QI ROUNDTABLE. NCQA PCMH 2017 Understanding the New Standards and Re-designed Recognition Process TUESDAY, NOVEMBER 7, 2017 YAKIMA, WA

Transcription

1 QI ROUNDTABLE NCQA PCMH 2017 Understanding the New Standards and Re-designed Recognition Process TUESDAY, NOVEMBER 7, 2017 YAKIMA, WA

2 WELCOME HOUSEKEEPING Please sign in Folders Restrooms Electronic devices Please refrain from using your devices until break periods

3 PRE-SURVEY

4 WACMCH QI Roundtable NCQA PCMH 2017 The New Standards and Recognition Process Trudy Bearden, PA-C Senior Consultant November 7, 2017 Advancing Healthcare Improving Health

5 Change Concepts for Practice Transformation Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient- Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:

6 The Redesigned Recognition Process 9:15 10:30 am 6

7 Leapfrog to 2017 with the Accelerated Recognition Process 2011 level 1, 2, or level 1 or 2 Attest to 18 out of 40 core criteria Attest to 34 out of 60 electives Your recognition must be current in order to use this process PCMH Accelerated Renewal Table 7

8 Annual Reporting Requirements 2014 Level 3 Reporting Period: 4/3/2017 9/30/2018 Attestation PCMH Annual Questionnaire in Q-PASS. Key Data Submission PCMH Annual Reporting Requirements table PCMH Annual Reporting Requirements 8

9 Enroll on Q-PASS and pay fees Initial Accelerated Annual Think you re ready? Take our assessment. NCQA representative helps with evaluation plan and schedule At least three virtual reviews Must submit evidence as outlined in the 2017 S Standards within 1 year of enroll & fees PCMH 2011 any level PCMH 2014 Level 1 or 2 Attest to certain criteria submit evidence for others At least three virtual reviews PCMH 2014 Level 3 30 days before anniversary date complete all Succeed steps Attest to previous performance Provide evidence (at any point within the year) of demonstrating continuing PCMH activities 9

10 2017 High-Level Changes Focus on the medical neighborhood Alignment with MACRA full credit for IA Flexible path to recognition Personalized service Single sign-on No ISS tool User-friendly approach Ownership of PCMH recognition process IA = Improvement Activity (one of the four categories in CMS Quality Payment Program) 10

11 Reduced Documentation Burden From 167 factors in 2014 PCMH to 100 criteria in 2017 PCMH 11

12 New Language Concepts = are the foundation on which a practice builds a medical home Competencies = organize the criteria in each concept area Criteria = the individual structures, functions and activities that indicate a practice is operating as a medical home 12

13 13

14 The Six Concepts Team-Based Care and Practice Organization (TC) Knowing and Managing Your Patients (KM) Patient-Centered Access and Continuity (AC) Care Management and Support (CM) Care Coordination and Care Transitions (CC) Performance Measurement and Quality Improvement (QI) 15

15 Concept Anatomy of a Standard Competency and Description of Performance Expectation Criteria Description Core or Elective Additional information NCQA wants to see Shareable across practice sites Documentation requirements 16

16 High Level Crosswalk PCMH 2017 Concept PCMH 2014 Standard Team-Based Care and Practice Organization (TC) Standard 2 Knowing and Managing Your Patients (KM) Standards 2, 3 and 4 Patient-Centered Access and Continuity (AC) Standard 1 and 2 Care Management and Support (CM) Standard 4 Care Coordination and Care Transitions (CC) Standard 5 Performance Measurement and Quality Improvement (QI) Standard 6 17

17 New Scoring Algorithm 18

18 PCMH 2017 Scoring No levels = No add-on surveys Pass or Fail Reconsideration is still an option Options for distinction Patient Experience Reporting Behavioral Health Integration Electronic Measure Reporting (ecqm) 19

19 PCMH 2017 Credits (Points) Meet all core criteria in the program = 40 credits Earn 25 credits in elective criteria across 5 of 6 concepts There are 60 elective criteria for a total of 83 elective credits available = criteria may be worth 1, 2, or 3 credits Minimum passing score is 65 credits 20

20 The Three C s Concepts Competencies Criteria Extra credit! How many concepts and criteria? How many of each to achieve recognition? 21

21 Evidence = Documentation 22 22

22 New Recognition Process Commit, Transform, Succeed? Transform, Commit, Succeed? 23

23 Commit via Q-PASS 24

24 Transform Register your practice Pay your fees Submit evidence Schedule 3 virtual check-in calls over a 12 month period 25

25 Succeed Annual data submission and attestation Done through Q- PASS and will not require a virtual check-in unless selected for audit Multisite practices submit annual data at same time 26

26 Complete online guided assessment Work with NCQA rep to develop evaluation schedule and to identify support and education for transformation Submit initial, additional and final documentation and checks in with NCQA evaluator Submit documentation and begin evaluation process Earn NCQA recognition Demonstrate continued readiness and high-quality performance thru annual check-ins 27

27 What Hasn t Changed Eligibility criteria 2014 Must Pass Elements are embedded in Core Concepts Record Review Workbook and QMIW Types of documentation (data sources) Multisite requirement Pre-validation credits Foundation of Medical Home Model 28

28 Select a Project Team Develop the multidisciplinary project team: clinician, nursing, admin, IT/analytics, QI Project team characteristics: Champions/leaders to bring about change and lead decision making Organizational and departmental knowledge Detail-oriented Policy knowledge Reporting skills Ability to obtain screen shots 29

29 Core Competencies Requiring Documented Processes TC Comp B and C KM Comp A AC Comp A and B CC Comp A, B, and C QI Comp A and C Processes need to be reviewed against NCQA requirements Processes may need to be edited and reapproved Staff need to be trained on new processes for full implementation 30

30 The Five P s Policy Procedure Purpose Process Protocol 31

31 Prepare Documentation Format the documents to communicate clearly to the NCQA Reviewers Sequence your documents to tell a story Carefully label each document with: Practice Name and Document Name on top of page PCMH standard and competency as footer Annotate with call outs/highlighting/text boxes, etc. to identify sections that meet specific factors Apply page numbers De-identify any PHI 32

32 Where Can I Learn More? Recognition Program - NCQA Q-Pass NCQA seminars-and-webinars/live-seminarswebinars NCQA PCMH Live Events What to Expect During a Virtual Review NCQA PCMH 2017 Getting Started Page 33

33 Best Practices Engage leadership and confirm (and quantify!) leadership support Start with your recognition status: new application vs or 2014 Level 1 or 2 vs Level 3 - this will determine some of your best practices Know your important dates: anniversary date, annual reporting date, date by which P&Ps need to have been implemented, date you paid fees (clock starts ticking if new enrollment!) Sign on to Q-PASS: enroll, pay fees, update information Download the 2017 materials: Standards and Guidelines, etc. 34

34 Best Practices, Continued Muster a team Carve out protected time Sign up for NCQA webinars Consider coaching (Ashley and Hannah?) Develop a project plan using a tool like the Qualis Health Tracking Tool Develop a standard nomenclature for NCQA materials so it's easy to find What else? 35

35 Break 10:30 10:45 am 36

36 The New and Not-So-New Deep Dive 10:15 am 12:00 pm 37

37 Team-Based Care and Practice Organization (TC) 38

38 Team-Based Care and Practice Organization (TC) The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care. 3 Competencies 9 Criteria 39

39 TC Criteria Requiring Documented Processes TC 04 Elective-patient involvement in governance - New TC 06 Core-staff structured communication Aligns with PCMH D3 (huddles) TC 07 Core-staff involvement in QI Aligns with PCMH D9 TC 09 Core-informs patients about the role of the medical home Aligns with PCMH 2B 40

40 Competency A The practice is committed to transforming into a sustainable medical home. Members of the care team serve specific roles as defined by the practice's organizational structure and are equipped with the knowledge and training to perform those functions. 41

41 Competency A Criteria TC 01 (Core) PCMH Transformation Leads TC 02 (Core) Structure and Staff Responsibilities Aligns with PCMH D 1 and 2 TC 03 (1 CREDIT) External PCMH Collaborations TC 04 (2 CREDITS) Patient/Family/Care giver Involvement in Governance TC 05 (2 CREDITS) Certified EHR System Aligns with PCMH G

42 Competency A - TC 01 (Core) Designates PCMH Transformation Leads NEW Identifies the clinician lead and the transformation manager (the person leading the PCMH transformation). This may be the same person. Evidence = details about the clinician lead and the PCMH manager; the practice provides details including the person s name, credentials, roles & responsibilities. 43

43 Competency A -TC 03 (1 Credit) Involvement in External PCMH Collaborations - NEW Demonstrates involvement in at least one state or federal initiative or participates in a health information exchange. Evidence = Description of involvement in external collaborative activity (e.g., CPC+, care management learning collaborative led by the state, two-way data exchange with a local health information exchange; populationbased care or learning collaborative). 47

44 Competency A -TC 04 (2 Credits) Patient/Family/Caregiver Involved in Governance NEW Patients/families/caregivers have a role in the practice s governance structure or Board of Directors. Organizing a patient and family advisory council (i.e., stakeholder committee). Evidence = Documented process and evidence of implementation 48

45 Competency B Communication among staff is organized to ensure patient care is coordinated, safe, and effective. 50

46 Competency B Criteria TC 06 (Core) Individual Patient Care Meetings/Communication Aligns with PCMH D3 TC 07 (Core) Staff Involvement in Quality Improvement Aligns with PCMH D9 TC 08 (2 Credits) Behavioral Health Care Manager - NEW 51

47 Competency B -TC 08 UPDATED! (2 Credits) Identified Behavioral Health Care Manager The practice identifies a behavioral healthcare manager and provides their qualifications. The care manager has the training to support behavioral healthcare needs in the primary care office and coordinates referrals to specialty behavioral health services outside the practice. 59

48 Competency B -TC 08 UPDATED! (2 Credits) Identified Behavioral Health Care Manager The practice demonstrates that it is working to provide meaningful behavioral healthcare services to its patients by employing a care manager who is qualified to address patients behavioral health needs. Evidence = identifying the behavioral healthcare manager and providing their qualifications. 60

49 Competency C The practice communicates and engages patients on expectations and their role in the medical home model of care. 61

50 NCQA Nuggets Evidence reviewed during virtual check-ins does not have to be uploaded to Q-PASS The Annual Reporting (AR) requirements have been updated for this year Version 2 of the 2017 standards published Oct 2,

51 TC Weak Links From 2011 to 2017 Core Criteria How are you structured to provide regular training to the care team on PCMH topics? Describe your structured care team communication processes (huddle, , direct messaging through EHR, other?) How are care team members involved in QI? How are patients/caregivers informed of the role of the medical home? 67

52 Knowing and Managing your Patients (KM) Competency A The practice routinely collects comprehensive data on patients to understand background and health risks of patients. The practice uses information on the population to implement needed interventions, tools, and supports for the practice as a whole and for specific individuals. 68

53 Knowing and Managing Your patients (KM) The practice captures and analyzes information about the patients and community it serves and uses the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services. 6 Competencies 28 Criteria 69

54 KM Criteria Requiring Documented Processes KM 02 Core a documented process for collecting health assessment data KM 03 Elective a documented process for depression screening KM 04 Elective a process for behavioral health screenings KM 05 Elective a process for oral health assessment and referral for care KM 25 Elective a process for maintaining partnerships with social service organizations or schools KM 28 Elective a process for holding case conferences 70

55 Competency A Core Criteria KM 01 Problem Lists (Core) KM 02 Comprehensive Health Assessment (Core) KM 03 Depression Screening (Core) Aligns with PCMH B and 3C 71

56 Competency A Five Elective Criteria All New KM 04 Behavioral Health Screenings (1 Credit) KM 05 Oral Health Assessment and Services (1 Credit) KM 06 Predominant Conditions and Concerns (1 Credit) KM 07 Social Determinants of Health (2 Credits) KM 08 Patient Materials (1 Credit) 72

57 Competency A - KM 02 (Core) Comprehensive Health Assessment - NEW A comprehensive patient assessment includes an examination of the patient s social and behavioral influences in addition to a physical health assessment. The practice uses evidence-based guidelines to determine how frequently the health assessments are completed and updated. 74

58 Competency A - KM 02 (Core) Comprehensive Health Assessment - NEW A. Medical history of patient and family. B. Mental health/substance use history of patient and family. C. Family/social/cultural characteristics. D. Communication needs. E. Behaviors affecting health. F. Social functioning. (NEW) G. Social determinants of health. (NEW) e.gov/ H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age.) I. Advance care planning. (NA for pediatric practices.) 75

59 Competency A - KM 02 (Core) Comprehensive Health Assessment - NEW All items required Evidence = Documented process AND evidence of implementation 76

60 Competency A Five Elective Criteria All New KM 04 Behavioral Health Screenings (1 Credit) KM 05 Oral Health Assessment and Services (1 Credit) KM 06 Predominant Conditions and Concerns (1 Credit) KM 07 Social Determinants of Health (2 Credits) KM 08 Patient Materials (1 Credit) 79

61 Competency A - KM 04 (1 Credit) Conducts Behavioral Health Screenings Using a Standardized Tool - NEW Implement two or more: A. Anxiety. B. Alcohol use disorder. C. Substance use disorder. D. Pediatric behavioral health screening. E. Post-traumatic stress disorder. F. Attention deficit/hyperactivity disorder. G. Postpartum depression. Evidence = Documented process AND evidence of implementation 80

62 KM 04 Resources Links to Screening Tools CAGE AID DAST-10 AAP Mental Health Tools for Primary Care 81

63 Competency A - KM 05 (1 Credit) Assess Oral Health & Provide Necessary Services - NEW Conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer. Evidence = Documented process and evidence of implementation. 82

64 Competency A - KM 06 (1 Credit) Identifies Predominant Conditions and Health Concerns of Patient Populations The practice identifies its patients most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists. Evidence = List of top priority conditions and concerns 83

65 Competency A - KM 07 (2 Credits) Understands Social Determinants of Health Within the Population - NEW Collects information on social determinants of health, demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources, or other tools to serve the on-going needs of its population. Evidence = Report and evidence of implementation 84

66 Competency A - KM 08 (1 Credit) Evaluates Patient Population Communication Preferences - NEW Demonstrates an understanding of the patients communication needs by utilizing materials and media that are easy for their patient population to understand and use. Considers patient demographics such as age, language needs, ethnicity, and education when creating materials for its population. 85

67 Competency A - KM 08 (1 Credit) Evaluates Patient Population Communication Preferences - NEW Considers how its patients like to receive information (i.e., paper brochure, phone app, text message, ), in addition to the readability of materials (e.g., general literacy and health literacy). Evidence = Report and evidence of implementation 86

68 Competency B Meets the needs of a diverse patient population by understanding the population s unique characteristics and language needs. The practice uses this information to ensure linguistic and other patient needs are met. 87

69 Competency B Criteria KM 09 (Core) Assess the Diversity of the Population Aligns with PCMH C KM 10 (Core) Assess the Language Needs of the Population Aligns with PCMH C KM 11 (1 Credit) Identifies Population-level Needs based on Diversity of the Practice and Community 88

70 Competency B - KM 11 (1 Credit) Addresses Population-Level Needs Based on Diversity NEW Recognizes the varied needs of its population and the community it serves, and uses that information to take proactive, health literate, culturally competent approaches to address those needs. 91

71 Competency B - KM 11 (1 Credit) Addresses Population-Level Needs Based on Diversity NEW The practice considers at least two: A. Disparities in care B. Health literacy of the organization C. Cultural competency of the organization Evidence for A, B, and C = A. Evidence of implementation or QI 5 and QI 13 (assess disparities and act to improve) B. Evidence of Implementation C. Evidence of implementation 92

72 Competency B - KM 11 (1 Credit) Resources IOM Ten Attributes of Health Literate Organizations AHRQ Health Literacy Toolkit.pdf Alliance for Health Reform Toolkit 93

73 Competency C The practice proactively addresses the care needs of the patient population to ensure needs are met. 2 Criteria: KM 12 (Core) Proactive Reminders Aligns with PCMH D KM 13 (2 Credits) Excellence in Performance 94

74 Competency C - KM 13 (2 Credits) Demonstrates Excellence in a Benchmarked/Performance-based Recognition Program - NEW At least 75% of eligible clinicians have earned NCQA HSRP or DRP recognition - OR- The practice demonstrates participation in a benchmarked program and demonstrates (through reports) that clinical performance is above national or regional averages. 98

75 Competency C - KM 13 (2 Credits) Demonstrates Excellence in a Benchmarked/Performance-based Recognition Program - NEW Evidence = Report or at least 75% of eligible clinicians have earned NCQA HSRP or DRP recognition 99

76 Competency D The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation, and assessment of barriers. 100

77 Competency D Criteria KM 14 (Core) Medication Reconciliation KM 15 (Core) Medication Lists KM 16 (1 Credit) New Prescription Education KM 17 (1 Credit) Medication Responses and Barriers KM 18 (1 Credit) Controlled Substance Database Review KM 19 (2 Credits) Prescription Claims Data 101

78 Competency D - KM 18 (1 Credit) Reviews Controlled Substance Database - NEW Consults a state controlled-substance database - also known as a Prescription Drug Monitoring Program (PDMP) or Prescription Monitoring Program (PMP) - before dispensing Schedule II, III, IV, and V controlled substances. Evidence = Evidence of implementation 104

79 Competency D - KM 19 (2 Credits) Obtains Prescription Claims Data to Assess Adherence - NEW Systematically obtains prescription claims data or other medication transaction history. This may include systems such as SureScripts e- prescribing network, regional health information exchanges, insurers, or prescription benefit management companies. Evidence = Evidence of implementation 105

80 Competency E 106

81 Competency F Identifies, considers and establishes connections to community resources to collaborate and direct patients to needed support. 109

82 Competency F Criteria KM 21 Community Resource Needs (Core). Aligns with PCMH E KM 22 Access to Educational Resources (1 Credit). Aligns with PCMH E KM 23 Oral Health Education (1 Credit) KM 24 Shared Decision-Making Aids (1 Credit). Aligns with PCMH E 110

83 Competency F Criteria KM 25 School/Intervention Agency Engagement (1 Credit) KM 26 Community Resource List (1 Credit). Aligns with PCMH E KM 27 Community Resource Assessment (1 Credit). Aligns with PCMH E KM 28 Case Conferences (2 Credits) 111

84 Competency F - KM 21 (Core) Uses Information to Prioritize Needed Community Resources - NEW Identifies needed resources by assessing collected population information. Assesses social determinants, predominant conditions, emergency department usage, and other health concerns to prioritize community resources. Evidence = List of key patient needs and concerns 112

85 Competency F - KM 23 (1 Credit) Provides Oral Health Education and Resources to Patients - NEW The practice provides an example of how it provides patients with educational and other resources that pertain to oral health and hygiene. Evidence = Evidence of implementation, one example 114

86 Competency F - KM 25 (1 Credit) Engages with Schools or Intervention Agencies in the Community - NEW Develops supportive partnerships with social services organizations or schools in the community. The practice demonstrates this through formal or informal agreements or identifies practice activities in which community entities are engaged to support better health. Evidence = Documented process AND evidence of implementation 119

87 Competency F - KM 28 (1 Credit) Case Conferences Involving Parties Outside the Practice Team - NEW Uses case conferences to share information and discuss care plans for high-risk patients with clinicians and others outside its usual care team. Case conferences are planned, multidisciplinary meetings with community organizations, or specialists to plan treatment for complex patients. Evidence = Documented process AND evidence of implementation 122

88 Lunch 12:00 12:30 pm Time for Lunch! 123

89 The Remaining Concepts 12:30 2:00 pm 124

90 The Numbers Game

91 The Numbers Game 100 total criteria 40 core criteria (must meet) 25 elective credits (choose) 65 total required (core + elective credits) 83 total elective credits 126

92 Patient- Centered Access and Continuity (AC) 127

93 Access to Care Concept Patients/families caregivers have 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team. The PCMH model expects continuity. The practice considers the needs and preferences of the patient population when establishing and updating standards for access - New 2 Competencies 14 Criteria 128

94 AC Criteria Requiring Documented Processes = 11 AC01-05 Core patient-centered access survey, same day appointments during and after business hours, timely telephone access during and after business hours AC 10 Core patient and family selection of personal provider AC 06 Elective - process for urgent and routine telephonic or other technology supported mechanism AC 08 Elective - process for two-way electronic secure communication for clinical advice AC 12 Elective - process for providing continuity of medical record information when the office is closed AC 13 Elective -process for review and active panel management - New AC 14 Elective reviews and reconciles panels based on health plan or outside assignment - New 129

95 Competency A COMPETENCY A The practice seeks to enhance access by providing appointments and clinical advice based on patients needs. 130

96 Competency A Core Criteria AC 01 Access Needs and Preferences AC 02 Same-Day Appointments AC 03 Appointments Outside Business Hours AC 04 Timely Clinical Advice by Telephone AC 05 Clinical Advice Documentation Criteria align with PCMH A and 1B 131

97 Competency A Elective Criteria 1 Credit Each AC 06 Alternative Appointments AC 07 Electronic Patient Requests AC 08 Two-Way Electronic Communication AC 09 Equity of Access Criteria align with PCMH A and1c 132

98 Competency A - AC 01 (Core) Assess Access Needs & Preferences of the Patient Population - NEW Evaluates patient access data (i.e., survey, patient interviews, comment box) to determine if existing access methods are sufficient for its population. Alternative methods for access may include evening/weekend hours, types of appointments or telephone advice. Evidence = Documented process AND evidence of implementation 133

99 AC 01 (Core) survey data may be used for AC 02 (Core) evidence in lieu of a report 134

100 Competency A - AC 09 (1 Credit) Assess Equity of Access that Considers Health Disparities Across the Population - NEW Evaluates whether identified health disparities demonstrate differences in access to care. Evidence = Evidence of implementation Example: A report of how an identified group has lower rates of access to same day appointments, higher no-show rates, higher ED use, or lower satisfaction with access than the general population. 147

101 Competency B Practices support continuity through empanelment and systematic access to the patient s medical record. 148

102 Competency B Criteria AC 10 Personal Clinician Selection (Core) AC 11 Patient Visits with Clinician/Team (Core) AC 12 Continuity of Medical Record Information (2 Credits) AC 13 Panel Size Review and Management (1 Credit) AC 14 External Panel Review and Reconciliation (1 Credit) 149

103 Competency B - AC 13 (1 Credit) Reviews and Actively Manages Panels - NEW The practice has a process to review the number of patients assigned to each clinician and balance the size of each providers patient panel. The American College of Family Physicians provides a tool for practices to use when considering and managing panel sizes: Evidence = Documented process and a report 155

104 Competency B - AC 14 (1 Credit) Reviews and Reconciles Panels - NEW The practice receives reports from outside entities such as health plans, ACOs and Medicaid agencies on the patients that are attributed to each clinician. The practice has a process to review the reports and a process to inform those entities of the patients known or not known to be under the care of each clinician. Evidence = Documented process and evidence of implementation 156

105 Care Management and Support (CM) 157

106 Care Management and Support (CM) 2 Competencies 9 Criteria One criterion requiring a documented process = CM 09 Elective makes care plan accessible across external care settings 158

107 COMPETENCY A The practice systematically identifies patients who CM may 01 benefit (Core): from Considers the following when care management. establishing a systematic process and criteria for identifying patients who may benefit from care management. 159

108 Competency A Criteria CM 01 Identifying Patients for Care Management (Core). Aligns with PCMH A CM 02 Monitoring Patients for Care Management (Core). Aligns with PCMH A CM 03 Comprehensive Risk-Stratification Process (2 Credits) 160

109 CM 03 (Credit) The practice may use it s own method to identify patients who are at high risk in order to meet CM 03 AND CM

110 Competency A - CM 03 (2 Credits) Applies a Comprehensive Risk- Stratification Process - NEW The practice demonstrates that it can identify patients who are at high risk, or likely to be at high risk, and prioritize their care management to prevent poor outcomes Practice identifies and directs resources appropriately based on need Evidence = Report 164

111 Additional Detail from NCQA CM03 For CM 03, is there an expectation of a minimum number of criteria (behavioral health, social determinants, multiple chronic conditions, other?) to be considered when a practice is developing their comprehensive riskstratification process as described in CM 03. NCQA s response: NCQA is not prescriptive how the risk stratification is done for their population but the practice must include every patient. For CM03, you need to assign a score for each patient. The categories in CM 01 do not need to be included but can be considered when assigning a risk score. If a practice is able to demonstrate CM03 then they would automatically get credit for CM01. The intent for both is for the practice to be able identify their high-risk/patients in need of care management. CM 03 looks at systems/programs that generate risk stratification for the practice. NCQA is looking for the practice to apply a risk-stratification process to help identify the patients at the highest risk. 165

112 COMPETENCY B For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals. 166

113 Competency B Criteria CM 04 Person-Centered Care Plans (Core) CM 05 Written Care Plans (Core) CM 06 Patient Preferences and Goals (1 Credit) CM 07 Patient Barriers to Goals (1 Credit) CM 08 Self-Management Plans (1 Credit) CM 09 Care Plan Integration (1 Credit) 167

114 Competency B - CM 09 (1 Credit) An Integrated Care Plan is Accessible Across Settings of Care - NEW Makes the care plan accessible across external care settings. It may be integrated into a shared electronic medical record, information exchange, or other cross-organization sharing tool or arrangement. Evidence = Documented process AND evidence of implementation 176

115 Care Coordination and Care Transitions (CC) The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood. 3 Competencies 21 Criteria 15 required documented processes 177

116 Competency A The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result. 1 Core criterion 2 Elective criteria 178

117 Competency A Criteria CC 01 Lab and Imaging Test Management (Core) CC 02 Newborn Screenings (1 Credit) CC 03 Appropriate Use for Labs and Imaging (2 Credits) - New 179

118 Competency A Required Documented Processes CC 01 Core - tracks and manages lab and imaging tests important for care and informs patients of the result CC 02 (1 credit) follows up with inpatient facilities about newborn hearing and blood-spot 180

119 Competency A - CC 03 (2 Credits) Uses Clinical Protocols to Determine When Imaging and Lab Tests are Indicated - NEW Determines when imaging and lab tests are necessary based on established protocols and evidencebased guidelines. May implement clinical decision supports to ensure that protocols are used (e.g., embedded in order entry system). Evidence = Evidence of implementation 183

120 Competency B The practice provides important information in referrals to specialists and tracks referrals until the report is received. Competency B The practice provides important information in referrals to specialists and tracks referrals until the report is received. 3 Core criteria 10 Elective criteria 1 Core criterion 9 Elective criteria 184

121 Competency B Criteria CC 04 Referral Management (Core) CC 05 Appropriate Referrals (2 Credits)- New CC 06 Commonly Used Specialists Identification (1 Credit)- New CC 07 Performance Information for Specialist Referrals (2 Credits) CC 08 Specialist Referral Expectations (1 Credit) 185

122 Competency B Criteria CC 09 Behavioral Health Referral Expectations (2 Credits) CC 10 Behavioral Health Integration (2 Credits) CC 11 Referral Monitoring (1Credit) CC 12 Co-Management Arrangements (1Credit) CC 13 Treatment Options and Costs (2 Credits)-New 186

123 Competency B Required Documented Processes CC 04 Core provides important information in referrals to specialists and tracks referrals until report is received CC 08 Elective works with specialists to set expectations for information sharing and patient care CC 09 Elective - works with behavioral health specialists to set expectations for information sharing and patient care (may use agreement in lieu of documented process) CC 10 Elective integrates behavioral health providers into the care delivery system CC 11 Elective monitors timeliness of referral responses CC 13 Elective engages with patients regarding cost implications of treatment option 187

124 Competency B Elective Criteria CC05 through CC13 = 14 Possible Credits CC 05 Appropriate Referrals - New CC 06 Commonly Used Specialists Identification - New CC 07 Performance Information for Specialist Referral CC 08 Specialist Referral Expectations CC 09 Behavioral Health Referral Expectations CC 10 Behavioral Health Integration CC 11 Monitoring CC 12 Co- Management Arrangements CC 13 Treatment Options and Costs - New 189

125 190

126 Competency B - CC 05 (2 Credits) Uses Clinical Protocols to Determine Referral Necessity - NEW Uses clinical protocols or decision support tools to determine if a patient needs to be seen by a specialist or if care can be addressed or managed by the primary care clinician. Evidence = Evidence of implementation 191

127 Competency B - CC 06 (1 Credit) Identifies Frequently Used Specialists/Specialty Types - NEW Monitors patient referrals to gain information about the referral specialists and specialty types it uses frequently. Evidence = Evidence of implementation 192

128 Competency B - CC 11 (2 Credits) Monitors Timeliness and Quality of the Referral Response - NEW Assesses the response received from the consulting/specialty provider, evaluates whether the response was timely and provided appropriate information about the diagnosis and treatment plan. 198

129 Competency B - CC 11 (1 Credits) Monitors Timeliness and Quality of the Referral Response - NEW The practice bases its definition of timely on patient need On-going assessment and referral monitoring may be helpful in CC 07 Evidence = Documented process AND report. Aligns with PCMH B 199

130 CC 11 (2 Credits) may be used to meet CC 07 (2 Credits) 200

131 Competency B - CC 13 (2 Credits) Engages with Patients Regarding Cost Implications of Treatment Options - New Makes patients aware of treatment costs as indicated. Evidence = Documented process AND evidence of implementation 202

132 Examples of CC 13 Implementation Add a financial question to the clinical intake screening Directs patients to copay and prescription assistance programs Use shared decisionmaking tools Ask about prescription drug coverage Tell patients which services are critical and should not be skipped Recommend less expensive treatment options, if appropriate 203

133 Shared Decision Making Tool with Reference to Cost 204

134 Competency C Connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care. 3 Core criteria 5 Elective criteria 205

135 Competency C Core Criteria = 3 CC 14 Identifying Unplanned Hospital and ED Visits CC 15 Sharing Clinical Information CC 16 Post- Hospital/ED Visit Follow-up 206

136 Competency C Elective Criteria = 5 CC 17 (1 Credit) Acute Care After Hours Coordination-New CC 18 (1 Credit) Information Exchange During Hospitalization CC 19 (1 Credit) Patient Discharge Summaries CC 20 (1 Credit) Care Plan Collaboration for Practice Transitions CC 21 (Max 3 Credits) External Electronic Exchange of Information 207

137 Competency C Criteria Requiring Documented Processes CC 14 Core Systematically identifies patients with unplanned hospital admissions and ED visits CC 15 Core - Shares clinical information with admitting hospitals and emergency departments CC 16 Core - Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit CC 17 Elective - Systematic ability to coordinate with acute care settings after office hours through access to current patient information. CC 18 Elective - Exchanges patient information with the hospital during a patient s hospitalization CC 19 Elective - Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities 208

138 Competency C Elective Criteria CC 17 CC 21 7 Credits Total CC 17 Acute Care After Hours Coordination (1 Credit) CC 18 Information Exchange During Hospitalization (1 Credit) CC 19 Patient Discharge Summaries (1 Credit) CC 20 Care Plan Collaboration for Practice Transitions (1 Credit) CC 21 External Electronic Exchange of Information (Maximum 3 Credits) 212

139 Competency C - CC 17 (1 Credit) Coordinates Patient Information with Acute Care Settings After Hours - NEW Communicates with acute care facilities when a patient is seen after the office is closed. Sharing patient information allows the facility to coordinate patient care based on current health needs and engage with practice staff. Evidence = Documented process AND at least one example of coordination with a facility 213

140 My NCQA Account 224

141 Break 1:45 2:00 pm 225

142 Finishing Up and Action Planning 2:15 3:45 pm 226

143 Performance Measurement and Quality Improvement (QI) The practice establishes a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/families/caregivers in quality improvement activities 3 Competencies 19 Criteria 227

144 Competency A The practice measures to understand current performance and to identify opportunities for improvement 4 Core criteria 3 Elective criteria 228

145 Competency A Core Criteria QI 01 Clinical Quality Measures (Core) Aligns with PCMH A QI 02 Resource Stewardship Measures (Core) Aligns with PCMH B QI 03 Appointment Availability Assessment (Core) Aligns with PCMH A4 QI 04 Patient Experience Feedback (Core) Aligns with PCMH C 229

146 Competency A Elective Criteria QI 05 Health Disparities Assessment (Elective) Aligns with PCMH A and 6C QI 06 Validated Patient Experience Survey Use (Elective) - Aligns with PCMH C QI 07 Vulnerable Patient Feedback (Elective) Aligns with PCMH C 230

147 Competency A Required Documented Process = One QI 03 Core - Assesses performance on availability of major appointment types to meet patient needs and preferences for access Aligns with PCMH A 231

148 Competency A - QI 01 (Core) Monitors at Least Five Clinical Quality Measures Across the Four Categories A. One immunization measure Aligns with PCMH A B. One preventive care measure (not including immunizations) Aligns with PCMH A A measure on oral health counts as a preventive clinical quality measure C. One chronic or acute care clinical measure Aligns with PCMH A D. One behavioral health measure New Evidence = Report 232

149 Competency B Competency B The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies 4 Core criteria 3 Elective criteria 242

150 243

151 Competency B Core Criteria QI 08 Goals and Actions to Improve Clinical Quality Measures (Core) QI 09 Goals and Actions to Improve Resource Stewardship Measures (Core) QI 10 Goals and Actions to Improve Appointment Availability (Core) QI 11 Goals and Actions to Improve Patient Experience (Core) Aligns with PCMH A6 and 6D 244

152 Competency B Elective Criteria QI 12 Improved Performance (2 Credits) Aligns with PCMH E QI 13 Goals and Actions to Improve Disparities in Care/Service (1 Credit) Aligns with PCMH D QI 14 Improved Performance for Disparities in Care/Service (2 Credits) - New 245

153 Competency B QI 08 (Core) Sets Goals and Acts to Improve on at Least 3 Measures Across Three of the Four Categories A. Immunization measures Aligns with PCMH A B. Other preventive care measures Aligns with PCMH 6A C. Chronic or acute care clinical measures Aligns with PCMH A D. Behavioral health measures New Category Evidence = Report OR Quality Improvement Worksheet Measures may be chosen from QI

154 Competency B QI 14 (2 Credits) Achieves Improved Performance on at Least 1 Measure of Disparities in Care or Service - NEW The practice demonstrates that it has improved performance on at least one measure related to disparities in care or service. Demonstration of improvement is determined by the goals set in QI 13 Report OR Quality Improvement Worksheet 252

155 Competency C The practice shares performance data with the practice, patients, and/or publicly for the measures and patient populations identified in the previous section 1 Core criterion 4 Elective criteria 253

156 Competency C Criteria QI 15 Reporting Performance within the Practice (Core) QI 16 Reporting Performance Publicly or with Patients (1 Credit) QI 17 Patients/Family Caregiver Involvement in Quality Improvement (2 Credits) QI 18 Reporting Performance Measures to Medicare/Medicaid (2 Credits) - New QI 19 Value-Based Contract Agreements (max 2 Credits) - New 254

157 Competency C Required Documented Processes QI 15 Core - Reports practice-level or individual clinician performance results within the practice for measures reported by the practice Aligns with PCMH F QI 16 Credit - Reports practice-level or individual clinician performance results publicly or with patients for measures reported by the practice Aligns with PCMH F QI 17 Credit - Involves patient/family/caregiver in quality improvement activities Aligns with PCMH D 255

158 Competency C - QI 18 (2 Credits) Reports Clinical Quality Measures to Medicare or Medicaid Used to be Informational Only The practice demonstrates it reports a minimum number of clinical quality measures to Medicare or to a state Medicaid agency At least one immunization measure One preventive care measure (not including immunizations) One chronic or acute care clinical measure One behavioral health measure Evidence = Evidence of submission 260

159 Competency C QI 19 (2 Credits Maximum) Engaged in Value-Based Agreements - NEW Upside Risk Contract A value-based program where the clinician/practice receives an incentive for meeting performance expectations but do not share losses if costs exceed targets Two-Sided Risk Contract A value-based program where the clinician/practice incur penalties for not meeting performance expectations but receive incentives when the care requirements of the agreement are met. Expectations relate to quality and cost. The practice demonstrates it participates in a valuebased program (such as ACOs) by providing information about their participation or a copy of agreement 261

160 Questions? 262

161 POST-SURVEY

162 THANK YOU! SAVE THE DATE! TUESDAY, JANUARY 23, 2017 VIRTUAL TRAINING Questions? Contact us! Practice Transformation Team