URAC Patient Centered Medical Home

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1 URAC Patient Centered Medical Home Presented by: Cynthia Cook, RN, BSN Sr. Director Business Development

2 Data Only 27% of U.S. adults can easily contact their primary care physicians by telephone, obtain care or advice after hours, and schedule timely office visits National Health Interview Survey estimates only 86.2% of persons have usual place to go for medical care states have implemented PCMH initiatives and have seen improved health outcomes, improved health care delivery and/or lowered overall health care costs. 3

3 URAC Patient Centered Medical Home Presented on behalf of North American Management November 7, 2013 Cynthia Cook, RN, BSN Sr. Director Business Development

4 4 Patient Centered Medical Home 1 Who is URAC? 2 3 URAC s Provider Suite URAC s Approach to Accreditation 4 URAC s Patient Centered Medical Home 5 URAC s PCMH Standards and Process 6 The URAC Difference

5 5 About URAC Founded in 1990, URAC is a nonprofit, independent organization originally chartered to accredit utilization review services URAC offers more than 30 distinct accreditation programs across the entire continuum of health care services URAC currently accredits more than 675 programs operating in all 50 states Government references to URAC accreditation appear in statutes, regulations, agency publications, Requests for Proposals, and contract language URAC is now recognized by 48 states, the District of Columbia, and six federal agencies: (OPM, DOD, VA, CMS, DOL, DOT )

6 6 About URAC Mission To promote continuous improvement in the quality and efficiency of healthcare management through the processes of accreditation, education and measurement Structure Non-profit, independent entity Broad-based governance Providers CO s Purchasers Regulators Patients Expert Advisory Panels Strategic Focus Patient Protection and Empowerment Improving and Innovating Healthcare Management

7 7 URAC Board Member Organizations The URAC Board also maintains at-large representatives from consumer groups, public organizations and other industry experts.

8 8 URAC s Provider Suite of Services URAC has identified and developed standards and programs to promote cost-effective quality care Patient Centered Medical Home Clinical Integration Accreditation Accountable Care Accreditation Quality-Based Incentive Programs These programs allow providers to achieve the goal of participating in quality-based incentive programs through providing quality, patient-centric, coordinated care

9 Advancing Levels of Provider Care Integration and Coordination 9

10 10 Quality Drivers Quality Aims 1. Safety 2. Effective 3. Patient-centered 4. Timely 5. Efficient How URAC Patient Centered Medical Home Standards Promote Quality Registry, Medication Reconciliation, Transitions of Care, Privacy and Security Evidence-Based Guidelines, Wellness Promotion, Quality Management Programs Individualized Focus, Informed Decision-Making, Patient Satisfaction, Consumer Education, Health Literacy Lab Values, Requests for Health Information, Enhanced Coordination of Care Organizational Structure, Policies and Procedures, Electronic Health Record, Total Quality Management 6. Equitable Disparity, Cultural Sensitivity, Complaint Process, Patient Advocacy

11 11 URAC s Accreditation Review Process Collaborative Educational Positive Physicians, Pharmacists, Nurses, Attorneys and Security Experts A URAC Accreditation Reviewer is assigned to every application Proprietary Internet Application Platform Online support for technical assistances Rigorous review of policies and procedures Onsite assessment of operations related to policies and procedures and URAC Standards Staff Model AccreditNet P & P s

12 URAC s Patient Centered Medical Home Began development March Large multi-stakeholder advisory group of over 60 thought leaders. Initial rollout in 2011, revised in 2013 URAC Copyright 2012 Dial-In Number: Participant Code: # 8

13 13 What is the URAC Patient Centered Medical Home? The URAC Patient Centered Medical Homes (PCMH) focuses on a quality-driven, interdisciplinary clinician-led team that delivers and coordinates care putting patients, family members, and personal caregivers at the center of all decisions. A PCMH provides comprehensive and individualized access to physical health, behavioral health, and supportive community and social services, ensuring patients receive the right care in the right setting at the right time.

14 14 Program Principles and Foundation Patient Centered Care Team Culture Commitment To Transparency Appropriate Access to Care PCMH Infrastructure and Operations Individualized Care Planning Cost-effective Use of Health Care Resources Eliminating Health Care Disparities Promoting Care Quality and Continuous Quality Improvement

15 15 Why URAC s Patient Centered Medical Home? Increased reimbursements from state and commercial payers Standardize care Help practices transition from fee-for-service to value-based purchasing model Improve patient care/outcomes, compliance, community health Improve processes and efficiencies through better tracking of workflows

16 16 Focus on Health Care Not Limited to Disease Focus on whole person, not just illness Wellness Modules Formation of Patient-Provider Agreement A Focus on the Patient as an Individual To Provide Personalized, Coordinated Care Respect for cultural differences/needs Accommodating health literacy Care coordination is enhanced

17 17 PCMH Achievement Evaluation PCMH Practice Achievement Requirement Modules (All) Core Quality Care Management Patient-Centered Operations Management Access and Communications Testing and Referrals Care Management and Coordination Advanced Electronic Capabilities Quality Performance Reporting and Improvement URAC PCMH Program Toolkit Patient Rights & Responsibilities Patient Access to Services & Information Enhancing Patient Access to Services Tracking & Follow Up on Referrals Ongoing Care Management Protocols for All Patients Coordination of Care Performance Reporting 7 Mandatory Standards 28 Essential Standards Practice must achieve a total 85% or better score Achievement Levels Achievement Achievement with Electronic Health Record (certified electronic health record technology required)

18 PCMH Practice Achievement Summary 18

19 URAC PCMH Program Practice Achievement Includes Seven (7) Modules Essential to Primary Health Care: Core Quality Care Management Patient-Centered Operations Management Access and Communications Testing and Referrals Care Management and Coordination Electronic Capabilities Quality Performance Reporting & Improvement Performance Reporting

20 20 PCMH PRACTICE ACHIEVEMENT I-Core Quality Care Management Medical Home Organizational Core MH 1: Staff Training Requirements MH 2: Effective Practice Workflow MH 3: Patient Empowerment and Engagement MH 4: Health Literacy MH 5: Patient Rights and Responsibilities

21 21 PCMH PRACTICE ACHIEVEMENT II-Patient Centered Operations Management Patient Registry MH 6: Registry Patient Information and Implementation

22 22 PCMH PRACTICE ACHIEVEMENT III-Access and Communications Access to Services MH 7: Patient Access to Services and Information MH 8: Enhancing Patient Access to Services Community Services and Resources MH 9: Comprehensive Services and Resources MH 10: Community Resource Referrals MH 11: Tracking and Follow-Up of Community Resource Referrals

23 PCMH PRACTICE ACHIEVEMENT IV-Testing and Referrals 23 Managing Tests and Results MH 12: Documented Process for Managing Test Results Referral Process MH 13: Referrals Process MH 14: Track and Follow-Up on Referral

24 24 PCMH Practice Achievement V. Care Management and Coordination Wellness and Health Promotion MH 15: Promoting Wellness and Comprehensive Health Risk Assessment MH 16: Wellness Information and Materials MH 17: Patient Reminders Individual Care Management MH 18: Ongoing Care Management Protocols All Patients MH 19: Informed Decision-Making with Patients MH 20: Medication Review and Reconciliation Coordination of Care MH 21: Coordination of Care MH 22: Coordinating Care Transition and Written Plans MH 23: Appropriate Use of Clinical Guidelines MH 24: Health Record Information Exchange and Alerts

25 25 PCMH PRACTICE ACHIEVEMENT V. Care Management and Coordination ( continued) Comprehensive Chronic Care Management MH 25: Chronic Condition Care Management MH 26: Self-Management of Chronic Conditions MH 27: Chronic Condition Appointments MH 28: Chronic Condition Follow-up Self-Management Support MH 29: Self-Management Support and Assessments Capabilities

26 PCMH PRACTICE ACHIEVEMENT VI. Electronic Capabilities 26 Electronic Prescribing and Dispensing MH 30: Electronic Prescribing Utilized Basic Electronic Health Records MH 31: Basic Electronic Health Record Advanced Electronic Health Records MH 32: Advanced Electronic Health Record Electronic Communications Portal MH 33: Electronic Communications Portal MH 34: Electronic Communications Portal Review and Evaluation

27 27 PCMH PRACTICE ACHIEVEMENT: VII. Quality Performance Reporting and Improvement Performance Reporting MH 35: Performance Reporting Tracking and Reporting MH 36: Performance Reporting and Validation MH 37: Analysis of Performance Reporting Data MH 38: Levels of Performance Reporting Performance Improvement MH 39: Performance Improvement

28 28 Onsite Review Process Onsite reviews may be performed by: URAC Certified PCHCH Auditor; or URAC Accreditation Reviewer Staff Agreed upon date(s) between auditor and practice Onsite review: The primary site will require a 1 day visit by two reviewers Onsite results will be submitted to URAC for Achievement decision by URAC Practice Onsite Review Activities Include: Document and data review Audit of patient health records Interviews: Leadership Staff Patient/Caregiver Observations

29 29 Why URAC? Educational Approach Standards are Less Prescriptive Builds Upon Integration and Care Coordination Capabilities On-Site Review Component Standards Align to Meaningful Use Standards Progression to Risk Based Contracting & Population Health

30 Discussion and Questions 2012 URAC

31 31 For questions please contact: URAC 1220 L Street NW, Suite 400 Washington, D.C Cynthia Cook, RN, BSN Sr. Director of Business Development ccook@urac.org

32 Q&A If you would like to ask the presenter a question please submit it through the questions box on your control panel If you are dialed in through your telephone and would like to verbally ask the presenter a question, use the raise hand icon on your control panel and your line will be unmuted.

33 Resources Start to Finish: Patient-Centered Medical Home (PCMH) Recognition PCMH Resource Center Patient-Centered Medical Home (PCMH) Fact Sheet Health Policy Brief: Patient-Centered Medical Homes

34 Contact Us Dr. Jose Leon Clinical Quality Manager Rachel Logan, MPH Health Research Assistant Warren Brown Resource Manager Johnette Peyton, MS, MPH, CHES Health Promotion Project Manager Joy Oguntimein, MPH Health Research and Policy Analyst Devon LaPoint Management Analyst Please contact our team for Training and Technical Support