Patient-Centered Connected Care 2015 Recognition Program Overview. All materials 2016, National Committee for Quality Assurance

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1 Patient-Centered Connected Care 2015 Recognition Program Overview All materials 2016, National Committee for Quality Assurance

2 Learning Objectives Introduction to Patient-Centered Connected Care and Eligibility Overview of the 5 Connected Care Standards Highlight the intent of each element Identify the Must-Pass elements Outline documentation requirements Review examples 2

3 Connected Care Recognition

4 Eligibility PCMH Family Medicine Internal Medicine Pediatrics PCSP ABMS/Behavioral Health & Mental Health Specialties PCCC Onsite Employee Health Clinics Convenient Care/Retail Clinics Urgent Care Centers/Free-Standing Walk-In Clinics School/University Based Health Clinics Non-Primary Care Outpatient Clinics

5 Eligibility (cont.) Eligible provider = clinic providing outpatient consultation or acute/episodic treatment May be at a single or multiple sites Site is one or more clinicians practicing together at a single geographic location Use same policies and procedures Share information systems

6 Connected Care Recognition 3-year recognition period Eligible provider sites are recognized Individual clinicians are not recognized 6

7 Patient-Centered Connected Care 2015 Content and Scoring (5 standards/24 elements) 1: Connecting With Primary Care A. *Connecting Patients With Primary Care B. Sharing Information With Primary Care C. *Demonstrating Information Sharing D. Working With Primary Care E. Coordination With Primary Care 2: Identifying Patient Needs A. *Informing Patients About Services Offered B. Triaging Patients C. Connecting Patients With Other Providers 3: Patient Care and Support A. *Implement Evidence-Based Decision Support B. Medication Management C. Test Tracking and Follow-Up D. Collaborating With the Patient E. Culturally and Linguistically Appropriate Services (CLAS) Pts Pts Pts : System Capabilities A. Patient Information B. Clinical Data C. Use of Electronic Prescribing 5: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. Set Goals and Analyze Results E. *Take Action to Improve F. Reduce Disparities G. Demonstrate Continuous Quality Improvement H. Report Performance *Must Pass Elements Scoring Levels Recognized: points Not Recognized: points Pts Pts

8 Must-Pass Elements Rationale for Must-Pass Elements Identifies critical concepts Helps focus on most important aspects Guides eligible providers in evolution and continuous quality improvement Standardizes Recognition 8

9 Connected Care Must-Pass Elements 1. Connected Care 1A: Connecting Patients With Primary Care 2. Connected Care 1C: Demonstrating Information Sharing 3. Connected Care 2A: Informing Patients About Services Offered 4. Connected Care 3A: Implement Evidence- Based Decision Support 5. Connected Care 5E: Take Action to Improve 9

10 Documentation Types 1. Documented process Written procedures, protocols, workflow forms (not explanations); these should show the eligible provider/organization name and date of implementation 2. Reports Aggregated organization data showing evidence meeting % threshold requirements 3. Meaningful Use Reports Data reports produced from certified EHR technology 4. Records or files De-identified patient records or registry entries documenting action taken 5. Materials Information for patients or clinicians, e.g. clinical guidelines, self-management and educational resources NOTE: Screen shots or electronic copy may be used as examples (EHR capability), materials (Web site resources), reports (logs) or records (advice documentation) 10

11 Documentation Time Periods Report Data, Files, Examples and Materials Should display information that is current within the last 12 months. Documented Process Policies, procedures and processes should be in place for at least 3 months prior to survey submission. Reporting Period (Meaningful Use) 3 months or 12 months Reporting Period (Log or Report) Refer to documentation guidelines for other references to minimum data for logs and reports (one week, one month, etc.) Documents MUST include dates of implementation or updates 11

12 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 12

13 Connected Care 1: Connecting with Primary Care All materials 2016, National Committee for Quality Assurance

14 Connected Care 1: Connecting with Primary Care Intent of Standard The eligible provider connects patients with primary care clinicians and shares information about the care they received during the visit. 14

15 Connected Care 1: Connecting with 30 Points Elements Primary Care PCCC 1A: Connecting Patients With Primary Care MUST-PASS PCCC 1B: Sharing Information With Primary Care PCCC 1C: Demonstrating Information Sharing MUST-PASS PCCC 1D: Working With Primary Care PCCC 1E: Coordination With Primary Care 15

16 Connected Care 1A: Connecting Patients With Primary Care The eligible provider has a documented process that it implements for connecting patients with primary care clinicians that includes: 1. Identifying and documenting the patient s primary care clinician. 2. Communicating the importance of patients following up with their primary care clinician. 3. Providing information on available primary care clinicians to patients without them. 16

17 MUST-PASS 9 Points Scoring Connected Care 1A: Scoring and Documentation 3 factors = 100% 2 factors = 75% No scoring option = 50% 1 factor = 25% 0 factors = 0% Documentation F1: Documented process, and 3 examples or a report showing the percent of patients identifying primary care provider F2: Documented process, and example of materials or script F3: Documented process, and example of materials 17

18 Connected Care 1A Factor 1: Collecting PCP Information From Patient Patient In-Take Form PCP Information Form Patient Information Primary Provider 18

19 Connected Care 1A Factor 1: Report Collecting PCP Information Form Patient info. Primary provider Need to also provide: Number and percentage of patients without PCP Number and percentage of patients who refused to provide PCP information

20 Connected Care 1A Factor 2: Website Communicating Importance of Following Up with PCP 20

21 Connected Care 1A Factor 2: Materials Communicating Importance of Following Up with PCP Language from a script used by practice staff to communicate information to patients 21

22 Connected Care 1A Factor 3: Providing Information on Available Primary Care Clinicians Example of a postcard sent to patients to assist in selecting a primary care clinician 22

23 Connected Care 1B: Sharing Information With Primary Care The eligible provider follows its documented process for sharing the following information with primary care clinicians after each patient visit: 1. Patient demographics. 2. Procedures performed by the eligible provider and the diagnosis. 3. Results of tests ordered by the eligible provider. 4. Information about new prescriptions from the eligible provider. 5. Instructions provided to the patient/family/caregiver, including recommendations for self-care support. 6. Consultation prior to nonurgent referrals to other (secondary) providers. 23

24 7.5 Points Scoring 5-6 factors = 100% 4 factors = 75% 3 factors = 50% 1-2 factor = 25% 0 factors = 0% Connected Care 1B: Scoring and Documentation Documentation F1-5: Documented process, and 3 examples of summaries of care from a recent 3-month period F6: Documented process, and 3 referrals showing the primary care provider was consulted Note: Factor 3 = NA if EP does not perform tests Factor 4 = NA if EP does not prescribe medications Factor 6 = Yes if EP does not refer to secondary providers (requires written explanation) All NA responses require a written explanation 24

25 Connected Care 1B Factors 1-5: Documented Process for Providing Information to PCP 25

26 Connected Care 1B Factors 1-5: Summary of Care 26

27 Connected Care 1B Factors 1-5: Summary of Care Summary of Care: Procedures Results PCP Update Follow-Up Scheduled with PCP 27

28 Connected Care 1B Factors 1-5: Clinical Summary 28

29 Connected Care 1B Factors 1-5: Summary of Care Need to provide: 3 De-identified examples of real clinical summaries of care. Cannot provide the form alone.

30 Connected Care 1C: Demonstrating Information Sharing The eligible provider demonstrates that it provides the following information to the primary care clinician: 1. A summary-of-care record for more than 50 percent of visits, within one business day of the patient visit. 2. More than 50 percent of test results that are not available before the patient leaves the provider s office, within one business day of receipt of the test results. 30

31 MUST-PASS 4.5 Points Scoring Connected Care 1C: Scoring and Documentation All sites meet both factors = 100% Some sites meet only one factor = 50% No sites meet either factor = 0% Documentation F1-2: Eligible providers must complete an Application Worksheet that includes: Dates used in the calculation (a recent 3-month period) Numerator, denominator and rate for each provider site If an eligible provider does not order tests, it may respond Yes to factor 2 and must provide a written explanation. 31

32 Connected Care 1C Summary of Care Records Provided to PCP within 1 Business Day Dr. Smith Dr. Woods Dr. Brady Dr. Coughlin Dr. Lee Data represents a recent 3-month period 32

33 Connected Care 1C Multi-Site Example Data represents a recent 3-month period Site A Site B Site C Site D Site E Site F Site G Site H Sites E and H can no longer be listed on the eligible provider s recognition because they did not meet either factor of the must-pass element 33

34 Connected Care 1D: Working With Primary Care The eligible provider demonstrates that it collaborates with primary care practices in the community. 34

35 4.5 Points Scoring Connected Care 1D: Scoring and Documentation The eligible provider meets = 100% The eligible provider does not meet = 0% Documentation Materials describing how the eligible provider collaborates with primary care practices in the community. 35

36 Connected Care 1D: Working with Primary Care Agreement with PCP Eligible Provider name(s) Date Policy Purpose Procedure includes referral method, criteria, steps, staff responsible Reporting to PCP process 36

37 Connected Care 1E: Coordination With Primary Care For patients receiving wellness or chronic care support, the eligible provider implements a documented process for: 1. Sharing clinical information with the primary care clinician. 2. Transitioning patients back to the primary care clinician. 37

38 4.5 Points Scoring Connected Care 1E: Scoring and Documentation 2 factors = 100% 1 factor = 50% 0 factors = 0% Documentation F1-2: Documented process If an eligible provider marks NA for both factors, the points from 1E will be re-distributed across the remaining elements in Standard 1. 38

39 Connected Care 1E Factor 2: Documented Process Transition Transition of Care Assessment of patient selfcare skills Clinical summary Patient self-assessment of concerns Recommended approach Educational fact sheets Information form for transitioning patient 39

40 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 40

41 Connected Care 2: Identifying Patient Needs All materials 2016, National Committee for Quality Assurance

42 Connected Care 2: Identifying Patient Needs Intent of Standard The eligible provider gives patients/families/caregivers information about its services, assesses the patients care needs and determines the appropriate site of care. 42

43 Connected Care 2: Identifying Patient 15 Points Elements PCCC 2A: Informing Patients About Services Offered MUST-PASS PCCC 2B: Triaging Patients Needs PCCC 2C: Connecting Patients With Other Providers 43

44 Connected Care 2A: Informing Patients About Services Offered The eligible provider has a documented process for providing the following information to patients/families/caregivers: 1. Its scope of services and its process for responding to patients whose care needs fall outside its scope of services. 2. Methods, nature and frequency of communication with patients. 3. How care is coordinated with the primary care clinician. 4. Estimation of costs or fee structure for common services. 44

45 MUST-PASS 4.5 Points Scoring Connected Care 2A: Scoring and Documentation 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-4: Documented process, and materials given to patient s about the eligible provider s services 45

46 Connected Care 2A Factor 1: Brochure Listing Services, p. 1 46

47 Connected Care 2A Factor 1: Brochure Listing Services, p. 2 47

48 Connected Care 2A Factor 1: Website Listing Services 48

49 Connected Care 2A: Example Brochure, p. 1 49

50 Connected Care 2A: Patient Brochure, p. 2 50

51 Connected Care 2A Factor 2: Documented Process Communication with Patient 51

52 Connected Care 2B: Triaging Patients The eligible provider has a documented process that it implements to: 1. Conduct patient assessments to determine care needs. 2. Determine if a patient s primary care clinician needs to be contacted during treatment. 3. Identify patients needing services not provided by the eligible provider. 4. Redirect patients to a more appropriate care setting if necessary. 5. Help patients determine if services provided by the eligible provider, and if applicable, the services of the provider they are referred to, are covered by insurance. 52

53 6 Points Scoring Connected Care 2B: Scoring and Documentation 4-5 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-5: Documented process, and at least 3 examples 53

54 Connected Care 2B Example Note: This is just an example of a form. Documentation requires 3 deidentified examples. Referral Form Includes: Date Referring site Degree of urgency Patient contact Test results sent to specialist Prescriptions Notes 54

55 Connected Care 2C: Connecting Patients With Other Providers The eligible provider includes the following information in referrals sent to other (secondary) providers: 1. Patient demographics. 2. Procedures performed by the eligible provider and the diagnosis. 3. Results of tests ordered by the eligible provider. 4. Information about new prescriptions from the eligible provider. 5. Instructions provided to the patient/family/caregiver, including recommendations for self-care support. 55

56 4.5 Points Scoring Connected Care 2C: Scoring and Documentation 5 factors = 100% 4 factors = 75% 3 factors = 50% 1-2 factor = 25% 0 factors = 0% Documentation Note: F1-5: Documented process, and at least 3 examples from a recent 3-month period Factor 3 = NA if EP does not perform tests Factor 4 = NA if EP does not prescribe medications If an eligible provider does not secondary providers, it should describe its process for alerting the patient s primary car provider of the need for a secondary referral. 56

57 Connected Care 2C Factors 2 & 3: Example of Referral Form Need 3 de-identified patient examples 57

58 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 58

59 Connected Care 3: Patient Care and Support All materials 2016, National Committee for Quality Assurance

60 Connected Care 3: Patient Care and Support Intent of Standard The eligible provider delivers patient-centered episodic care. 60

61 Connected Care 3: Patient Care and Support 25 Points Elements PCCC 3A: Implement Evidence-Based Decision Support MUST-PASS PCCC 3B: Medication Management PCCC 3C: Test Tracking and Follow-Up PCCC 3D: Collaborating With the Patient PCCC 3E: Culturally and Linguistically Appropriate Services (CLAS) 61

62 Connected Care 3A: Implement Evidence- Based Decision Support The eligible provider implements five clinical decision-support interventions (e.g., point-of-care reminders) following evidence-based guidelines for conditions appropriate to the services it provides. 62

63 MUST-PASS 5 Points Scoring Connected Care 3A: Scoring and Documentation 5 interventions = 100% 4 interventions = 75% 3 interventions = 50% 1-2 interventions = 25% 0 interventions = 0% Documentation For each clinical decision support intervention, NCQA reviews: Topic of the implemented, evidence-based intervention Source of the guideline At least one example of the guideline implementation 63

64 Connected Care 3A: Example of Decision Support Need 3 Interventions to Pass Must-Pass Element 3A 64

65 Connected Care 3A: Example of Implemented Guidelines Pediatric Obesity Guidelines Treatment Template when Obesity is selected. Each selection brings up tools. 65

66 Connected Care 3A: Clinical Decision Support 66

67 Connected Care 3B: Medication Management The eligible provider has a process for managing medications it prescribes, and demonstrates that it follows its documented process in the following ways: 1. Reviews and documents all medications for more than 80 percent of patients. (CRITICAL FACTOR) 2. Provides information about new prescriptions from the eligible provider to patients/families/caregivers. 3. Assesses patient/family/caregiver understanding of medications prescribed by the eligible provider. 4. Assesses potential barriers to adherence. 5. Assesses response to medications when appropriate. 6. Documents over-the-counter medications, herbal therapies and supplements. 7. Reviews controlled substance database when prescribing relevant medications. 67

68 Connected Care 3B: Scoring and Documentation 5 Points Scoring 5-7 factors (including factor 1) = 100% 4 factors (including factor 1) = 75% 3 factors (including factor 1) = 50% 1-2 factor = 25% 0 factors = 0% Documentation F1-7: Documented process and F1: Reports (aggregate) F2-7: At least 3 examples for each factor Note: Factors 2-5 and 7 are NA if the EP does not prescribe medications. A written explanation is required. 68

69 Connected Care 3B: Example Medication Management Process

70 Connected Care 3B: Components of Medication Management EP Reviews & documents medications for patient safety and effectiveness of medications EP Reviews and reconciles medications at each visit Reviews current medications; discusses patient concerns Motivational interviewing/shared decision-making to help with risks/benefits of medications Staff explain about medication administration Follow-up call to patient when major change to medications Documents over-the-counter medications Check and review if refill requests are conflicting 70

71 Connected Care 3B Factor 1: Medication Management Medication Reconciliation Performed 99% 71

72 Connected Care 3B Factor 2: Information Provided About New Prescriptions Print out provided with information on new prescriptions. 72

73 Connected Care 3B Factor 4: Assess Barriers to Taking Medication 3 Patient Examples Needed 73

74 Connected Care 3B Factor 4: Assess Barriers to Taking Medication 3 Patient Examples Needed 74

75 Connected Care 3B Factor 6: Recording Over the Counter Medications 3 Patient Examples Needed 75

76 Connected Care 3B Factor 7: Reviews Controlled Substance Abuse Database 76

77 Connected Care 3C: Test Tracking and Follow-Up The eligible provider has a documented process for and demonstrates that it: 1. Tracks diagnostic tests until results are available, flagging and following up on overdue results. 2. Flags abnormal diagnostic test results, bringing them to the attention of the clinician. 3. Notifies patients/families/caregivers about normal and abnormal diagnostic test results. 4. Provides more than 50 percent of test results that were not available until after the visit to the patient/family/caregiver within one business day of receiving them. 77

78 Connected Care 3C: Scoring and Documentation 5 Points Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-3: Documented process, and report or log with 5 days of data or 3 examples F4: Report (aggregate) If an EP marks NA for all factors (because it does not order tests), the points from 3C will be re-distributed across the remaining elements in Standard 3. 78

79 Connected Care 3C Factors 1-3: Example of Documented Lab Process Missing Flagging Overdue labs and Follow-Up Also a 5 Day Report/Log or 3 examples 79

80 Connected Care 3C Factor 2: Flagging Abnormal Results Flagging in Red Abnormal Results 80

81 Connected Care 3C Factor 2: Policy for Abnormal Test Results

82 Connected Care 3C Factors 1-3: Example Electronic Test Tracking All lab and imaging tests are tracked until results are available Overdue results are flagged Abnormal results are flagged

83 Connected Care 3C Factor 2 & 3: Example Tracking Normal vs. Abnormal

84 Connected Care 3C Factors 2 & 3: Example Test Tracking Log DATA COLLECTED Patient name DOB Provider Order date Test ordered Urgency Date results received Results normal/abnormal Date results to provider Date results to patient

85 Connected Care 3C Factor 3: Letter of Notification of Abnormal Results Need 3 Examples Patient/family was notified by provider of abnormal test results and given follow-up instructions 85

86 Connected Care 3D: Collaborating With the Patient The eligible provider has a documented process for and demonstrates that it: 1. Collaborates with the patient/family/caregiver to make treatment decisions. 2. Collaborates with the patient/family/caregiver to develop instructions that include patient goals, potential barriers and selfcare abilities. 3. Provides the patient/family/caregiver written instructions, including recommendations for self-care. 4. Provides educational resources or refers patients/families/caregivers to resources for help in patient self-management. 86

87 Connected Care 3D: Scoring and Documentation 5 Points Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-4: Documented process, and at least 3 examples 87

88 Connected Care 3D: ABIM Foundation Choosing Wisely To Prompt Clinician/Patient Discussions Specialty Societies Each lists five things physicians and patients should question Physician information

89 Connected Care 3D Factor 2: Documented Process for Collaborating with Patient 89

90 Connected Care 3D Factor 3: Providing Patient with Instructions/Self-Care 90

91 Connected Care 3D Factor 4: Documented Process for Providing Educational Materials 91

92 Connected Care 3D Factor 4: Example Patient Education Prenatal Care: Steps Toward a Healthy Pregnancy Prenatal Session #1 PROGRAM: Comprehensive Perinatal Services Program TIME: 1-1 ½ Hours OBJECTIVES By the end of the session, the participant will be able to: 1. Identify basic anatomy of human reproductive system 2. Identify common discomforts of pregnancy including aspects of fetal growth and development 3. Identify danger signs during pregnancy and action to take during complications 4. Identify lab tests including the importance of ultrasound 5. Understand the importance of Oral health during pregnancy Must also attach a complete set of education materials that would be provided to the patient. 92

93 Connected Care 3E: Culturally and Linguistically Appropriate Services (CLAS) The eligible provider engages in activities to understand and meet the cultural and linguistic needs of its community it serves by: 1. Assessing the diversity. 2. Assessing the language needs. 3. Providing interpretation or bilingual services to meet language needs. 4. Providing printed materials to meet language needs. 93

94 5 Points Scoring Connected Care 3E: Scoring and Documentation 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-2: Report of the assessment of racial, ethnic and language compositions of the community the eligible provider serves F3: Documentation of the availability of interpretative services F4: Patient materials in languages other than English (NA if no language is spoken by 5 percent ore more of the patient population) 94

95 Connected Care 3E: Federal Office of Civil Rights Policy Re: Family Interpreters It is advised that qualified medical interpreters be utilized who are not family members or friends of the patient. The Office for Civil Rights Policy Guidance states that any hospital or clinic that receives federal funds may expose itself to liability under the Title VI if it requires, suggests, or encourages a limited-english-proficiency (LEP) person to use friends, minor children or family members as interpreters. This is because family members, friends or children may: provide inadequate service, or their services may result in breach of confidentiality, have no training in medical terminology, not interpret or translate accurately, produce family stress especially when using younger family members, no longer be fluent in their native language, be reluctant to be involved in invasive procedures and during injections, not have the skills necessary to offer cultural recommendations and explanations to XXX staff and physicians. More Information: 95

96 Connected Care 3E Factors 1 & 2: Ethnicity, Language, Race Jan Jan 2015

97 Connected Care 3E Factor 2: Example Language Report 11/1/14 through 4/30/15

98 Connected Care 3E Factor 2: Assessing the Language Needs Patient Distribution by Language # of Patients & % of Patients English % Spanish % Russian % Other % All other % Blank field % Total 2763 This is based on unique pts seen between 1/1/15-6/1/15. This sampling indicates that most of our patients speak English. We utilize staff that speak Spanish and also have available language line for any other languages that might be needed 98

99 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 99

100 Connected Care 4: System Capabilities All materials 2016, National Committee for Quality Assurance

101 Connected Care 4: System Capabilities Intent of Standard The eligible provider uses electronic systems to collect and record patient information and clinical data in structured fields, usable for quality and performance improvement. 101

102 Connected Care 4: System Capabilities 10 Points Elements PCCC 4A: Patient Information PCCC 4B: Clinical Data PCCC 4C: Use of Electronic Prescribing 102

103 Connected Care 4A: Patient Information The eligible provider uses an electronic system to record the following information as structured (searchable) data, for more than 80 percent of its patients: 1. Date of birth. 2. Sex. 3. Race. 4. Ethnicity. 5. Preferred language. 6. Telephone numbers. 7. addresses. 8. Primary caregiver. 9. Health insurance information. 10.Name and contact information of primary care clinician. 103

104 3.5 Points Scoring Connected Care 4A: Scoring and Documentation 7-10 factors = 100% 5-6 factors = 75% 4 factors = 50% 3-2 factor = 25% 0-1 factors = 0% Documentation F1-10: Reports (aggregate) from electronic system with data element, dates, numerator, denominator and rate 104

105 Connected Care 4A Factors 1-9: Example Patient Information PCSP 3, Element A, Items Percentage of patients with documented items recorded as structured (searchable) data within the practice's EMR. The report is 12 months of data from May Feb. 4, 2014-Feb 2011 to May , 2012 General Internal Medicine Associates Total Patient Count Dates of Previous Visits Factor 10 Missing: Name and Contact Info of PCP Ethni Phone Legal Primary Insur DOB Gender Race city Lang # Guardian Caregiver Adv Dir Info # of PTS NA NA NA 9541 % 100% 100% 100% 95% 95% 100% 98% 35% 100% NA NA NA 96% Correct Responses Yes Yes Yes Yes Yes Yes No Yes No No No Yes

106 Connected Care 4A: Example Patient Information Extract Dt: This certified system produced another graphic presentation for a 3 month reporting period Jan. 3, March 3,

107 Connected Care 4A: Report Includes Factor

108 Connected Care 4B: Clinical Data The eligible provider uses an electronic system to record the following as structured (searchable) data: 1. A current problem list with active diagnoses for more than 80 percent of patients. 2. Allergies, including medication allergies and adverse reactions, for more than 80 percent of patients. 3. Blood pressure, with collection date, for more than 80 percent of patients 3 years of age and older. 4. Status of tobacco use for patients 13 years of age and older for more than 80 percent of patients. 5. List of prescription medications for more than 80 percent of patients. 6. Enter at least one electronic progress note, created, edited and signed by a clinician for more than 30 percent of patients with at least one office visit. 108

109 4 Points Scoring Connected Care 4B: Scoring and Documentation 5-6 factors = 100% 4 factors = 75% 3 factors = 50% 1-2 factor = 25% 0 factors = 0% Documentation F1-6: Reports (aggregate) from electronic system with data element, dates, numerator, denominator and rate 109

110 Connected Care 4B Factors 1,3,5: Clinical Data 110

111 Connected Care 4C: Use of Electronic Prescribing The eligible provider uses an electronic prescription system and does the following: 1. Writes at least 75 percent of eligible prescriptions electronically. 2. For more than 50 percent of eligible prescriptions it writes, compares them to drug formularies and electronically sends them to pharmacies. 3. Enters electronic medication orders in the medical record for more than 60 percent of medications. 4. Performs patient-specific checks for drug-drug and drug-allergy interactions. 5. Alerts prescribers to generic alternatives for prescriptions ordered. 111

112 2.5 Points Scoring Connected Care 4C: Scoring and Documentation 3-5 factors = 100% 2 factors = 75% 1 factors = 50% 0 factors = 0% Documentation F1-3: Reports (aggregate) from electronic system including dates, numerator, denominator and rate F4-5: Reports or screenshots demonstrating system capabilities If an EP marks NA for all factors (because it does not prescribe medications), the points from 4C will be re-distributed across the remaining elements in Standard

113 Connected Care 4C 1,3,4: E-Prescribing and Entry into Medical Record Factor 1 E-prescribing: 4571/4573 = 100% Factor 3 Enter electronic med. orders into medical record: 6905/7066 = 98% Factor 4 Drug-drug and drug allergy interaction = attestation yes

114 Connected Care 4C Factor 1: Report Electronic Prescription Writing 114

115 Connected Care 4C Factor 1: Example Electronic Prescription Writing Prescription Writing Activity Electronic 57% 2563 Rx Printed, given to patient 31% 1419 Rx Print, fax to pharmacy 1% 89 Rx TOTAL Rx 4474 Rx

116 Connected Care 4C Factor 2: Example Formulary Drug Alternative

117 Connected Care 4C Factor 3: Example Percent of Use for Electronic Prescriptions Evaluation: We put all prescriptions in our EMR which is linked to patient -specific demographic and clinical data Note the screen shot that denotes the number of scripts for our physicians in the last three months, 2046 and the report which notes the number of patients seen during that same time period, 2482 We propose that this represents a percentage between 75% and 100%, understanding that one prescription does not mean one patient 2046 prescriptions = numerator Another report showed summary of 2482 patients = denominator Determined percentage = 82% 117

118 Connected Care 4C Factor 4: Example Drug-Drug Interactions Drug-Drug Interactions

119 Connected Care 4C Factor 4: Example Prescription Allergy 119

120 Connected Care 4C Factor 5: Example Generic Alternatives 120

121 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 121

122 Connected Care 5: Measure and Improve Performance All materials 2016, National Committee for Quality Assurance

123 Connected Care 5: Measure and Improve Performance Intent of Standard The eligible provider uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. 123

124 Connected Care 5: Measure and Improve Performance 20 Points Elements PCCC 5A: Measure Clinical Quality Performance PCCC 5B: Measure Resource Use and Care Coordination PCCC 5C: Measure Patient/Family Experience PCCC 5D: Set Goals and Analyze Results PCCC 5E: Take Action to Improve MUST-PASS PCCC 5F: Reduce Disparities PCCC 5G: Demonstrate Continuous Quality Improvement PCCC 5H: Report Performance 124

125 Connected Care 5A: Measure Clinical Quality Performance At least annually, the eligible provider measures or receives data on at least three clinical measures appropriate to its scope of services. 125

126 4 Points Scoring Connected Care 5A: Scoring and Documentation EP reports or receives data on at least 3 measures = 100% EP does not report or receive data on at least 3 measures = 0% Documentation Reports including dates, numerator, denominator and rates If the eligible provider has two or more sites, reports should include: Aggregate rate across all sites Rate for each provider site 126

127 Connected Care 5A: Example Clinical Measures 127

128 Connected Care 5A: Example Clinical Measures

129 Connected Care 5B: Measure Resource Use and Care Coordination At least annually, the eligible provider measures or receives quantitative data on: 1. At least one measure related to care coordination. 2. At least one utilization measure affecting health care costs. 129

130 2 Points Scoring Connected Care 5B: Scoring and Documentation 2 factors = 100% 1 factors = 50% 0 factors = 0% Documentation F1-2: Reports including dates, numerator, denominator and rates If the eligible provider has two or more sites, reports should include: Aggregate rate across all sites Rate for each provider site 130

131 Connected Care 5B Factor 2: Measures Affecting Health Care Costs 131

132 Connected Care 5C: Measure Patient/Family Experience At least annually, the eligible provider obtains feedback from patients/families on their experiences with the eligible provider and their care: 1. The eligible provider conducts a survey to evaluate patient/family experiences on at least three of the following categories: Access. Communication. Coordination. Self-management support. 2. The eligible provider obtains feedback on experiences of vulnerable patient groups. 3. The eligible provider obtains feedback from patients/families through qualitative means. 132

133 2 Points Scoring Connected Care 5C: Scoring and Documentation 3 factors = 100% 2 factors = 75% 1 factors = 50% 0 factors = 0% Documentation F1-3: Reports including dates and survey results If the eligible provider has two or more sites, reports should include: Aggregate rate across all sites Rate for each provider site 133

134 Connected Care 5C: Patient Experience Survey Report 134

135 Connected Care 5C: Patient Experience Survey Example of a Survey. A Report is Needed to Meet Factor 1 135

136 Connected Care 5C Factor 2: Obtains Feedback from Vulnerable Population Results Shown for Vulnerable Population 136

137 Connected Care 5C Factor 1: Access, Communication, Self-Management Support Jan 2015 March

138 Connected Care 5C Factor 1: Example Patient Experience Survey Results Survey questions include: Access Communication NEEDS A THIRD CATEGORY 138

139 Connected Care 5D: Set Goals and Analyze Results The eligible provider uses an ongoing quality improvement process to set goals and analyze: 1. At least one clinical quality measure from Element A. 2. At least one measure from Element B. 3. At least one patient experience measure from Element C. 139

140 Connected Care 5D: Scoring and Documentation 2 Points Scoring 3 factors = 100% 2 factors = 75% 1 factors = 50% 0 factors = 0% Documentation F1-3: Reports or completion of the Quality Measurement and Improvement Worksheet 140

141 Connected Care 5E: Take Action to Improve The eligible provider acts to improve results on: 1. At least one clinical quality measure from Element A. 2. At least one measure from Element B. 3. At least one patient experience measure from Element C. 141

142 MUST-PASS 3 Points Scoring Connected Care 5E: Scoring and Documentation 3 factors = 100% 2 factors = 50% 1 factors = 25% 0 factors = 0% Documentation F1-3: Initial survey: Submit plan for taking action within 12 months Renewal survey: Reports, or completion of the Quality Measurement and Improvement Worksheet 142

143 Connected Care 5F: Reduce Disparities The eligible provider sets goals for addressing at least one identified disparity in care/service for identified vulnerable populations. 143

144 Connected Care 5F: Scoring and Documentation 2 Points Scoring EP sets goals to address at least 1 disparity= 100% EP does not set goals to address at least 1 disparity= 0% Documentation Reports or completion of the Quality Measurement and Improvement Worksheet 144

145 Vulnerable Populations Defined Those who are made vulnerable by: their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability. Source: AHRQ 145

146 Connected Care 5D, E, F: Quality Measurement and Improvement Instructions 146

147 Connected Care 5D, E, F: Quality Measurement and Improvement, cont. 147

148 Connected Care 5G: Demonstrate Continuous Quality Improvement The eligible provider demonstrates continuous quality improvement by: 1. Measuring the effectiveness of the actions it takes to improve results of the measures selected in Elements D F. 2. Improving performance on at least one clinical quality measure. 3. Improving performance on at least one utilization or care coordination measure. 4. Improving performance on at least one patient experience measure. 148

149 Connected Care 5G: Scoring and Documentation 3 Points Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% Documentation F1-4: Reports If an EP marks NA for all factors (because it is submitting an initial survey), the points from 5G will be re-distributed across the remaining elements in Standard

150 Connected Care 5G Factor 1: Patient Survey Results Over Time

151 Connected Care 5G Factor 1: Example Tracking Data Over Time Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

152 Connected Care 5H: Report Performance The eligible provider produces performance data reports using measure results from Elements A C, and shares site-specific results: 1. With staff. 2. With patients. 3. With the public. 152

153 Connected Care 5H: Scoring and Documentation 2 Points Scoring 3 factors = 100% 2 factors = 75% 1 factors = 50% 0 factors = 0% Documentation F1: Reports showing site-specific performance and explanation of how results are shared F2: Example of report provided to patients and explanation of how results are shared F3: Example of report provided to public and explanation of how results are shared 153

154 Connected Care 5H Factor 2: Example of Results Posted in Waiting Room 154

155 Connected Care 5H Factor 1&2: Example Reporting by Clinician

156 Connected Care 5H Factor 1, 2, 3: Example Reporting Across Sites Shows data for multiple sites 156

157 NCQA Contact Information Visit NCQA Web Site at to: Follow the Start-to-Finish Pathway View Frequently Asked Questions For questions about interpretation of standards or elements to submit a question to (Policy/Program Clarification Support & Recognition Programs) Contact NCQA Customer Support at M-F, 8:30 a.m.-5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access 157