Fast-Track PCMH Recognition

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1 Fast-Track PCMH Recognition i2i Systems integrated package of Population Health Management and reporting technology, documented processes and consulting services aligned with NCQA guidelines supports and helps expedite your practice s efforts to achieve PCMH Recognition

2 PCMH Transforms Traditional Care The Patient-Centered Medical Home (PCMH) transforms the traditional care practice model by replacing episodic care based on illnesses and patient complaints with proactive, coordinated care and a long term healing relationship. The provider led care team is responsible for ensuring that all of a patient s care needs are met. By elevating and enhancing primary care, PCMH could improve clinical outcomes, lower costs, promote wellness, and increase patient and physician satisfaction. In a recent study*, the Commonwealth Fund Commission reported that the U.S. health care system could reduce health care expenditures by more than $2 trillion and save U.S. households $537 billion during the next 10 years by adopting a series of polices that include greater use of primary care and the patient-centered medical home (PCMH). NCQA s Patient-Centered Medical Home 2011 includes a set of standards that describe clear and specific criteria, and the program gives practices information about organizing care around patients, care team coordination, and tracking the care of populations and sub-populations over time. The 2011 NCQA Patient-Centered Medical Home standards strengthen and add to the issues addressed by NCQA s original program in NCQA Recognized PCMH Solution A pioneer and leading provider of Population Health and Business Intelligence solutions, i2i Systems i2itracks 7.3 has achieved NCQA PCMH Prevalidation status. i2itracks supports several PCMH standards including Managing Populations Tracking Referrals and Measuring Improving Performance i2i Systems provides practices with a PCMH Toolkit of approved Population Health Management technology, documented processes, and PCMH expertise to help automate the process and overcome the complexities associated with achieving PCMH Recognition. i2i Systems can save practices time by providing a solution aligned with the goals of PCMH and capable of producing documentation and supporting evidence required by NCQA. Primary Care, PCMH Key to Improving Health Care Quality, Saving Billions, Says Report, AAFP News Now, posted 1/21/2013,

3 Pre-loaded Software Streamlines, Expedites the Recognition Process i2i Systems PCMH Toolkit includes i2itracks 7.3, the leading population analytics tool. i2itracks 7.3 comes pre-loaded with: Search and Reporting functions Report and Dashboard samples Screen Shots Demonstrations Other relevant documentation Systems Content Services PCMH success requires more than technology. It s also about process and workflows. The i2i PCMH Solution delivers a complete package by integrating systems, professional services and best-practice content. The i2i PCMH Toolkit combines this package of prebuilt items with user guide elements, software and professional services that help to fast-track your organization towards being on pace with NCQA s requirements. In addition, you ll have access to the i2i Systems Knowledge Community. Through our online forums, you can share knowledge and lessons learned, as many of i2itracks users have already achieved recognition and/or accelerated to levels two and three. Utilizing i2itracks 7.3 to Achieve PCMH Recognition (2011) i2itracks, the leading Population Health Management system, empowers organizations to achieve PCMH recognition. i2itracks supports more than seventy percent of the work necessary to meet PCMH requirements. As the table below illustrates, i2itracks plays a vital role in PCMH attainment, especially for those elements highlighted in gold.

4 Standard 2: Identify and Manage Patient Populations A. Patient Information i2itracks interfaces with PM and EHR systems, accessing all collected demographic data. As a result, i2itracks can produce patient lists and the required numerator and denominator for each of the patient information elements collected. i2itracks Search supports QI efforts by reporting on missing data and providing insight into standardization of data collection. B. Clinical Data With an EHR interface, i2itracks can report for multiple factors, with required numerator and denominator. i2itracks Search supports QI efforts by helping practices discover patients with incomplete data records. D. Using Data for i2itracks is a purpose-built Population Health Management system designed to Population generate required lists for each of the 4 Factors, and support proactive care Management* and outreach for patient populations. Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients i2itracks delivers proactive care modules, like pre-visit summaries and morning huddle reports, to identify services due according to implemented evidence-based guidelines. i2itracks Search generates patient lists based on high-risk criteria and can be used to evaluate resource use and identify patients with co-morbidities or who are out of compliance. i2itracks Population Analytics reports measure the percentage of high-risk patients as defined by the practice. C. Manage Care* i2itracks outreach modules, including pre-visit summaries and Morning Huddle reports, help care teams prepare for patient visits. i2itracks Search identifies patients who do not keep important appointments, while i2itracks correspondence features enable practices to follow up with these patients and provide appointment reminders and communication on treatment plans and self-management goals. i2itracks Today provides quick, at-a-glance access to this information. Standard 4: Provide Self-Care and Community Support A. Self-Care Process* For practices documenting self-care activities in the EHR, i2itracks provides the tools to report on this data for several self-care goals. B. Referral to Community Resources i2itracks delivers a complete Referral Manager Module that enables reporting on frequency and the types of referrals made to community agencies. Standard 5: Track and Coordinate Care A. Test tracking and i2itracks delivers tools to help practices manage imaging referrals, track labs, Follow-up B. Referral tracking and Follow-up* C. Coordinate with Facilities/Care and notify patients of lab results (e.g. cancer screening for women). i2itracks Referral Manager module tracks all aspects of referrals to a specialist, internal or external. The Referral Manager monitors all outstanding referrals, generates reminders and follow-ups, and supports referral management to meet time requirements. The module enables reporting on statistical data related to referrals, including referring provider, specialist, and the types of referrals. For practices capturing admissions data in the EHR, i2itracks can generate lists of patients in need of care coordination and provides tools to reach out to

5 Transitions NCQA Requirement A. Measure Performance B. Patient/Family Feedback C. Implements Continuous Quality Improvement D. Demonstrates Continuous Quality Improvement E. Performance Reporting F. Report Data Externally *must-pass element these patients within the appropriate period. Standard 6: Measure and Improve Performance i2itracks and PCMH Requirements i2itracks Health Registry reports enable reporting and performance review on any number of preventive care measures and chronic or acute care clinical measures. Reporting can be by organization, site or provider, and performance data can be stratified to access disparities in care. i2itracks correspondence features allow practices to mail or satisfaction surveys to patients. i2itracks statistical reports inform your QI process and evaluation of goals, including identifying disparities and highlighting vulnerable areas of focus. i2itracks supports regular reviews of performance data and performance evaluation against goals. i2itracks reports make it easy to show effects of interventions and clinical outcome improvements, including producing graphs of data over time. i2itracks enables reporting on performance data by individual clinician and across the practice. Results can be reported by practice or clinician and saved for export. i2itracks is certified for reporting Meaningful Use Clinical Quality Measures. i2itracks supports the electronic submission of data to an immunization registry or information system. As the table above illustrates, i2itracks plays a vital role in PCMH attainment, especially for those elements highlighted in gold. In addition, i2itracks supports Meaningful Use and Pay-for-Performance target initiatives. Contact i2i Systems Contact i2i Systems today for more information on how we can fast-track your practice s goal of achieving PCMH Recognition, or for a demonstration of i2itracks: Call toll-free: info@i2isys.com You can visit us on the web at