:{ic0fp'16. The Patient Centered Medical Home. Rebecca Moore, DO. ACOFP 53 rd Annual Convention & Scientific Seminars

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1 :{ic0fp'16 ACOFP 53 rd Annual Convention & Scientific Seminars The Patient Centered Medical Home Rebecca Moore, DO

2 ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP 53rd Annual Convention and Scientific Seminars Dates and Location of CME Activity: April 6-9, 2016, The San Juan Puerto Rico Convention Center Your presentation: Saturday, April 9, 2016: 7:00am-9:00am: Medicare Wellness, Transition Codes and Patient Centered Medical Home Name of Faculty/Moderator: _Rebecca Moore DO X DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds) Speakers Bureaus* Employment Ownership Partnership Consultant for Fee Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved *If you checked Speakers Bureaus in item B, please continue: Did you participate in company-provided speaker training related to your proposed Topic? Yes: No: Did you travel to participate in this training? Yes: No: Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: Did the company pay the travel/lodging/other expenses? Yes: No: Did you receive an honorarium or consulting fee for participating in this training? Yes: No: Have you received any other type of compensation from the company? Please specify: Yes: No: When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No: Will your Topic1 involve information or data obtained from commercial speaker training? Yes: No: DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS X A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices. B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement. Signature: Rebeccca Moore DO Date: 12/22/15 Rebecca Moore, DO Please this form to joank@acofp.org as soon as possible Deadline: Friday, January 15, 2016

3 The Patient Centered Medical Home (2014 Standards) Rebecca Moore DO Associate Professor Family Medicine Rowan SOM Disclosures NONE Objectives Review the background behind the Patient Centered Medical Home Review how to become PCMH recognized Review the standards to achieve PCMH status Discuss the benefits of a PCMH model 1

4 Background NCQA developed the PCMH model to help improve patient care Collaboration between the the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association Developed a set of standards to help give practices information about organizing care around patients, working in teams and coordinating and tracking care over time. The standards encourage the use of electronic health records The standards align themselves with the information technology similar to that required to meet CMS Meaningful Use Requirements Focus is on patient - centeredness AND the ability to track care over time and across settings How are PCMH 2015 Standards Different for 2011? More integration of behavioral healthcare Additional emphasis on team - based care Focus care management for high-need populations Encourage involvement of patient and families in QI activities Alignment of QI activities with the Triple Aim improved quality, cost and experience of care Alignment with health information technology Meaningful Use Stage 2 2

5 ACP Position Paper The PCMH-N Who is eligible to participate in a PCMH? Clinicians who hold a curent, unrestricted license as a MD, DO, APRN, or PA Only clinicians that a patient/family can select as a Personal Clinician are eligible The practice defines a personal clinician as A residency group under a supervising clinician or faculty physician, although residents themselves are not identified individually for selection as personal clinicians A combination physician and APRN or PA who share a panel of patients 3

6 Physicians, APRN and PA s who practice in the specialty of internal medicine, family medicine or pediatrics with the intention of serving as a personal clinician for their patients. Physician-led practices applying with identified APRNs or Pas: Patients may choose the APRN or PA as their PCP or ARPNs or PAs share a panel of patients as a primary care team with the physician Clinicians who do not qualify: Non-primary care specialty clinicians and APRNs and PAs who do not have a panel of patients Special Circumstances Practices that do not have a physician with a panel of patient at the site may achieve NCQA Recognition with the following considerations: It is allowed according to the scope of practice determined by state law Practices are reviewed against the same requirements as physician-lead practices 4

7 What about practices with multiple sites? Organization must have at least three sites share an electronic record system standardized policies and procedures across all practice sites You and/or your practice are eligible to apply for PMH recognition. Now what? 5

8 PCMH 1: Enhance access and Continuity Element A: Patient-Centered Access** Provide same - appointments for routine and urgent care (Critical factor) Provide routine and urgent-care appointments outside regular business hours Provided alternative types of clinical encounters Availability of appointments Monitoring no-show rates Acting on identified opportunities to improve access 6

9 Element B: 24/7 Access to Clinical Advice Providing continuity of medical record information for care and advice when the office is closed Providing timely clinical advice by telephone when the office is not open (Critical Factor) Providing timely clinical advice using a secure, interactive electronic system when the office is not open Documenting after-hours clinical advice in patient records Element C: Electronic Access More than 50 percent of patients have online access to their health information within four business days of when the information is available to the office includes problem list, diagnosis, diagnostic test results, allergies, med list More than 5 percent of patients view, and are provided the capability to download their health information or transmit their health information to a third party Clinical summaries are provided within 1 business day for more than 50% of office visits A secure message was sent to more than 5% of patients Patients have two-way communication with the practice Patients can request appointments, prescription refills, referrals and test results PCMH 2: Team-Based Care 7

10 Element A: Continuity Assisting patients/families to select a personal clinician and documenting the selection in practice records Monitoring the percentage of patient visits with a select clinician or team Having a process to orient new patients to the practice Collaborating with the patient/family to develop/implement a written care plan for transition from pediatric care to adult care Element B: Medical Home Responsibilities The practice is responsible for coordinating patient care across multiple settings Instructions on obtaining care and clinical advice during office hours and when the office is closed The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice The care team gives the patient/family access to evidence-based care and self-management support The scope of services available within the practice including how behavioral health needs are addressed The practice provides equal access to all of their penitents regardless of source of payment The practice gives uninsured patients information about obtaining coverage Instructions on transferring records to the practice, including a point of contact at the practice 8

11 Element C: Culturally and Linguistically Appropriate Services Assessing the diversity of its population Assessing the language needs of its population Providing interpretation or bilingual services to meet the language needs of its population Providing printed materials in the languages of its population Element D: The Practice Team** Defining roles for clinical and nonclinical team members Identifying the team structure and the staff who lead and sustain team based care. Holding scheduled patient care team meetings or a stretch communication process focused on individual patient care. (Critical factor) Using standing orders for services Training and assigning members of the care team to coordinate care for individual patients. Training and assigning member so of the care team to support patients/families/caregivers in selfmanagement, self-efficiency and behavior change. Training assigning members of the care team to management eh patient populations. Holding scheduled team meetings to address practice functioning. Involving care team staff in the practice s performance evaluation and quality improvement activities. Involving patients/families caregivers in quality improvement activities or on the practice s advisory council. 9

12 PCMH 3: Identify and Manage Patient Populations Element A: Patient Information Date of birth Gender Race Ethnicity Preferred language Telephone numbers address Occupation Dates of previous clinical visits Legal guardian/health care proxy Primary caregiver Presence of advance directions (NA for pediatric practices) Health insurance information Name and contact information of other health care professionals involved in patient s care Element B: Clinical Data An up-to-date problem list with current and active diagnoses for more than 80% of patients Allergies for more than 80% of patients (include medications allergies and adverse reactions) Blood pressure with the date of update for more than 80% for patients 3 yrs and older Height/length for more than 80% of patients Weight for more than 80% of patients 10

13 System calculates and displays BMI (NA for pediatric practices) System plots and displays growth charts and BMI percentile for ages 0-20 years (NA for adult practices) Status of tobacco use for patients 13 years and older for more than 80% of patients List of prescription medications with the date of updates for more than 80% of patients More than 20% of patients have family history recorded as structured data At least one electronic progress note created, edited and signed by an eligible professional for more than 30% Element C: Comprehensive Health Assessment Documentation of age and gender appropriate immunizations and screenings Family/social/cultural characteristics Communication needs Medical history of patient and family Advance care planning (NA for pediatric practices) Behaviors affecting health Patient and family mental health/substance abuse Developmental screening using a standardized tool (NA for adult-only practices) Depression screening for adults and adolescents using a standardized tool. Assessment of health literacy 11

14 Element D: Use Data for Population Management** At least two different preventive care services At least two different immunizations At least three different chronic or acute care services Patients not recently seen by the practice Medication monitoring or alert Element E: Implement Evidence- Based Decision Support A mental health or substance use disorder (Critical Factor) A chronic medical condition An acute condition A condition related to unhealthy behaviors Well child or adult care Overuse/appropriateness issues PCMH 4: Care Management and Support 12

15 Element A: Identify Patients for Care Management Behavioral health conditions High cost/high utilization Poorly controlled or complex conditions Social determinants of health Referrals by outside organizations (ex: insurers, health system, ACO), practice staff or patient/family/caregiver The practice monitors the percentage of the total patient population identified through its process and criteria (Critical Factor) Element B: Care Planning and Self-Care Support** Incorporates patient preferences and functional/lifestyle goals Identifies treatment goals Assesses and addresses potential barriers to meeting goals Includes a self-management plan Is provided in writing to the patient/family/caregiver Element C: Medication Management Reviews and reconciles medications with patients/families for more than 50% of care transitions (Critical Factor) Reviews and reconciles medications with patients/families for more than 80% of care transitions Provides information about new prescriptions to more than 80% of patients/families Assesses patient/family understanding of medications for more than 50% of patients with date of assessment Assesses patient response to medications ad barriers to adherence for more than 50% of patients with date of assessment Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients/families, with the date of updates 13

16 Element D: Use Electronic Prescribing More than 50% of eligible prescriptions written by the practice are compared to the drug formularies and electronically sent to pharmacies. Enters electronic medication orders into the medical record for more than 60% of patients Performs patient-specific checks for drug-drug and drugallergy interactions Alerts prescribers to generic alternatives Element E: Support Self-Care and Shared Decision Making Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients Provides educational materials and resources to patients Provides self-management tools to record self-care results Adopts shared decision making aids Offers or refers patients to structured health education programs, such as group classes and peer support Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates Assess usefulness of identified community resources PCMH 5: Care Coordination and Care Transitions 14

17 Element A: Test Tracking and Follow-Up Tacks lab tests until results are available, flagging and following up on overdue results (Critical Factor) Tracks imaging tests until results are available, flagging and following up on overdue results (Critical Factor) Flags abnormal lab results, bringing them to the attention of the clinician Flags abnormal imaging results, bringing them to the attention of the clinician Notifies patients/families of normal and abnormal lab and imaging test results Follows up with the inpatient facilities about newborn hearing and bloodspot screening (NA for adults) More than 30% of radiology orders are electronically recorded in the patient record More than 30% of radiology orders are electronically recorded in the patient record Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record More than 10% of scans and tests that result in an image are accessible electronically Element B: Referral Tracking and Follow Up ** Considers available performance information on consultants/specialist when making referral recommendations Maintains formal and informal agreements with a subset of specialist based on established criteria Maintains agreements with behavioral healthcare providers Integrates behavioral healthcare providers within the practice site Gives the consultant or specialist the clinical question, the required timing and the type of referral 15

18 Give the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan Has the capacity for electronic exchange of key clinical information and provides the electronic summary of care record to another provider for more than 50% of referrals Tracks referrals until the consultant or specialist s report is available, flagging and following up on overdue reports. (Critical Factor) Documents co-management arrangements in te patient s medical records Asks patients/families about self-referrals and requesting reports from clinicians. Element C: Coordinate Care and Transitions Proactively identifies patients with unplanned hospital admissions and emergency department visit Shares clinical information with admitting hospitals and emergency departments Consistently obtains patient discharge summaries from the hospital and other facilities Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visits Exchanges patient information with the hospital during a patient s hospitalization Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners, Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50% of transitions of care 16

19 PCMH 6: Performance Measurement and Quality Improvement Element A: Measure Performance At least two immunization measures At least two preventive care measures At least three chronic and acute are clinical measures Performance data stratified for vulnerable populations (to assess disparities in care) Element B: Measure Resource Use and Care Coordination At least two measures related to care coordination At least two utilization measures affecting health care costs 17

20 Element C: Measure Patient/Family Experience The practice conducts a survey (using any instrument) to evaluate patient/family experiences on at least three of the following categories: Access Communication Coordination Whole-person care/self-management support The practice uses the PCMH version of the CAHPS Clinician and Group Survey Tool The practice obtains feedback on the experiences of vulnerable patient groups The practice obtains feedback from patients/families through qualitative means Element D: Implement Continuous Quality Improvement** Set goals and act to improve performance on at least three measures form Element A Act to improve at least three clinical quality measures from Element A Set goals and analyze at least one measure from Element B Act to improve at least one measure from Element B Set goals and analyze at least one patient experience measure from Element C Act to improve at least one patient experience measure from Element C Set goals and address at least one identified disparity in care/service for identified vulnerable populations Element E: Demonstrate Continuous Quality Improvement Measuring the effectiveness of the actions it takes to improve the measures selected in Element D Achieving improved performance on at least two clinical quality measures Achieving improved performance on one utilization or care coordination measures Achieving improved performance on at least one patient experience measure 18

21 Element F: Report Performance Individual clinician performance results with the practice Practice-level performance results with the practice Individual clinician or practice-level performance results publicly Individual clinician or practice-level performance results with patients Element G: Use Certified EHR Technology The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID The practice conducts a security risk analysis of its EHS system and implementing security updates as necessary and correction identified security deficiencies The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agency electronically The practice demonstrates the capability to identify and report cancer cases to a pu bloc health central cancer registry electronically The practice demonstrates the capability to identify and report specific cases to a a specialized registry (other than a cancer registry) electronically The practice reports clinic quality measures to Medicare and medicaid agency, as required for Meaningful Use The practice demonstrates the capability to su bit data to immunization registries or immunization information systems electronically Then practice has access to a health information exchange The practice has bidirectional exchange with a health information exchange The practice generates lists of patients,, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care THIS ELEMENT IS NOT SCORED, BUT REQUIRED 19

22 How do I show the documentation? The guidelines and survey tool suggest the appropriate way to attest May be by screen shots May be percentages Each element may have different timelines required one month vs three month vs six months How do you apply for PCMH? Go to NCQA website and order the PCMH online application You will receive confirmation from NCQA Address the PCMH online application system and order a PCMH survey tool one survey tool per location Sign the program agreement and Business Associate Agreement Submit the online applications to NCQA Submit the application fee to NCQA What s next? Complete the survey tool Respond to the questions Complete the worksheets provided Attach the required documentation Submit 20

23 Why is the survey tool so important? It helps break down the requirements into the separate standards and elements Helps track the requirements needed Helps add up your points Can you upgrade after you have already been recognized for specific PCMH level? Yes you can! A practice that has Level 1 or 2 recognition status may apply for an Add-On Survey within the 3 year recognition period. Can move up to Level 2 or 3 based on the points. So what are the Benefits?? 21

24 Percent 113 Blood Pressure Under Control Last Time Checked, by Medical Home Has Heart Disease, Hypertension, and/or Diabetes Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Rated Quality of Care in Past Year as Excellent or Very Good, by Medical Home Percent Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 38 Percent* Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 22

25 Doctor Patient Relationship and Communication, by Medical Home Percent reporting positive doctor patient relationship and communication* Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US * Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand. Base: Has a regular doctor/place of care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Percent* Hospital or Surgery Discharge Gap in Past Two Years, by Medical Home Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US * Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. There is Evidence... Early evidence suggests that PCMH improves the quality of care and returns savings Fields, Leshen, Patel Article found reduced use of the hospital, emergency room visits and overall savings Reid Followed an integrated group practice and found significant improvement in patient/provider experiences and in the quality of clinical care 23

26 The End Questions? 24