Medical Home. update. Western Montana Region- PCMH Implementation and the Varying HIT Components & Impacts. May 16, 2014

Transcription

1 Medical Hme update Western Mntana Regin- PCMH Implementatin and the Varying HIT Cmpnents & Impacts May 16, 2014

2 Agenda Current Medical Hme Status- Prvidence WMT Applicatin- HIT determinants Wrkflw- Patient Registry (Ppulatin Health Outreach) Patient Prtal Care Crdinatin Advancing yur Medical Hme/CPI Reprting Access Clinical Quality QCI

3 PMG WMT PCMH Visin T be the Patient-Centered Medical Hme f chice acrss Mntana, with the capabilities necessary t supprt an integrated care delivery system.

4 Our Jurney Pilt Clinics ( ) Preparatin (March Octber 2013) Applicatin (Octber 2013) Recgnized Status (December 2013) CQI Prcess (January ) NCQA PCMH recgnitin is valid fr 3 years.

5 Our Jurney, cnt d. 7 practices recgnized with NCQA in 2013, with 2 additinal applicatins (Internal Medicine) submitted in April pints = Level pints = Level pints = Level 3 Scres range frm 69-88/100 All Level 2 except 1- Plsn 2 clinic edits

6 Primary Care is nt PCMH

7 Anther view -Grup Health Innvates: Medical Hme Mdel f Primary Care, August 2, 2012, Eric B. Larsn

8 Key Medical Hme Functins Care Transitins (ED and Hspital Discharge Fllw-up) Ppulatin Health Outreach Care Crdinatin fr cmplex/high needs patients Referral & Lab/Imaging tracking and fllw up Standardized quality reprting and quality imprvement Care team develpment Develpment f ancillary medical hme services (chrnic disease educatin, mental/behaviral health) Pre-visit preparatin

9 PCMH Stakehlder Cuncil

10 Recgnized PCMH Prgrams

11 NCQA 2011 Standards NCQA just released the PCMH 2014 reqs

12 NCQA 2014 Standards Anticipated Changes. Integratin f behaviral health Expectatins rise. Practices are expected t cllabrate with behaviral health care prviders and t cmmunicate behaviral health care capabilities t patients. Care management fcus n high-need ppulatins Practices are expected t address sciecnmic drivers f health and prly cntrlled r cmplex cnditins. Practices shuld als fcus n the special needs f patients referred frm the medical neighbrhd. Enhanced emphasis n team-based care Revised standards emphasize cllabratin with patients as part f the care team and establish team-based care as a must-pass criterin fr NCQA Recgnitin. Alignment f imprvement effrts with the triple aim Practices must shw that they are wrking t imprve acrss all three dmains f the triple aim: patient experience, cst and clinical quality. Sustained transfrmatin In keeping with the gal f cntinuus imprvement, practices shw that they cmply with NCQA standards ver lng perids.

13 Applicatin HIT Determinants fr creating a PCMH applicatin per NCQA 2011

14 Enhance Access and Cntinuity Same day appintments* Timely clinical advice by telephne (during and after hurs)* Timely electrnic cmmunicatin (during and after hurs)* Mnitrs visits with selected prvider/cntinuity Assess racial and ethnic diversity f ppulatin Assess language needs f ppulatin Electrnic Access Patients can request electrnic cpy f health infrmatin and receive within 3 business days Patients have electrnic access t health inf within fur days Clinical summaries are prvided fr mre than 50% f ffice visits within three business days Tw way cmmunicatin Patient can request appintments r refills via electrnic means Patient can request referrals r test results via electrnic means

15 Identify & Manage Patient Ppulatins Practice uses an electrnic system that recrds primary demgraphic infrmatin fr mre than 50% f patients. System is searchable and structured fr >80% f patients: Up-t-date prblem list with current and active dx Allergies, including medicatin allergies and adverse reactins Bld pressure, Height and Weight with date f update, fr mre than 50% f patients 2 years and lder Calculates and displays BMI, Plts and displays grwth charts Status f tbacc use List f prescriptin medicatins Age and gender apprpriate immunizatins Ppulatin Health Management* 3 preventive care services; 3 chrnic care services Patients nt recently seen Specific medicatins

16 Plan and Manage Care Care Management fr chrnic, high-risk r cmplex patients* Individual care plan including treatment plan Written plan f care & Summary (AVS) Assess barriers Additinal benefit frm additinal care management supprt Fllw-up with thse wh have nt kept appintments Medicatin Management Reviews and recnciles medicatins Infrmatin fr new medicatins Assess patient/family understanding Assess patient respnse and barriers t adherence Dcument ver the cunter medicatins Electrnic Prescribing E-prescribe Perfrms patient specific checks fr drug-drug and drug-allergy reactins Alerts fr generic alternatives HINT: Creatin f Smart Phrases within electrnic medical recrd, by ur PCMH physician champin.

17 Track and Crdinate Care Self-Management Prcess Uses HER t identify patient-specific educatin resurces and prvide t patient Develp and dcument self-management plans and abilities Prvides self-management tls Test/Referral Tracking* and Fllw-Up Tracks lab and imaging until results are available, flagging, f/u n verdue Flags abnrmal results Electrnically cmmunicates with labs/facilities t rder and retrieve results Electrnically incrprate lab results int structured field in med recrd Crdinate and Manage Care Transitins Identify patients with hspital admissin and ER visit Sharing infrmatin- discharge summaries, fllw-up care, transitining pediatric, etc. Prvides electrnic summary f care recrd t anther facility

18 Measure & Imprve Perfrmance Measure Perfrmance 3 Preventive Care services; 3 Chrnic Care services 2 Utilizatin Measures Data stratified by vulnerable ppulatins Cntinuus Quality Imprvement* Set gals and act t imprve Tracking results ver time Blinding data by prvider and clinic Assessing effects and achieving perfrmance Sharing data by clinic and prvider detail Reprt Data Externally Electrnically reprts ambulatry clinical quality measures t CMS, states r ther external entities Electrnically reprts data t immunizatin registries r systems Electrnically reprts syndrmic surveillance data t public health agencies

19 MU - Tw Birds, One Stne?

20 Wrkflw

21 Patient Registry

22 Patient Prtal MyChart is the Epic Patient Prtal Sign up ptins In the rm Thrugh the After Visit Summary prir t scheduled appintment Increase Cmmunicatin Patient t prvider Lab and imaging results Pre-visit questinnaires Meaningful Use

23 Care Crdinatin- Cmplex Care Crdinatr Referral Management Tls in Epic Care Manager Health Maintenance Synpsis Optins 20 different flw sheets that gather metrics related t varius disease prcesses Hme mnitring flw sheets Dcumentatin flw sheets Educatinal material Team apprach

24 Transitin f Care Discharge Reprt generated daily within clinic by Clinical staff. See Tips and Tricks fr reprt generatin. Reprt filtered by clinic specific hspital inpatient discharges and PCP Clinical staff initiates call t patient r caregiver within tw business days f discharge. Transitin f Care telephne encunter cmpleted with template f questins, discharge summary reviewed. Encunter ruted t PCP with appintment date fr prvider review. Patient is scheduled fr Transitin f Care visit within 7 days f discharge

25 Transitin f Care Prvider determines whether Transitin f Care cdes are apprpriate based n criteria. Criteria: Patient must be established within the practice and present with mderate r high cmplexity within 7 calendar days f discharge. Cdes: Mderate, High Dcument date patient had cntact pst discharge and date f discharge. Only ne TCM cde can be billed within 30 day perid. If patient des nt meet criteria, standard fllw up visit cded.

26 Advancing Yur Medical Hme

27 Reprting- PCMH Specific

28 Reprting: Access

29 Reprting: Clinical Quality

30 Reprting: CQI

31 Reprting: Prvider Engagement

32 Questins?