HCH Recertification Year One

Transcription

1 HCH Recertification Year One 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 Health Care Homes

2 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.

3 The Health Care Homes Recertification Process Learning Objectives 1. Describe the Health Care Home legislative rule subpart criteria required at recertification year one. 2. Define the progression of quality improvement requirements 3. Identify strategies to implement the standards at recertification year one.

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

5 Timelines: Recertification

6 The Recertification Process Window is: 90 Days On the one year anniversary of your initial certification date, MDH will send you an to notify you that you have 90 days to complete the recertification process: LOI Application Assessment (if changes) Site Visit Your clinic will now have a rolling 15 month recertification due date.

7 Recertification Time Line: 60 Days 60 days before the end of your recertification: Submit a Letter of Intent to indicate your wish to pursue recertification. Update the application with new clinicians or clinic information. MDH Planner will contact via phone or e mail Plan a date for your site visit.

8 Recertification Time Line: 45 Days 45 days before the end date of your recertification: Submit your recertification assessment Address any recommendations from previous year s report Complete the HCH audit tool or your clinic audit Update number of care coordinated patients and number of care plans and send to planner Submit corrective action plans for variance resolution Apply for extension of variances, if needed

9 Recertification Timeline: 30 Days All documents have been submitted for MDH review MDH conducts site visit team meeting with clinic unless the clinic outcomes are Superior MDH reviews information presented and may request additional information and/or interviews MDH completes the recertification report

10 Recertification Timeline: Finish Line Final Steps: MDH sends the recertification final report to the commissioner/assistant commissioner for review and signature MDH sends a signed recertification letter with the final report to the clinic, Along with a list of recertified clinicians MDH updates certified clinicians on the MDH website

11 HCH Rolling Recertification Dates

12 Recertification by Spread As HCH model is implemented in new clinic sites, referred to as spread the new clinicians are certified and the certified status for the clinic will be declared at annual recertification. When a previously certified clinician leaves a clinic and goes to work at a non-certified clinic, the new clinic and clinician/s apply for their certification. The previous clinic employer identifies an end date for that clinician in the HCH on-line portal.

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

14 Recertification Resources: Training tools for your reference can be accessed by going to: 14

15 Recertification Assessment Tool 15

16 Recertification Site Visits Team Meeting Format

17 Recertification Site Team Meeting 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. 17

18 Preparing for Site Visit Be in contact with your planner / common topics: Culture change and care team development Successes and challenges New planned initiatives Discuss the required updates to subparts for recertification Share how variances and recommendations were addressed. Quality improvement activities, committee structure changes, data collection. 18

19 Recertification Requirements Year One

20 Recertification Requirements Year One continued Continue to meet all initial certification (ODD numbered subparts:.0040 Subparts 1,3,5,7,9). Submit documentation by exception. Address any variances and/or recommendations made at initial certification (if applicable). Updates to specific subparts are required (1A, 5A, 9A, 9D) At year one recertification the new EVEN numbered subparts are added to reflect progress (2,4,6,8,10).

21 Recertification Year One.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.

22 Recertification Year One.0040 Subpart 5A Subpart 5A Care Coordination Program Expansion: Submit the number of patients receiving care coordination services and the number of 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.

23 HCH Clinic Audit Tool

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

25 .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.

26 Subpart 2 Recertification Year One New Subparts to reflect progress Patient Activation Subpart 4 Subpart 6 Subpart 8 Registries to Track Gaps in Care Shared Decision Making, Community Partnerships, Teams working to the full extent of licensure, Transitions in Care External Care Plans Subpart 10 Quality Measurement and Triple Aim Quality Plan

27 .0040 Subpart 2 Patient Participation in Managing Their Care Submit strategies used to encourage patients to take an active role in managing their care. Demonstrate one of the following criteria through procedures/workflows and concrete examples: Participant s readiness for change Literacy level Barriers to learning

28 Clinic Level Process: Measurement of patient and family centered care: PCMH-A (questions 9-11) Family voices.0040 Subpart 2 Patient Participation Examples: The Institute for patient & family centered care Individual Patient Process: Teach-Back Method Ask Me 3 Patient Activation Measure (PAM) Literacy Assessment/Questionnaire

29 .0040 Subpart 4 Registries & Tracking Gaps in Care Documented process with identified staff time for: Pre-visit planning Call reminders for preventive care or procedures Follow-up appointments for chronic conditions Guidelines to identify patients with gaps in services Evidence that the registry is actively worked by the care team Internal audit process Job performance review Blinded copies of completed work tools Work assignments

30 .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

31 .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

32 .0040 Subpart 6C Care Team Practices to the top of licensure Clinicians & team members working at the top of their education, licensure, and training. Job descriptions/responsibilities Workflows QI project related to workflow or team responsibilities

33 .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

34 .0040 Subpart 8 External Care Plans Identify patients with care plans who also have external care plans. Process used to create a comprehensive care plan which adds relevant information from the external care plan. Examples: wound care, falls prevention, behavioral health, asthma action plan. Submit three integrated care plans for review.

35 .0040 Subpart 10 A Reporting & Quality Improvement 1 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.

36 .0040 Subpart 10 A Reporting & Quality Improvement 2 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

37 .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

38 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

39 Health Care Homes Recertification Quality Plan Document

40 Health Care Homes Recertification Quality Plan Document Examples

41 .0040 Subpart 10 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

42 HCH Benchmark Reporting Preparing for Recertification Years 2, 3 and Beyond

43 HCH Benchmarks Benchmarking Continuum for HCH Low Average High PerformancePerformancePerformance Variance Low Average Variance for Performance Continued Superior Corrective Transformation Performance Action Plan Action Plan Recertification Performance Continuum for HCH 43

44 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. 44

45 Access to Benchmarking Reports

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

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