NCQA PPC-PCMH TM Specifics

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1 NCQA PPC-PCMH TM Specifics Presented by Jed Constantz, Executive Director Cayuga Area Physicians Alliance Central New York Medical Support Services The Patient-centered Medical Home (PCMH) provides enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care Today s Care My patients are those who make appointments to see me Care is determined by today s problem and time available today Care varies by scheduled time and memory or skill of the doctor I know I deliver high quality care because I m well trained Patients are responsible for coordinating their own care It s up to the patient to tell us what happened to them Clinic operations center on meeting the doctor s needs Medical Home Care Our patients are those who are registered in our medical home Care is determined by a proactive plan to meet health needs, with or without visits Care is standardized according to evidencebased guidelines We measure our quality and make rapid changes to improve it A prepared team of professionals coordinates all patients care We track tests and consultations, and follow-up after ED and hospital An interdisciplinary team works at the top of our licenses to serve patients Source: Adapted with permission by IBM from Daniel F. Duffy, M.D. 009 IBM Corporation 1

2 Detailed Review of the Nine Standards Access and Communications Patient Demographics/Registry Patient Care Management Patient Self Management Electronic Prescribing Test Tracking Referral Tracking Measurement and Reporting Advanced Communication PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for patient access and patient communication** B. Uses data to show it meets its standards for patient access and communication** Standard : Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly non-clinical data) B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information** E. Uses data to identify important diagnoses and conditions in practice** F. Generates lists of patients and reminds patients and clinicians of services needed (population management) Standard : Care Management A. Adopts and implements evidence-based guidelines for three conditions ** B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Standard : Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management** Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically** B. Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system** Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice** B. Survey of patients care experience C. Reports performance across the practice or by physician ** D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support **Must Pass Elements Physician Practice Connections--Patient-Centered Medical Home PT

3 Detailed Review of the Must Pass Standards PPC 1A: Written standards for patient access and patient communication PPC 1B: Use of data to show meeting standards PPC D: Use of paper or electronic-based charting tools to organize clinical information PPC E: Use of data to identify important diagnoses and conditions in practice PPC A: Adoption and implementation of evidencebased guidelines for three conditions

4 Detailed Review of the Must Pass Standards PPC B: Active support of patient selfmanagement PPC 6A: Test tracking and follow-up PPC 7A: Tracking referrals with paper-based or electronic system PPC 8A: Measurement of clinical and/or service performance PPC 8C: Performance reporting by physician or across the practice Access and Communication Personal Clinician Coordinated Encounter Scheduling Logic Timely Communications Advanced Communication Patient Portal Electronic Outreach Web Based Patient Education/Orientation

5 Patient Demographics, Tracking & Registry Searchable Patient Database Demographics Clinical Data/Bio Metrics Demonstrate Ability to Use the Database Preventive Care Allergies and Adverse Reactions Condition Tracking Top Conditions Patient Care Management Access to and use of Clinical Decision Support consistent with Top Conditions Clinician Reminders/Alerts Maximize Non-Physician Staff Detailed Patient Plan of Care Outbound/Inbound Continuity of Care Documentation Bi-directional HIE 5

6 Patient Self Management Documenting/Accommodating Communication Needs Documented Support for Self Management Top Conditions Readiness for Self Management Coordinating Resources/Services for Self Management Level Coding Written Plan of Care for Self Management Recommendations/Tracking/ Follow up Electronic Prescribing Electronic Prescription Writing Electronic Decision Support Safety/Alerts Electronic Decision Support Efficiency Generic vs. Brand Options Formulary Support 6

7 Test Tracking Documented Process/System/Protocol Supported by an Electronic System Ordered but not resulted Patient Follow up/notification Referral Tracking Documented Process/System/ Protocol Results/Patient Follow up Bi-Direction HIE Measurement and Reporting for Improvement Clinical Process/Outcomes Service Data/Patient Safety Patient Satisfaction CHAPS Access/Communication/Self-Care/Satisfaction Reporting to Physicians Individually/Entire Practice Goal Setting Using Standardized Measures External Reporting 7

8 Leveraging the PCMH Opportunity PCMH Good for Patients, Staff, & Physicians... and business Ending Medical Homelessness Improved Health Status Improved Job Satisfaction Improved Working Environment Maximizing Encounters/ Service Expansion Questions/ Community Expectations Access to care Cost of care Health Plans/Government Programs Community Health Status Patient Behaviors Patient Health Literacy Health Information Therapy vs. Drug Therapy Can Primary Care Deliver the Goods? 8

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