2014 PCMH Standards: How CPCI Can Help with Transformation. CHCANYS Quality Improvement Program November 20, 2014

Transcription

1 2014 PCMH Standards: How CPCI Can Help with Transformation CHCANYS Quality Improvement Program November 20, 2014

2 Agenda Review of PCMH 2014 Standards and Stage II MU Crosswalk PCMH Transformation and the CPCI 2

3 Today s Presenters Kathy Alexis, Director, Quality Improvement Program, CHCANYS Amy Grandov, Managing Director, NYS-HCCN, CHCANYS Heather Budd, VP of Clinical Transformation, Azara Healthcare 3

4 PCMH 2014: Key Changes Additional emphasis on team-based care Care management focused on high-risk patients More focused, sustained Quality Improvement (QI) on patient experience, utilization, clinical quality Alignment with Meaningful Use stage 2 Further integration of Behavioral Health Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 4

5 PCMH 2014 Content and Scoring (6 standards/27 elements) 1: Enhance Access and Continuity A. *Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access 2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate Services (CLAS) D. *The Practice Team 3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence-Based Decision- Support Scoring Levels Level 1: points. Level 2: points. Level 3: points. Pts Pts Pts : Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. *Referral Tracking and Follow-Up C. Coordinate Care Transitions 6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology *Must Pass Elements Pts Pts Pts

6 PCMH 2014 Standards and Related MU Stage 2 Alignment 11/20/2014 6

7 PCMH 1: Patient-Centered Access Intent of Standard The practice provides access to team-based care for both routine and urgent needs of patients/families/care-givers at all time. A. Patient-centered appointment access B. 24/7 Access to clinical advice C. Electronic access Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 7

8 PCMH 1: MU Stage II Alignment PCMH 1 Element C: Electronic Access aligns to: Core 7: Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP Core 8: Provide clinical summaries for patients for each office visit Core 17: Use secure electronic messaging to communicate with patients on relevant health information Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 8

9 PCMH 2: Team-Based Care Intent of Standard The practice provides continuity of care using culturally and linguistically appropriate, teambased approaches. Meaningful Use Alignment No alignment A. Continuity B. Medical Home Responsibilities C. CLAS D. The Practice Team Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 9

10 PCMH 3: Population Health Management Intent of Standard The practice uses a comprehensive health assessment and evidencebased decision support based on complete patient information and clinical data to manage the health of its entire patient population. A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management E. Implement Evidence-Based Decision Support Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 10

11 PCMH 3: MU Stage II Alignment PCMH 3 Element A: Patient Information aligns to: Core 3: Record the following demographics: preferred language, sex, race, ethnicity, date of birth PCMH 3 Element B: Clinical Data aligns to: Core 4: Record and chart changes in vital signs Core 5: Record smoking status for patients 13 years old or older Menu 2: Record electronic notes in patient records Menu 4: Record patient family health history as structured data Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 11

12 PCMH 3: MU Alignment PCMH 3 Element D Use Data for Population Management aligns to: Core 11: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach PCMH 3 Element E Implement Evidence-Based Decision Support aligns to: Core 6: Use clinical decision support to improve performance on high-priority health conditions Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 12

13 PCMH 4: Care Management and Support Intent of Standard The practice systematically identifies individual patients and plans, manages and coordinates care, based on need. A. Identify Patients for Care Management B. Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 13

14 PCMH 4: MU Stage II Alignment PCMH 4 Element C Medication Management aligns to: Core 14: The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. PCMH 4 Use Electronic Prescribing aligns to: Core 1: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. Core 2: Generate and transmit permissible prescriptions electronically (erx). Core 6: Use clinical decision support to improve performance on highpriority health conditions Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 14

15 PCMH 4: MU Stage II Alignment PCMH 4 Element E Support Self-Care and Shared Decision- Making aligns to: Core 13: Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 15

16 PCMH 5: Care Coordination and Care Transitions Intent of Standard The practice systematically tracks, test and coordinates care across specialty care, facility based care and community organizations. A. Track and follow-up B. Referral Tracking and Follow-up C. Coordinate Care Transitions Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 16

17 PCMH 5: MU Stage II Alignment PCMH 5 Element A Track and Follow-up aligns to: Core 1 : Use computerized provider order entry (CPOE) Core 10: Incorporate clinical lab-test results into Certified EHR Technology as structured data Menu 3: Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 17

18 PCMH 5: MU Stage II Alignment PCMH 5 Element B Referral Tracking & Follow-up AND Element C Coordinate Care Transitions both align to: Core 15: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 18

19 PCMH 6: Performance Measurement and Quality Improvement Intent of Standard The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 19

20 PCMH 6: MU Stage II Alignment (1 of 2) PCMH 6 Element G Use Certified EHR Technology aligns to: Core 9: Protect electronic health information created or maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities Core 12: reminders for preventive/follow-up care Core 16: Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice. Menu 1: Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice. Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 20

21 PCMH 6: MU Stage II Alignment (2 of 2) PCMH 6 Element G Use Certified EHR Technology aligns to (cont): Menu 5: Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. Menu 6: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Clinical Quality Measures Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf 21

22 Using CPCI as a Tool to Transform Your Practice 22

23 Patient Centered Medical Home Practice Transformation Supported by CPCI at all levels of Care Delivery TRANSFORMATION GOALS CPCI TOOLS Proof of performance and tracking for regulatory, grant, program and board reporting. Mid-period performance evaluation for proactive management. External Performance Scorecards / Dashboards Measure Analyzer (graphics) Regulatory reports (UDS, MU, PCMH, state, grant, etc.) Performance tracking, continuous quality improvement to test change, and meet strategic QI goals, Population Management for outreach, tracking and follow-up. QI & Population Management Scorecards / Dashboards Measure Analyzer Registries Referral Management Team-based, proactive care planning to maximize opportunity for delivering care and engaging patient. Point of Care Visit Planning for huddle prep Registries for care managers 23 Azara Healthcare 2014

24 Putting the Visit Planning Report into Daily Practice: Team Based Care Visit Planning Responsibilities 24 Azara Healthcare 2014

25 Sample Care Team Members Transition of Care Provider Patient Health Educator BH Patient BH Pharmacist MA Care Manager Front Desk 25 Azara Healthcare 2014

26 Visit Planning Responsibilities MA 1. Run Azara DRVS Visit Planning Report for scheduled patients daily and for walk-in patients if there is time. 2. Identify missing data for Diagnostics or Labs. If scanned only results exist, enter in EHR as structured data (especially Mammogram, Pap, Colonoscopy). 3. Assist Provider with completing alerts for patients, supported by standing orders. Enter reminders in the secondary chief complaint field. Primary chief complaint still used for true chief complaint. Order labs and diagnostics as needed (supported by standing orders). 4. Cancel pre-ordered labs for patients who cancel or no-show by the end of each session. Front Desk 1. Check what has been ordered for the patient in order to charge the correct co-pay at check in and avoid needing to send patient out to FD during visit. 26 Azara Healthcare 2014

27 Visit Planning Responsibilities Health Educator/ Care Manager / Pharmacy/ BH/ Other 1. Huddle with MA to determine high risk patients to see face-to-face or offer additional education or care coordination. 2. Share any special patient circumstances with the team. Provider 1. Delegate standing order tasks to appropriate support team members. Visit Planning Report provides technology foundation for trust. 2. Ensure huddles are happening. May take many forms but at the very least there should be some conversation with your MA about the plan for patients- a quick team meeting, or passing check in. Essential for MAs to feel supported when acting on Standing Orders. 3. Delete secondary chief complaint items not addressed in visit. All 1. Data Hygiene: Report data errors so they can be addressed and fixed. Workflows and inputs change overtime. Azara will find root cause and update. Send an with details to support@azarahealthcare.com. 27 Azara Healthcare 2014

28 PCMH Update Timeline PCMH 2011 PCMH 2011 survey tools are no longer available for purchase December 31, 2014 last date to submit PCMH 2011 Corporate survey tools March 31, 2015 last date to submit PCMH 2011 survey tools PCMH 2014 Available Standards and Guidelines Survey tools Adapted from NCQA s Intro to PCMH: Foundational Concepts of the Medical Home 28

29 Resources Order the PCMH 2014 Online Application from NCQA 11/20/

30 Azara Healthcare 2014