstrates that these materials were given to the patient/family and counseling was provided, then yes. If counseling was not provided, then it does not meet the factor. PCMH 5: Track and Coordinate Care Element C: Coordinate with Facilities and Care Transitions On its own or in conjunction with an external organization, the practice systematically: Factor 5: Demonstrates its process for exchanging patient information with the hospital during a patient s hospitalization. Q Does this have to be two way communication? Our providers have access to both local hospitals but they do not have access to our records. A The communication does not necessarily have to be exchanged through the EMR. Information could be exchanged verbally, over the phone, by fax, etc. There should be documentation of the process of how there is communication between the provider at health center and the provider at hospital. PCMH Standard 6: Measure and Improve Performance Element C: Implement Continuous Quality Improvement The practice uses an ongoing quality improvement process to: Factor 4: Involve patients/families in quality improvement teams or on the practice s advisory council. Q We have board members that are patients that attend our QI meetings. Will that satisfy the requirement with copies of the minutes/agenda for those meetings?

6 A Probably yes. The minutes presented should clearly identify t which attendees are patients. The QI Committee minutes should reflect discussion of clinical issues addressed. There needs to be a documented process of how patients are engaged/selected for the QI committee, including an explanation of patients roles and responsibilities on the committee. The process could be addressed in your QI plan. Element C is a Must Pass Element the practice must achieve at least 50% score on each Must Other Questions Q As we begin the process toward PCMH should we purchase anything such as workbooks, etc.? A The Medical Record review Workbook is a part of the ISS tool. The 2011 PCMH Survey Tool information is under the Publication tab on the NCQA website, The cost of the survey tool is $80. NCQA s Customer Support department ( ) Q Is there a cheat sheet to tell us how to organize and name our documents? A Not that we know of. Q On the TPCA PCMH Webinar, it mentioned a workbook? How do we obtain the workbook and the instructions? Do we have to purchase from NCQA? A The Medical Record review Workbook is a part of the ISS tool. The 2011 PCMH Survey Tool information is under the Publication tab on the NCQA website, The cost of the survey tool is $80. NCQA s Customer Support department ( ) Q NextGen does not provide the Patient Plan in Spanish. How can Hispanic patient receive their Patient Plan in their language? A Patient Plans in languages other than English are usually generated outside of the EMR system. It could be a paper format, gained through internet search. Diabetes.org has plans in Spanish. The practice could have the plans in English translated to the languages most common in their practice.

7 Q In the Records Review Notebook there is mention of a random sample. If the practice is going to submit their application in June (as will most who received the $55,000 supplemental funding to improve cervical cancer screening rate) what are the criteria for the random sample? A A recent three month period is adequate. If submitting in June, the end date should probably be April 30 allowing the practice a month before submission to perform quality check, upload documents, etc. Q If the practice is getting close to submitting but thinks there are a couple of Must Pass Elements that it will not pass, what should it do? A Talk to project officer. If the practice does not meet the Must Pass Elements, it will not be recognized. Ask the PO if a submission extension is possible. Be transparent, honest with the PO. Be ready to discuss with the PO how much time will be needed for the practice to meet Must Pass elements. TJC / NCQA Crosswalk accessible on TPCA website