Deep Dive on the Must Pass NCQA PCMH Requirements & Standards

Transcription

1 PATIENT CENTERED MEDICAL HOME & MEANINGFUL USE COLLABORATIVE Kick Off Session July 21, 2010 Deep Dive on the Must Pass NCQA PCMH Requirements & Standards Presentation by: Deborah Johnson Ingram

2 What is a Patient Centered Medical Home The concept of a medical home is not new. It was ini4ally introduced by the American Academy of Pediatrics (AAP) in 1967 and referred to a central loca4on for a child s medical records; it was par4cularly important for children with special health care needs. This concept evolved over 4me from a centralized medical record to a method of providing comprehensive primary care for children at the community level. The American College of Physicians (ACP), and the American Academy of Family Physicians (AAFP) then developed their own concep4ons of the concept, expanding its reach to care for adults. The Pa4ent Centered Medical Home A Purchaser Guide2007

3 Medical Home Tenets Personal physician Physician directed medical prac4ce Whole person orienta4on Care is coordinated and/or integrated Quality and safety Enhanced access Payment Accessed May 9, 2008.

4 Improvements in: Quality of care Patient experience and access Work environment Reimbursement from key payors (in some states if recognized) Reductions in: Benefits of PCMH Costs related to preventable, duplicative and unnecessary care ER visits/inpatient stays

5 NY State PCMH Incentive Payment For claims coded with E&M and/or Preven4ve Medicine codes For fee for service claims $5.50 for Level 1 $11.25 for Level 2 $16.75 for Level 3 For Medicaid Managed Care & Family Health Plus claims Plans receive $2/$4/$6 PMPM for Levels 1/2/3 Payments must go to recognized prac4ces; cannot be retained by Plans or rolled over to subsequent year Plans will provide details on payout method Payments for Level 1 will end a\er December 2012 to promote prac4ces obtaining Levels 2 & 3 recogni4on

6 Learning objectives of the PCMH Deep Dive A brief overview of the 10 Must Pass Elements Examples of actual documents used for NCQA submissions Tips and hints of submi_ng a NCQA survey More accurately complete your detailed self assessment

7 PCMH Assessment Results

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10 The NCQA PPC-PCMH Survey 9 NCQA Standards 30 NCQA Elements 166 NCQA Factors

11 Standards Standards are defini4ve statements about acceptable performance or results Each Standard includes a statement of an abribute or expecta4on has a designated number of points which is the sum of points from all elements assigned to the standard Has a statement of intent that describes the purpose of the standard Example: PPC1 (or Standard 1), Access and Communica4on [9 points] Statement: The prac4ce has standards for access to care and communica4on with pa4ents and monitors its performance to meet the standards Intent: The prac4ce provides pa4ents with access during & a\er regular business hours, and communicates with pa4ents effec4vely

12 Elements There is at least one Element for each Standard Each Element has specific number of points describes a specific component of performance that is individually evaluated and scored Example: PPC 1A, Access & Communica4on Processes [4 points] & PPC 1B, Access & Communica4on Results [5 points] PPC 1A: The prac4ce establishes in wri4ng standards for the following processes to support pa4ent access PPC 1B: The prac4ce s data show that it meets access & communica4on standards in PPC 1A

13 Must Pass Elements These are 10 of the 30 Elements that a prac4ce must pass at a 50% or greater score in order to achieve any level of recogni4on (5 for Level 1; 10 for Level 2 or 3) They are considered to be the fundamental building blocks for a medical home that any prac4ce must be able to demonstrate to be a medical home

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15 PPC1 Element A: Access and Communication Processes The practice establishes in writing standards for the following processes to support patient access: Scoring: 100% 75% 50% 25% 0% PracWce has wrizen process for 9 12 items PracWce has wrizen process for 7 8 items PracWce has wrizen process for 4 6 items PracWce has wrizen process for 2 3 items PracWce has wrizen process for 0 1 items Data Source: Documented process, Reports

16 PPC1A Sample Policy Manual MP Table of contents

17 PPC1 A Sample Policy for PCMH submission MP

18 PPC1 Element B: Access and Communication Results The practice s data shows that it meets access and communication standards in 1A: Scoring: 100% 75% 50% 25% 0% PracWce s data meets 5 items PracWce s data meets 4 items PracWce s data meets 3 items PracWce s data meets 2 items PracWce s data meets 1 items Data Source: Reports

19 PPC1B Sample Patient Satisfaction Survey MP

20 PPC1 B Practice Data Related to 1A MP Text box includes comment for surveyor

21 Tips and Hints: PPC1 A & B The prac4ce should submit annotated policy and procedure documents There are benefits of submi_ng your en4re P&P reflects con4nuity Data results for PPC 1 B must reflect P&P s submibed in PPC 1 A

22 PPC2 Element D: Organizing Clinical Data The practice uses the following electronic or paper based charting tools to organize and document clinical information in the medical record: Scoring: 100% 75% 50% 25% 0% % of records of pawents seen in the past 3 months include at least 3 tools w/ informawon documented 50 74% of records of pawents seen in the past 3 months include at least 3 tools w/ informawon documented 25 49% of records of pawents seen in the past 3 months include at least 3 tools w/ informawon documented 10 24% of records of pawents seen in the past 3 months include at least 3 tools w/ informawon documented Less than 10 % of records of pawents seen in the past 3 months include at least 3 tools w/ informawon documented Data Source: Records or files

23 PPC 2 D Chart Review MP Method 1- Query the practices eregistry, or EPM system: Denominator = total # of patients seen at least once in the last 3 months Numerator = number of patients for whom three tools have information entered Method 2- Review a sample of medical records using the sample method in NCQA s Record Review Book

24 PPC2 Element E: Organizing Clinical Data The practice uses an electronic or paper based system to identify the following diagnosis and conditions: Scoring: 100% 75% 50% 25% 0% PracWce idenwfies 3 items PracWce idenwfies 2 items PracWce idenwfies 1 items No scoring opwon PracWce idenwfies 0 items Data Source: Reports

25 PPC 2E Most Frequently Seen Dx s MP The practice gave a full ICD9 report = to 1yr of encounters

26 Tips and Hints: PPC 2 D&E Perform sample chart reviews Retain the list of pa4ents iden4fied for your sample Generate an ICD 9 report from the EMR or EPM Report of most frequently seen Dx codes Analyze your results

27 PPC3 Element A: Guidelines for Important Conditions The practice adopts and implements evidence based guidelines: Scoring: 100% 75% 50% 25% 0% PracWce implements guidelines for 3 condiwons No scoring opwon PracWce implements guidelines for 2 condiwons PracWce implements guidelines for 1 condiwons PracWce does not implements guidelines for any condiwons Data Source: Materials

28 PPC 3A Practice shows adopted evidence based clinical guidelines in facility policy with references

29 PPC 3A Sources for Guidelines Scientific Statement from the AHA MP

30 PPC 3A The practice continues by showing how they incorporate the guidelines in their daily workflow This is their DM Flow sheet

31 Tips and Hints: PPC 3 A All evidence based clinical guidelines are implemented in the prac4ce Usage of flow sheets or process maps related to the clinical condi4ons The prac4ce uses pop up alerts or reminders for screening tests due, immuniza4ons due, etc Capture evidence of wriben care plans, pa4ent goals and progress, assessing barriers and a\er visit follow up

32 PPC4 Element B: Self Management Support The practice conducts the following activities to support patient/ family self-management, for the three conditions: Scoring: 100% 75% 50% 25% 0% % of pawents seen in the past 3 months have at least 3 acwviwes documented 50 74% of pawents seen in the past 3 months have at least 3 acwviwes documented 25 49% of pawents seen in the past 3 months have at least 3 acwviwes documented 11 24% of pawents seen in the past 3 months have at least 3 acwviwes documented 10% of pawents seen in the past 3 months have at least 3 acwviwes documented Data Source: Records of Files

33 PPC 4B Chart Review MP Spread sheet provided by NCQA

34 Tips and Hints: PPC 4 B Adopt a process that is clear and universal across the prac4ce Perform sample chart reviews Retain the list of pa4ents you iden4fied for your chart review. (no iden4fiable informa4on beyond condi4on should be used)

35 PPC6 Element A: Test Tracking The practice systematically tracks tests and follows up in the following manner: Scoring: 100% 75% 50% 25% 0% The pracwce does 4 6 types of follow up and teswng No scoring opwon The pracwce does 3 types of follow up and teswng PracWce s electronic system has the capability to do all 4 types of tracking and follow up but does not use it PracWce s system does not have the capability to track Data Source: Reports

36 PPC6 A Test Tracking MP Practice had a paper based system but still had a process to track labs - lab report received daily, MA responsibility to reconcile labs, abnormals are flagged (bought to MD s attention), follow up to pts family made as per practice policy. Factors 1,3,4,6

37 Tips and Hints: PPC 6A The EMR or paper based system should allow the prac4ce to order a test or lab, confirm the test or lab was completed and follow up with test or lab status Was it reviewed by the ordering MD? Was the test flagged abnormal? If so, was their follow up by informing the pa4ent?

38 PPC7 Element A: Referral Tracking Outside of paper medial records and patients visits, the practice uses a paper based or electronic system to assist in tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice. The practice uses a system that includes the following information for its referrals: Scoring: 100% 75% 50% 25% 0% PracWce uses system that includes all 4 items PracWce uses system that includes 2 3 items PracWce uses system that includes 1 item No scoring opwon System does not include any items Data Source: Reports

39 PPC 7A Example of Referral Tracking MP Factor 1- Origination Factor 3-status Factor 2 clinical details

40 PPC 7A Example of Referral Tracking MP Factor 4- Administrative details= includes insurance information, whether the referral requires plan approval

41 Tips and Hints: PPC 7A You can use either an EMR or external process so long as the cycle reflects a closed loop process Administra4ve details = insurance informa4on including whether the referral requires health plan approval

42 PPC8 Element A: Measures of Performance The practice measures and receives data on the following types of performance by physician or across the practice Scoring: 100% 75% 50% 25% 0% PracWce measures at least 2 types of performance No scoring opwon PracWce measures 1 type of performance No scoring opwon No areas of performance measured Data Source: Reports

43 PPC8 A Measure of Performance MP Watch out for 8 C they are linked

44 PPC8 Element C: Reports to Physicians The practice reports on performance on the measures in 8A and 8B: Scoring: 100% 75% 50% 25% 0% PracWce reports to physicians results both across the pracwce and by physician No scoring opwon PracWce reports to physicians results either across the pracwce or by physician No scoring opwon No areas of performance reported to physicians Data Source: Reports

45 PPC 8 C. meeting minutes of reports related to PPC 8 A & B

46 Tips and Hints: PPC 8 A & C Use your EMR to perform QI reports, status reports, effectiveness, efficiency and timeliness reports Perform/ use patient experience reports or data results (Press Ganey, CAHPS) Reports by practice and or by individual physician Reports/ data relevant to 8A and 8B Data should reflect care provided to all patients Not covered by a solo payer

47 PPC 8 A Quiz is this acceptable documentation?

48 PCDC recently released a manual to assist practices with the process for obtaining recognition from NCQA as a medical home. Developed through generous support provided by the New York Community Trust. Free and available on the PCDC website using the following URL:

49 Questions?