Patient Centered Medical Home 2011

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1 Patient Centered Medical Home 2011 NCQA Standards Rand David, MD, FACP Associate Professor of Medicine Director, Dept. of Ambulatory Care Mount Sinai School of Medicine Elmhurst Hospital Center I have no financial or other conflict of interest to report.

2 Goals and Objectives At the completion of this session, attendees will be able to: 1. recite the individual PCMH standards from memory 2. generate the necessary documentation to qualify their practice as a PCMH OR 1. explain the magnitude of the task of achieving PCMH accreditation 2. choose the right team members to begin the journey of creating a PCMH 3 Team Members Ambulatory Care Medical Director (or equivalent) Ambulatory Care Administrator IT Department Representative Residency Program Director Nursing Administrator Quality Management Personnel Project Manager Any and every other discipline on an ad hoc basis

3 PCMH 2011 Program Goals Emphasis on patient centered, team based care coordinated across the health care system Use of health information technology to improve the quality of care, including the use of secure, interactive electronic systems Incorporates aspects of CMS EHR Incentive Programs Emphasis on patient experience of care which is used to help implement quality improvement Focuses attention on aspects of primary care that improve quality and reduce cost (overall cost and for the practice) Enhanced use of clinical performance measure results Integrates behaviors affecting health, substance abuse, mental health and risk factor assessment and care management Standards and explanations are more inclusive of pediatric practices 5 The six standards align with the core components of primary care. 6

4 New Elements and Concepts in PCMH 2011 PCMH 2011 Standards 1E 2C 3A 3B 3D PCMH 2011 Element Titles Medical Home Responsibilities Comprehensive Health Assessment Implement Evidence guidelines Identify High Risk Patients Medication Management Critical Factors Description of Change New Element: Process and materials provided to patients and families on the roll of the medical home New Element: Physical assessment and examination of social and behavioral influences Introduces conditions related to unhealthy behaviors, mental health or substance abuse problems New Element and population group: Identify and measure percent in patient population New Element: Review and reconcile medications, provide information, assess patient/family understanding of and response to medications, including adherence barriers A factor that is required for practices to receive more than minimal points, or in some cases any points for the element. Critical factors are identified in the scoring section of the element. 7 PCMH Scoring and Must Pass Elements 6 standards = 100 points 6 Must Pass elements Must Pass elements require a 50% performance level to pass 1A: Access During Office Hours 2D: Use Data for Population Management 3C: Manage Care 4A: Self Care Process 5B: Referral Tracking and Follow Up 6C: Implement Continuous Quality Improvement Level of Qualifying Points Must Pass Elements at 50% Performance Level Level of 6 Level of 6 Level of 6 Not Recognized 0 34 < 6 Practices with a numeric score of 0 to 34 points and/or less than 6 Must Pass Elements are not Recognized. 8

5 PCMH 1: Enhance Access and Continuity Standard s Intent Patients have access to routine/urgent care and clinical advice during/after hours that are culturally and linguistically appropriate Electronic access Clinician selected by patient Team based care; trained staff Elements PCMH 1 A: Access During Office Hours MUST PASS PCMH 1 B: After Hours Access PCMH 1 C: Electronic Access PCMH 1 D: Continuity PCMH 1 E: Medical Home Responsibilities PCMH 1 F: Culturally and Linguistically Appropriate Services (CLAS) PCMH 1 G: The Practice Team 9 PCMH 1 A: Access During Office Hours Must Pass Element PCMH 1 B: Access After Office Hours Practice has written process/standards and demonstrates that it monitors performance against the standards to: Provide same day appointments (1A,Critical Factor) Provide access to routine and urgent care outside business hours (extended hours) (1B) Provide continuity of medical record information for care and advice when office is closed (1B) Provide timely advice by telephone during (1A) and after office hours (1B, Critical Factor) Provide timely advice by secure electronic message during office hours (1A) and by an interactive electronic system when office is closed (1B) Document clinical advice in the medical record (1A and 1B) Documented process for all factors in 1A and 1B Reports showing same day and after hours availability, telephone and electronic response times Screen shots or copies of documented clinical advice Materials that communicate practice hours 10

6 PCMH 1C: Electronic Access Practice provides through a secure electronic system: 1. Electronic copy of health information within 3 days to patients who request it 2. Electronic access to current health information within 4 days to patients 3. Clinical summaries provided for office visits within 3 days 4. Two way communication 5. Request for appointments or prescription refills 6. Request for referrals or test results Report showing percentage of patients who received electronic copy of health information, access to requested health information, electronic clinical summaries (# 1 3: New Measures Required) Screen shots of its secure web site or portal, web page where patients can make requests and communication capability with patients (#4 6) 11 PCMH 1D: Continuity Practice provides continuity by: 1. Expecting patients to select a personal clinician 2. Documenting the choice of clinician 3. Monitoring percent of patient visits with clinician Documented process or materials for clinician selection Screen shot showing patients choice of clinician Report showing patient encounters with clinician 12

7 PCMH 1E: Medical Home Responsibilities Practice has process and provides materials about role of medical home and patient/family responsibilities: 1. Practice responsible for coordinating patient care (across settings) 2. How to obtain care/advice during/after office hours 3. Patients provide complete medical history and information on care obtained outside practice 4. Care team gives patient access to evidence based care and self management support Process for providing information and materials Materials provided to patients (patient brochures, Web site, written statement for patient/family 13 PCMH 1F: CLAS (PCMH B, 2A, 4A, 4B) Practice meets the cultural and linguistic needs of its patients: 1. Assesses racial/ethnic diversity of patients 2. Assesses language needs of patients 3. Provides interpretation services 4. Provides printed materials in patient language Report showing assessment of racial/ethnic/language of patients Documentation showing use of interpretation service Materials in other languages or website in other languages 14

8 PCMH 1G: The Practice Team Practice provides patient care services by: 1. Defining roles for clinical/nonclinical team members 2. Holding regular team meetings Critical factor 3. Using standing orders 4. Training and assigning care team to coordinate care 5. Training on self management, self efficacy and behavior change 6. Training on patient population management 7. Training on communication skills 8. Care team involvement in performance evaluation and QI Staff position descriptions Written standing orders Description of staff communication processes Description of training process, schedule, materials Description of how staff is involved in practice improvements 15 PCMH 2: Identify and Manage Populations Standard s Intent Electronic systems have searchable fields for demographic and clinical data Patients receive documented comprehensive health assessments Electronic systems used to identify patients who need services Elements PCMH 2A: Patient Information PCMH 2B: Clinical Data PCMH 2C: Comprehensive Health Assessment PCMH 2D: Use Data for Population Management MUST PASS 16

9 PCMH 2A: Patient Information (PCMH A ) Practice uses a searchable electronic system and records data more than 50% of the time for the following: Fields 1. Date of birth 2. Gender 3. Race 4. Ethnicity 5. Preferred language 6. Telephone numbers 7. E mail address 8. Dates of previous clinical visits 9. Legal guardian/health care proxy 10. Primary caregiver 11. Advance directives (NA for pediatrics) 12. Health insurance Documentation Electronic system reports showing percent of all patients for each individual populated data field Populated fields must contain information including: Did not provide None Refused to answer No Blank fields do not receive credit. 17 PCMH 2B: Clinical Data Practice uses a searchable electronic system to record the following data: 1. Up to date problem list of active diagnoses for patients 2. Allergies, including medications and reactions for patients 3. Blood pressure with the date of update for patients 4. Height, Weight (#5) and BMI (#6) 7. Length/height, weight head circumference (less than 2 years); BMI percentile (2 20); for pediatric patients for patients 8. Tobacco use status for patients 13 and older for patients 9. List of prescription medications with date of update of patients Factors 1 5, 8, and 9: Report showing percentage of all patients seen in last three months for each data field NCQA is not accepting chart reviews of patient samples Factors 6 and 7: Screen shots demonstrating capability 18

10 PCMH 2C: Comprehensive Health Assessment (PCMH 2008 Factors from 2A, 2B, 2D, 3B, 4A) Practice conducts and documents a health assessment: 1. Age and gender appropriate immunizations/screenings 2. Family/social/cultural characteristics 3. Communication needs 4. Medical history of patient and family 5. Advance care planning (NA for pediatrics) 6. Behaviors affecting health 7. Patient and family mental health/substance abuse 8. Developmental screening using standardized tool (NA for adult only practices) 9. Depression screening for teens/adults using standardized tool Report or a completed patient assessment (de identified) 19 PCMH 2D: Use Data for Population Management Must Pass Element Practices uses patient data and evidence based guidelines to generate lists and remind patients about needed services: 1. At least three different preventive care services 2. At least three different chronic care services 3. Patients not recently seen by the practice 4. Specific medications 1. Lists or summary reports of patients who need services: Reports must contain at least three different immunizations/screenings and three different acute/chronic care services 2. Materials demonstrating patient notification 20

11 PCMH 3: Plan and Manage Care Standard s Intent Practice implements evidence based guidelines High risk patients identified Care team performs care management through pre visit planning, developing plan and treatment goals Elements PCMH 3A: Implement Evidence Based Guidelines PCMH 3B: Identify High Risk Patients PCMH 3C: Care Management MUST PASS PCMH 3D: Medication Management PCMH 3E: Use Electronic Prescribing 21 PCMH 3A: Implement Evidence Based Guidelines Practice implements guidelines through point of care reminders for patients with: 1. The first important condition 2. The second important condition 3. The third condition, related to unhealthy behaviors or mental health or substance abuse Documentation Identification of 3 conditions (cannot be screening or a single preventive service process) Name and source of guidelines Demonstration of how guidelines are implemented 22

12 PCMH 3B: Identify High Risk Patients The practice does the following to identify high risk patients: 1. Establishes criteria and a process to identify high risk or complex patients 2. Determines the percentage of high risk patients in the population Note: A sample of high risk patients will be used in the medical record reviews for 3C, 3D, and 4A. Process to identify patients Report showing number and percentage of high risk patients 23 PCMH 3C: Care Management Must Pass Element Care team performs the following for at least 75% of patients from Elements A and B: 1. Conducts pre visit preparations 2. Collaborates with patient to develop care plan, including treatment goals 3. Gives patient written care plan 4. Assesses and addresses barriers to treatment goals 5. Gives patient clinical summary at relevant visits 6. Identifies patients who need more care management support 7. Follows up with patients who have not kept important appointments Report from electronic system or submission of Record Review Workbook 24

13 PCMH 3D: Medication Management Practice manages medications in the following ways: 1 & 2: Reviews and reconciles medications for care transitions (Critical factor) 3. Provides information about new prescriptions to patients 4. Assess patient understanding of medications for patients 5. Assesses patient response to medication and barriers to adherence for patients 6. Documents OTCs and herbal/supplements for patients, with date of update Report from electronic system or submission of Record Review Workbook 25 PCMH 3E: Use Electronic Prescribing Practice uses e prescribing system with the following capabilities: 1. Generates and transmits prescriptions to pharmacies 2. Generates at least 75% of eligible prescriptions 3. Integrates with patient medical records 4. Performs patient specific checks for drug drug and drug allergy interactions 5. Alerts prescribers to generic alternatives 6. Alerts prescribers to formulary status 1. Factors 1 2: Reports showing percent of electronic prescriptions written and transmitted 2. Factors 3 6: Screen shots demonstrating the system s capabilities 26

14 PCMH 4: Provide Self Care Support and Community Resources Standard s Intent Practice provides self care tools and support to patients Practice identifies and refers patients to community resources Elements PCMH 4A: Support Self Care Process MUST PASS PCMH 4B: Provide Referrals to Community Resources 27 PCMH 4A: Support Self Care Process Must Pass Element Practice conducts activities to support patients in self management: 1. Provides education resources or refers patients to educational resources 2. Uses EHR to identify education resources and provide them to patients 3. Collaborates with patients to develop and document selfmanagement plans and goals Critical factor 4. Documents self management abilities for patients 5. Provides self management result recording tools to patients 6. Counsels patients on adopting healthy lifestyles Report from electronic system or submission of Record Review Workbook 28

15 PCMH 4B: Provide Referrals to Community Resources Practice supports patients who need access to community resources: 1. Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support) 2. Tracks referrals provided to patients 3. Arranges for or provides treatment for mental health/substance abuse disorders 4. Offers opportunities for health education and peer support List of community services or agencies Referral log or report covering at least one month Processes to provide/arrange for mental health/substance abuse treatment and health education support PCMH 5: Track and Coordinate Care Standard s Intent Track and follow up on lab and imaging results Track and follow up on referrals Coordinates care received at hospitals and other facilities Elements PCMH 5A: Test Tracking and Follow Up PCMH 5B: Referral Tracking and Follow Up MUST PASS PCMH 5C: Coordinate with Facilities and Care Transitions 30

16 PCMH 5A: Test Tracking and Follow Up Practice has documented process for and demonstrates: 1. Tracks lab tests and flags and follows up on overdue results Critical factor 2. Tracks imaging tests and flags and follows up on overdue results Critical factor 3. Flags abnormal lab results 4. Flags abnormal imaging results 5. Notifies patients of normal and abnormal lab/imaging results 6. Follows up on newborn screening (NA for adults) 7. Electronically order and retrieve lab tests and results 8. Electronically order and retrieve imaging tests and results 9. Electronically incorporates lab results in records 10. Electronically incorporate imaging test results into records Factors 1 6: Staff process or procedure and an example of how each are met Factors 7 10: Electronic system examples 31 PCMH 5B: Referral Tracking & Follow Up Must Pass Element Practice coordinates referrals: 1. Provides specialist with reason and key information for the referral 2. Tracks referral status 3. Follows up to obtain specialist reports 4. Has agreements with specialists documented in the record 5. Asks patients about self referrals and requests specialist reports 6. Demonstrates electronic exchange of key clinical information 7. Provides electronic summary of care for referrals Reports or logs demonstrating tracking system data collection Documented processes with three examples Reports from electronic system showing frequency of information exchange and summary of care records 32

17 PCMH 5C: Coordinate with Facilities and Care Transitions Practice systematically demonstrates: 1. Process to identify patients with hospital admissions or ED visits 2. Process to share clinical information with hospital/ed 3. Process to obtain patient discharge summaries 4. Process to contact patients for follow up care after discharge 5. Process to exchange patient information with hospital 6. Collaboration with patient to develop written care plan for transitions from pediatric to adult care (NA for adults) 7. Electronic exchange of key clinical information with facilities 8. Provides electronic summary of care for transitions of care Factors 1 5: Documented processes for patient identification, providing clinical information, systematic follow up, obtaining discharge summaries and two way communication plus examples of each Factor 6: Copy of a written transition care plan Factor 7: Reports illustrating electronic information exchange Factor 8: Electronic report summarizing % of records sent for transitions of care 33 PCMH 6: Measure and Improve Performance Standard s Intent Measure preventive, chronic and acute care; utilization affecting costs; patient experience and report performance Use and monitor effectiveness of quality improvement process Elements PCMH 6A: Measure Performance PCMH 6B: Measure Patient/Family Experience PCMH 6C: Implement Continuous Quality Improvement MUST PASS PCMH 6D: Demonstrate Continuous Quality Improvement PCMH 6E: Report Performance PCMH 6F: Report Data Externally 34

18 PCMH 6A: Measure Performance Practice measures or receives the following data: 1. Three (3) preventive care measures 2. Three (3) chronic or acute care measures 3. Two (2) utilization measures affecting health care costs 4. Vulnerable population data Reports showing performance 35 PCMH 6B: Measure Patient/Family Experience Practice obtains feedback on patient experience with the practice and their care: 1. Practice conducts survey measuring experience on at least three (3) of the following: access, communication, coordination, whole person care 2. Practice uses PCMH CAHPS CG survey tool 3. Practice obtains feedback from vulnerable populations 4. Practice obtains feedback through qualitative means Reports showing results of patient feedback 36

19 PCMH 6C: Implement Continuous Quality Improvement Must Pass Element Practice uses ongoing quality improvement process: 1. Set goals and act to improve performance on three (3)measures from Element 6A 2. Set goals and act to improve performance on one (1)measure from Element 6B 3. Set goals and address at least one (1) identified disparity in care for vulnerable populations 4. Involve patients in QI teams or on the practice s advisory council Factors 1 3: Report or completed PCMH Quality Measurement and Improvement worksheet Factor 4: Process and examples demonstrating how it involves patients/families in QI teams or advisory council 37 PCMH 6D: Demonstrate Continuous Quality Improvement Practice demonstrates ongoing monitoring of the effectiveness of its improvement process: 1. Tracks results over time 2. Assesses effect of its actions 3. Achieves improved performance on one measure 4. Achieves improved performance on a second measure Reports showing measures over time, recognition results or completed Quality Improvement Measurement and Improvement Worksheet 38

20 PCMH 6E: Report Performance Practice shares data from Element A and B: 1. Individual clinician results within the practice 2. Practice results within the practice 3. Individual clinician or practice results to patients or public Blinded reports showing summary data and an explanation of how it provides results within the practice Blinded reports showing summary data 39 PCMH 6F: Report Data Externally Practice electronically reports: 1. Ambulatory clinical quality measures to CMS 2. Data to immunization registries or systems 3. Syndromic surveillance data to public health agencies Reports demonstrating data submission to CMS and public health agencies. 40

21 Thank You!