Topic 3B: Documentation Prep for NCQA Recognition Focus on Standards 3, 4, and 1F Diane Altman Dautoff, MSW, EdD, Senior Consultant Heather Russo, Consultant January 2013
Welcome Introductions and Housekeeping lori.hooks@tmf.org FQHC_MH_DEMO@cms.hhs.gov PCMH-GRIP@ncqa.org http://www.ncqa.org/gri Please visit the AIR FQHC Learning Portal for more information on upcoming events at http://fqhcportal.airprojects.org Speaker introductions 2
PCMH Transformation Framework 3
Learning Objectives Understand documentation requirements for NCQA PCMH TM 2011 recognition by Standard, Element and Factor Understand formatting tips for outlining documentation in a clear and understandable manner Review documentation examples and tips for formatting documentation for submission 4
Session Road Map Documentation Tips PCMH Standard 3 Plan and Manage Care: Element A: Implement Evidence-Based Guidelines (4 points) Element B: Identify High- Risk Patients (3 points) Element C: Care Management (4 points) (Must Pass) Element D: Medication Management (3 points) Element E: Use Electronic Prescribing (3 points) PCMH Standard 4 Provide Self-Care Support and Community Resources: Element A: Support Self-Care Process (6 points) (Must Pass) Element B: Provide Referrals to Community Resources (3 points) PCMH Standard 1 Enhance Access and Continuity: * Element A: Access and Continuity (4 points) (Must Pass) Element B: After-Hours Access (4 points) Element C: Electronic Access (2 points) Element D: Continuity (2 points) Element E: Medical Home Responsibilities (2 points) Element F: Culturally and Linguistically Appropriate Services (2 points) Element G: The Practice Team (4 points) * This webinar covers element F of PCMH Standard 1. Elements A, B, C, D, E, and G of Standard 1 will be covered in other webinars. 5
General Tips on Documentation Accentuate information for the NCQA surveyor Format documentation in a clear and organized manner Include a narrative description as a summary of information presented in the documentation Save documentation for a single element into one document, with sub-headers for each factor 6
General Tips on Documentation (Cont d) Reports: Include the name of the report, reporting period, numeric values of the numerator and denominator Policies: Include date of most recent update Screen shots: use real patient data, de-identified Policies, procedures and job descriptions must not be younger than 3-months from date of submission. Data must not be older than 12-months. 7
Example of Documentation Formatting 8
PCMH 3: Plan and Manage Care The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines. Elements: A. Implement Evidence-Based Guidelines (4 points) B. Identify High-Risk Patients (3 points) C. Care Management (4 points) (Must Pass) D. Medication Management (3 points) E. Use Electronic Prescribing (3 points) 9
PCMH 3A: Implement Evidence-Based Guidelines Practice implements evidence-based guidelines through point-of-care reminders for patients with: Factors: 1. The first important condition 2. The second important condition 3. The third condition, related to unhealthy behaviors or mental health or substance abuse (Critical Factor) 10
PCMH 3A Scoring 4 points for this element Scoring: 3 factors = 100% 2 factors (including factor 3 [critical factor]) = 50% 1 factor = 25% 0 factors = 0% 11
PCMH 3A Documentation Example Example of format: XXX Clinic s Three Important Conditions: 1. Name First Condition Here (ex. Diabetes) List name and source of evidence-based guidelines for first condition 2. Name Second Condition Here List name and source of evidence-based guideline for second condition 3. Name Third Condition Here List name and source of evidence-based guideline for third condition, related to unhealthy behavior, mental health or substance abuse 12
PCMH 3A-1, 3A-2 or 3A-3 Documentation Example 13
PCMH 3A-1, 3A-2, or 3A-3 Documentation Example 14
PCMH 3A-1, 3A-2, or 3A-3 Documentation Example 15
PCMH 3A-1, 3A-2, or 3A-3 Documentation Example 16
PCMH 3B: Identify High-Risk Patients To identify high-risk or complex patients, the practice: Factors: 1. Establishes criteria and a systematic process to identify high-risk or complex patients 2. Determines the percentage of high-risk patients in its population. 17
PCMH 3B Scoring 3 points for this element Scoring: 2 factors = 100% 1 factor = 25% 0 factors = 0% 18
PCMH 3B-1 Documentation Example High-Risk Patient Definition: Patients with co-morbidities of diabetes and hypertension Process for Identification: Patients diagnosed with diabetes and hypertension will receive a high-risk flag in the EHR. Once a month, the Nurse Manager will run a report to determine if there are any patients newly meeting this criteria. If so, the Nurse Manager will designate these patients within the EHR with a high-risk flag. 19
PCMH 3B-2 Documentation Example 20
PCMH 3C: Care Management (Must Pass) The care team performs the following for at least 75 percent of the patients identified in Elements A and B. Factors: 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments 21
PCMH 3C Scoring (Must Pass) 4 points for this element Scoring: 6-7 factors = 100% 5 factors = 75% 3-4 factors = 50% 1 factor = 25% 0 factors = 0% 22
Record Review Workbook 48 patient records 12 high-risk patient records 36 patient records of the three important conditions (12 patient records x 3 separate conditions) 3C: Care Management (Must Pass) 3D: Medication Management 4A: Support Self-Care Process (Must Pass) 23
Record Review Workbook 24
Record Review Workbook 25
Record Review Workbook 26
Record Review Workbook 27
Record Review Workbook 28
Record Review Workbook 29
PCMH 3C: Care Management (Must Pass) The care team performs the following for at least 75 percent of the patients identified in Elements A and B. Factors: 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments 30
PCMH 3D: Medication Management The practice manages medications in the following ways: Factors: 1. Reviews and reconciles medications with patients/families for more than 50% of care transitions (Critical Factor) 2. Reviews and reconciles medications with patients/families for more than 80% of care transitions 3. Provides information about new prescriptions to more than 80% of patients/families 4. Assesses patient/family understanding of medications for more than 50% of patients with date of assessment 5. Assesses patient response to medications and barriers to adherence for more than 50% of patients with date of assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients/families, with the date of updates 31
PCMH 3D Scoring 3 points for this element Scoring: 5-6 factors (including factor 1 [critical factor]) = 100% 3-4 factors (including factor 1) = 75% 2 factors (including factor 1) = 50% Only factor 1 = 25% 0 factors or does not meet factor 1 = 0% 32
Record Review Workbook 33
PCMH 3D: Medication Management The practice manages medications in the following ways: Factors: 1. Reviews and reconciles medications with patients/families for more than 50% of care transitions (Critical Factor) 2. Reviews and reconciles medications with patients/families for more than 80% of care transitions 3. Provides information about new prescriptions to more than 80% of patients/families 4. Assesses patient/family understanding of medications for more than 50% of patients with date of assessment 5. Assesses patient response to medications and barriers to adherence for more than 50% of patients with date of assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients/families, with the date of updates 34
PCMH 3E: Use Electronic Prescribing The practice uses e-prescribing system with the following capabilities: Factors: 1. Generates and transmits at least 40% of eligible prescriptions to pharmacies 2. Generates at least 75% of eligible prescriptions (Critical Factor) 3. Enters electronic medication orders into the medical record for more than 30% of patients with at least one medication in their medication list 4. Performs patient-specific checks for drug-drug and drug-allergy interactions 5. Alerts prescribers to generic alternatives 6. Alerts prescribers to formulary status 35
PCMH 3E Scoring 3 points for this element Scoring: 5-6 factors (including factor 2 [critical factor]) = 100% 4 factors (including factor 2) = 75% 2-3 factors (including factor 2) = 50% 1 factor or 2-5 (but not factor 2)= 25% 0 factors = 0% 36
PCMH 3E-1 Documentation Example 37
PCMH 3E-2 Documentation Example 38
PCMH 3E-3 Documentation Example 39
PCMH 3E-4 Documentation Example 40
PCMH 3E-5 Documentation Example 41
PCMH 3E-6 Documentation Example 42
PCMH 4: Provide Self-Care Support and Community Resources The practice acts to improve patients ability to manage their health by providing a self-care plan, tools, educational resources and ongoing support. Elements: A. Support Self-Care Process (6 points) (Must Pass) B. Provide Referrals to Community Resources (3 points) 43
PCMH 4A: Support Self-Care Process (Must Pass) The practice conducts activities to support patients/families in self-management: Factors: 1. Provides educational resources or refers at least 50% of patients/families to educational resources to assist in self-management 2. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients, if appropriate 3. Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families (Critical Factor) 4. Documents self-managements abilities for at least 50% of patients/families 5. Provides self-management tools to record self-care results for at least 50% of patients/families 6. Counsels at least 50% of patients/families to adopt healthy behaviors 44
PCMH 4A Scoring (Must Pass) 6 points for this element Scoring: 5-6 factors (including factor 3 [critical factor]) = 100% 4 factors (including factor 3) = 75% 3 factors (including factor 3) = 50% 1-2 factors or 3-5 (but not factor 3)= 25% 0 factors = 0% 45
Record Review Workbook 46
PCMH 4A: Support Self-Care Process (Must Pass) The practice conducts activities to support patients/families in self-management: Factors: 1. Provides educational resources or refers at least 50% of patients/families to educational resources to assist in self-management 2. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients, if appropriate 3. Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families (Critical Factor) 4. Documents self-managements abilities for at least 50% of patients/families 5. Provides self-management tools to record self-care results for at least 50% of patients/families 6. Counsels at least 50% of patients/families to adopt healthy behaviors 47
PCMH 4B: Provide Referrals to Community Resources Practice support patients who need access to community resources: Factors: 1. Maintains current resource list covering five (5) community service areas. 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 48
PCMH 4B Scoring 3 points for this element Scoring: 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% 49
PCMH 4B-1 Documentation Example 50
PCMH 4B-2 Documentation Example 51
PCMH 4B-3 Documentation Example Example Policy Excerpt Behavioral Health Referral Procedures Effective 12/10/2011 1. Evaluation Outpatient: Patients who are assessed by their provider to be in need of Behavioral Health care will be evaluated by the Behavioral Health Consultant. Based on the outcome of that assessment, the Behavioral Health consultant will either resolve or agree to manage the patient within the clinic or arrange for or refer care to one of the resources listed below. Inpatient: Following assessment by either their provider or the Behavioral Health Consultant, patients in need of voluntary psychiatric care will have their care coordinated by the care team. Refer to Inpatient Admission procedures for inpatient care coordination. If involuntary psychiatric admission is determined to be necessary, refer to the Involuntary Admission policy and procedure. 2. Referrals Adults and adolescents who are experiencing psychiatric, emotional, behavioral and/or addictive disorders should be referred to the services provided by ABCD Hospital Center, unless the provider has identified another facility to meet the immediate needs of the patient. 52
PCMH 4B-4 Documentation Example XYZ Community Health Center Asthma Health Education Program for Adults For 2012, this program is scheduled the first Tuesday of the month, 7-8:30pm If you have asthma, you may breathe easier when you join our innovative program, which complements your doctor's care. All participants, ages five and older, have access to professional care specialists and educational materials to help them better understand and manage their asthma. If you participate in the program, we can help you understand: Your asthma medications How to properly use an inhaler device and peak flow meter How to develop an action plan Understand the danger signs when you have symptoms For more information, please call 1-888-xxx-9006, 53
PCMH 1: Enhance Access and Continuity The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: Elements: * A. Access During Office Hours (4 points) (Must Pass) B. After-Hours Access (4 points) C. Electronic Access (2 points) D. Continuity (2 points) E. Medical Home Responsibilities (2 points) F. Culturally and Linguistically Appropriate Services (2 points) G. The Practice Team (4 points) * This webinar focuses only element F. 54
PCMH 1F: Culturally and Linguistically Appropriate Services The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by: Factors: 1. Assessing the racial and ethnic diversity of its population 2. Assessing the language needs of its population 3. Providing interpretation or bilingual services to meet the language needs of its population 4. Providing printed materials in the languages of its population 55
PCMH 1F Scoring 2 points for this element Scoring: 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factor = 25% 0 factors = 0% 56
PCMH 1F-1 Documentation Example Patients By Ethnicity 1/1/2012 12/31/2012 Non- Total Refused to Hispanic/La Hispanic/La Unique Report tino tino Patients # 124 198 523 845 % 15% 23% 62% 100% Patients By Race 1/1/2012 12/31/2012 American Indian or Hawaiian or Pacific Islander Other Total Unique Patients Refused African Alaska to Report White American Native Asian # 56 423 267 45 29 2 23 845 % 7% 50% 32% 5% 3% 0% 3% 100% 57
PCMH 1F-2 Documentation Example Patients By Language English Spanish Other Total # 667 155 23 845 % 79% 18% 3% 100% 58
PCMH 1F-3 Documentation Example 59
PCMH 1F-4 Documentation Example 60
Review of Session Utilize NCQA Standards, Policies and Procedures as a resource Ensure the information presented in your documentation is clear and easy to understand Create and modify documentation for your practice, not for NCQA Create a plan for completing documentation, prioritize Must Pass Elements Stay focused on the purpose: to enhance patient care 61
Acknowledgment This presentation was produced by Qualis Health under a contract with the American Institutes for Research (AIR), with funding from the Center for Medicare & Medicaid Innovation, as part of the Federally Qualified Health Center (FQHC) Advanced Primary Car Practice Demonstration (contract no. GS-10F-0112J, order no. HHSM-500-2011-00147G). AIR would like to thank its partners the National Association of Community Health Centers, Inc.; Qualis Health; and the MacColl Center for Health Care Innovation at Group Health Research Institute for assisting with this endeavor. 62