BCBSM Physician Grup Incentive Prgram Patient-Centered Medical Hme Dmains f Functin Interpretive Guidelines September 2010
Table f Cntents Page 1.0 PATIENT-PROVIDER PARTNERSHIP 1 2.0 PATIENT REGISTRY 4 3.0 PERFORMANCE REPORTING 9 4.0 INDIVIDUAL CARE MANAGEMENT 12 5.0 EXTENDED ACCESS 18 6.0 TEST RESULTS TRACKING & FOLLOW-UP 21 7.0 *** currently unused; previusly used t cllect evidence-based care data 8.0 *** used t cllect self-reprted E-Prescribing data*** 9.0 PREVENTIVE SERVICES 23 10.0 LINKAGE TO COMMUNITY SERVICES 26 11.0 SELF-MANAGEMENT SUPPORT 29 12.0 PATIENT WEB PORTAL 31 13.0 COORDINATION OF CARE 33 14.0 SPECIALIST REFERRAL PROCESS 35
Blue Crss Blue Shield f Michigan Physician Grup Incentive Prgram Patient-Centered Medical Hme Dmains f Functin Interpretive Guidelines Under Blue Crss Blue Shield f Michigan s (BCBSM) Physician Grup Incentive Prgram (PGIP), Patient-Centered Medical Hme (PCMH)-based infrastructure and care prcesses have been rganized int 12 Dmains f Functin (listed in Table f Cntents). Each PCMH Dmain f Functin has a set f required capabilities, cllabratively develped by BCBSM and PGIP Physician Organizatins (POs). T prvide further infrmatin regarding the definitin f each required capability, a BCBSM-PO team was assembled t review and finalize these PCMH Interpretive Guidelines. Any capability reprted t BCBSM as in place must be fully in place and in use by all apprpriate members f the practice unit team n a rutine and systematic basis. Clinical Practice Unit teams shuld be cmpsed f clinicians, defined as physicians, nurse practitiners, r physician assistants (unless therwise specified in the guidelines). Capabilities are nt necessarily listed in sequential rder (except fr patientprvider partnership capabilities) and may be implemented in any sequence the PO and/r practice unit feels is mst suitable t their practice transfrmatin strategy. Nte: Dmains 7 and 8 are nt included in this dcument. Dmain 7 was previusly used t cllect evidence-based care data, and Dmain 8 is used t cllect self-reprted electrnic prescribing data. 1.0 Patient-Prvider Partnership 1.1 Practice unit has develped PCMH-related patient cmmunicatin tls, has trained staff, and is prepared t implement patient-prvider partnership with each established patient, which may cnsist f a signed agreement r ther dcumented patient cmmunicatin prcess t establish patientprvider partnership - Patient cmmunicatin prcess must include a cnversatin between the patient and a member f the clinical practice unit team. In extenuating circumstances, well-trained Medical Assistants wh are highly engaged with patient care may be cnsidered a member f the clinical practice unit team. 1
- The patient-prvider partnership must nly be established ne time per patient. - Dcumentatin may cnsist f nte in medical recrd, sticker placed n frnt f the chart, indicatr in patient registry, patient lg, r similar system that can be used t identify the percent f patients with whm the partnership has been discussed. - Dcuments and patient educatin tls are develped that explain PCMH cncepts and utline patient and prvider rles and respnsibilities. - Practice unit team members and all apprpriate staff are educated/trained n patient-prvider partnership cncepts and patient cmmunicatin prcesses - Prcess has been established fr patients t receive PCMH infrmatin, and fr practitiner t have cnversatin with patients abut PCMH patientprvider partnership. - Mechanism and prcess has been develped t dcument establishment f patient-prvider partnership in medical recrd r patient registry. 1.2 Prcess f reaching ut t established patients is underway, and practice unit is using a systematic apprach t infrm patients abut PCMH, including patients wh d nt visit the practice regularly - Established patients are defined as, at a minimum, all patients within the practice (regardless f insurance cverage) wh were seen within the past 12 mnths. - Outreach may cnsist f distributin f material at time f visit Outreach may als (but is nt required t) include mailings, emails, websites, telephne utreach, r ther electrnic means, prviding the mechanism incrprates an active push functin t cmmunicate with patients, including thse wh d nt visit the practice regularly Mass mailings d nt meet the requirements fr 1.3 thrugh 1.8 Outreach materials shuld explain the PCMH cncept and patient-prvider partnership Fr any reference t a practice having BCBSM Designatin status please reference BCBSM s recmmended language fr cmmunicatins t patients frm PCMH-Designated practices 1.3 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 10% f current patients - Current patients are defined as patients wh the practice unit cnsiders t be active in the practice (e.g., practices may define current as seen within the past 12 mnths r 24 mnths) - Establishment f patient-prvider partnership must include cnversatin between patient and a member f the practice unit clinical team BCBSM PCMH Interpretive Guidelines September 2010 2
In extenuating circumstances, well-trained Medical Assistants wh are highly engaged with patient care may be cnsidered a member f the clinical practice unit team. Cnversatin shuld preferably take place in persn, but may take place ver phne in extenuating circumstances, fr a limited number f patients Other team members may begin the cnversatin, r fllw-up after physician cnversatin with mre detailed discussin/infrmatin, but a clinical team member must participate in at least part f the patientprvider partnership cnversatin - Cnversatin may be dcumented in medical recrd, patient registry, r ther type f list. - Practice must als have mechanism t track percent f patients that have established partnership, and be able t prvide data during site visit shwing denminatr (ttal number f current patients in the practice) and numeratr (ttal number f patients with whm cnversatins have been held and partnerships established at any pint in the past, wh are in the denminatr). 1.4 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 30% f current patients - Reference 1.3 1.5 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 50% f current patients - Reference 1.3 1.6 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 60% f current patients - Reference 1.3 1.7 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 80% f current patients BCBSM PCMH Interpretive Guidelines September 2010 3
1.8 Patient-prvider agreement r ther dcumented patient cmmunicatin prcess is implemented and dcumented fr at least 90% f current patients - Reference 1.3 2.0 Patient Registry - A patient registry is a database that cntains clinical data n patients t enable prviders t manage their ppulatin f patients. - Registry data must be in the frm f data fields that are accessible fr tabulatin and ppulatin management - Registry may be paper r electrnic. - Registry must include all established patients with the disease referenced in the capability, regardless f insurance cverage (including Medicare patients). - Patients assigned by managed care rganizatins d nt have t be included in registry if they are nt established patients (reference 2.15). - Patient infrmatin may be entered by the practice, ppulated frm EMR r ther electrnic r manual surces, r ppulated with payer-prvided data Registry must include data pertinent t the clinical perfrmance measures cntained in the EBCR (e.g., BCBSM-prvided data r similar data frm ther surces) - Registry may initially be a cmpnent f EMR fr basic-level functining, as lng as the practice r the PO has the capability t use the EMR t generate rutine ppulatin-level perfrmance reprts and reprts n subsets f patients requiring active management. Subsets f patients requiring active management refers t thse patients with particular chrnic illness management needs including but nt limited t thse wh have particular physilgic parameters ut f cntrl r wh have nt received specified, essential services - Practice Units with registries and EMRs may elect t use EMR, prvided it has the capabilities t prduce ppulatin-level infrmatin in an autmated r semi-autmated frm. - Reference AAFP article fr additinal infrmatin n creating a registry: http://www.aafp.rg/fpm/20060400/47usin.html - Fr all Patient Registry capabilities except 2.9, registry may be paper r electrnic. A fully electrnic registry may be the last capability t be implemented. - Eight f the Patient Registry capabilities identify the ppulatin(s) f patients included in the registry. The ther ten Patient Registry capabilities pertain t registry functinality. All capabilities pertaining t functinality that are marked as in place must be in place fr each ppulatin f patients marked as included in the registry. BCBSM PCMH Interpretive Guidelines September 2010 4
2.1 A paper r electrnic all-payer registry is being used t manage all established patients in the Practice Unit with: Diabetes - Reference definitin under 2.0. 2.2 Registry incrprates patient clinical infrmatin, fr all established patients in the registry, fr a substantial majrity f health care services received at ther sites that are necessary t manage chrnic care and preventive services fr the ppulatin - Registry may be paper r electrnic - All patients in the registry may cnsist, fr example, f diabetes patients nly, if practice unit has nly implemented task 2.1. - The registry is nt expected t cntain clinical infrmatin n all health care services received at any site fr 100% f patients in the registry, but is expected t cntain a critical mass f infrmatin frm varius surces, including the PO s r practice unit s wn practice management system, and electrnic r ther recrds frm facilities with which the PO r practice unit is affiliated - Other sites and service types are defined as labs, inpatient admissins, ER, UCC, and pharmaceuticals (with dates and diagnses where applicable). - The definitin f substantial majrity f health care services is threequarters f preventive and chrnic cnditin management services rendered t patients. - If registry is paper, infrmatin may be extracted frm recrds and recrded in registry manually, and must be in the frm f an accessible data field 2.3 Registry incrprates evidence-based care guidelines - Registry functinality may be paper r electrnic. - Guidelines shuld be drawn frm recgnized, validated surces at the state r natinal level (e.g., MQIC Guidelines, USPSTF). - Determinatin f which evidence-based care guidelines t use shuld be based n judgment f practice leaders. 2.4 Registry infrmatin is available and in use by the Practice Unit team at the pint f care - Registry functinality may be paper r electrnic. BCBSM PCMH Interpretive Guidelines September 2010 5
- Practice unit has and is fully using the capability t generate up-t-date, integrated individual patient reprts at the pint and time f care t be used during the visit. - EMR wuld meet the requirements f this capability prvided it has evidencebased guidelines embedded in the tl, and relevant infrmatin is identified and imprted int screens r reprts that facilitate easy access t all relevant data elements particular t the cnditins under management, fr the purpse f guiding pint f care services. 2.5 Registry cntains infrmatin n the individual attributed practitiner fr every patient currently in the registry wh has a medical hme in the practice unit - Registry may be paper r electrnic - The individual practitiner respnsible fr the care f each patient is identified in the registry Occasinal gaps in infrmatin abut sme patients individual attributed practitiner due t changes in medical persnnel are acceptable 2.6 Registry is being used t generate rutine, systematic cmmunicatin t patients regarding gaps in care - Registry may be paper r electrnic. - Cmmunicatins may be manual, prvided there is a systematic prcess in place and in use fr generatin f regular and timely cmmunicatins t patients. - Cmmunicatins may be sent t patients via email, fax, regular mail, text messaging, r phne messaging. 2.7 Registry is being used t flag gaps in care fr every patient currently in the registry - Registry may be paper r electrnic. - Registry must have capability t identify all patients with gaps in care based n evidence-based guidelines incrprated in the registry. - EMR wuld meet the requirements f this capability if it can be used t prduce ppulatin level infrmatin n gaps in care fr chrnic cnditin patients. BCBSM PCMH Interpretive Guidelines September 2010 6
2.8 Registry incrprates infrmatin n patient demgraphics and key clinical parameters fr all patients currently in the registry - Registry may be paper r electrnic. - Registry must cntain all relevant patient demgraphics, such as name, gender, age. - Registry must cntain all key clinical indicatrs pertinent t the chrnic cnditin(s) being tracked in the registry, such as current levels fr HbA1c, LDL, BP, and micralbumin fr diabetics. 2.9 Registry is fully electrnic, cmprehensive and integrated, with analytic capabilities - Practice unit must have capability 2.2 in place in rder t receive credit fr 2.9 - All entities must flw electrnically int the registry - Data is hused electrnically - Linkages t ther surces f infrmatin (as defined in 2.2) are electrnic fr all facilities and ther health care prviders with whm the practice unit regularly share respnsibility fr health care. - Registry has ppulatin-level database and capability t electrnically prduce cmprehensive analytic integrated reprts that facilitate management f the entire ppulatin f the Practice Unit s patients. 2.10 Registry is being used t manage all patients with: Asthma - Reference 2.0 2.11 Registry is being used t manage all patients with Crnary Artery Disease (CAD) - Reference 2.0 2.12 Registry is being used t manage all patients with: Cngestive Heart Failure (CHF) - Reference 2.0 BCBSM PCMH Interpretive Guidelines September 2010 7
2.13 Registry is being used t manage patients with at least 2 ther chrnic cnditins fr which there are evidence-based guidelines and the need fr nging ppulatin and patient management, and which are sufficiently prevalent in the practice t warrant inclusin in the registry based n the judgment f the practice leaders - Examples f ther chrnic cnditins include (but are nt limited t) depressin r sickle cell anemia - Reference 2.0 2.14 Registry incrprates preventive services guidelines and is being used t generate rutine, systematic cmmunicatin t all patients in the practice regarding needed preventive services - Reference 2.0 - Registry must include all current patients in the practice, including well patients, regardless f insurance cverage and including Medicare patients - Preventive services guidelines must be drawn frm a recgnized state r natinal surce, such as HEDIS measures, CDC, r natinal guidelines that address standard primary and secndary preventive services (i.e., mammgrams, pap smears, clrectal screening, immunizatins, well-child visits, well adlescent visits). 2.15 Registry incrprates patients wh are assigned by managed care plans and are nt established patients in the practice - Patients assigned by managed care plans wh are nt established patients must be included in the registry, and active utreach cnducted t engage them as established patients 2.16 Registry is being used t manage all patients with: Chrnic Kidney Disease - Reference 2.0 2.17 Registry is being used t manage all patients with: Pediatric Obesity BCBSM PCMH Interpretive Guidelines September 2010 8
- Reference 2.0 2.18 Registry is being used t manage all patients with: Pediatric ADHD - Reference 2.0 3.0 Perfrmance Reprting - Perfrmance reprts are systematic, rutine reprts that prvide current, clinically meaningful health care infrmatin n the entire ppulatin f patients f all ages that are included in the registry (e.g., all diabetics, regardless f payr and including Medicare patients), allwing cmparisn acrss the ppulatin f patients, at a single pint in time. - The perfrmance reprts may be prduced and distributed n a regular basis by the PO r sub-po, as lng as the practice units have the capability t request and receive reprts n a timely basis. - Eight f the Perfrmance Reprting capabilities identify the ppulatin(s) f patients included in the reprts. The ther five Perfrmance Reprting capabilities pertain t reprt attributes. All capabilities pertaining t reprt attributes that are marked as in place must be in place fr each ppulatin f patients marked as included in the reprts. - 3.1 Perfrmance reprts that allw tracking and cmparisn f results at a specific pint in time acrss the ppulatin f patients are generated fr: Diabetes 3.2 Perfrmance reprts are generated at the PO/Sub-PO, Practice Unit, and individual prvider level - Perfrmance reprts prvide infrmatin and allw cmparisn at the PO/ Sub-PO, practice unit, and individual prvider level fr all patients currently in the registry, regardless f insurance cverage and including Medicare patients 3.3 Perfrmance reprts include patients with at least 2 ther chrnic cnditins fr which there are evidence-based guidelines and the need fr nging ppulatin and patient management, and which are sufficiently prevalent in the practice t warrant inclusin in the registry based n the judgment f the practice leaders BCBSM PCMH Interpretive Guidelines September 2010 9
- Reference 2.13 - Perfrmance reprts are being generated n the ppulatin f patients with at least 2 ther chrnic cnditins fr which there are evidence-based guidelines and the need fr nging ppulatin and patient management, and which are sufficiently prevalent in the practice t warrant inclusin in the registry based n the judgment f the practice leaders (regardless f insurance cverage and including Medicare patients). 3.4 Data cntained in perfrmance reprts has been fully validated and recnciled t ensure accuracy 3.5 Trend reprts are generated, enabling physicians and their POs/sub-POs t track, cmpare and manage perfrmance results fr their ppulatin f patients ver time - Perfrmance reprts include bth current and past health care infrmatin fr the ppulatin f patients currently in the registry (regardless f insurance cverage and including Medicare patients), allwing analysis and cmparisn f results acrss time (e.g., quarter t quarter, year t year). - Trend reprts must be generated by the PO/sub-PO at the individual prvider, practice unit, and sub-po/po level 3.6 Perfrmance reprts are generated fr the ppulatin f patients with: Pediatric Obesity - Reference Guidelines under 3.0 3.7 Perfrmance reprts include all current patients in the practice, including well patients, and include data n preventive services - Perfrmance reprts include all current patients in the practice, including well patients, as defined in 2.13. - Reprts include preventive services infrmatin 3.8 Perfrmance reprts include patient clinical infrmatin fr a substantial majrity f health care services received at ther sites that are necessary t manage chrnic care and preventive services fr the ppulatin BCBSM PCMH Interpretive Guidelines September 2010 10
- Reference guidelines fr Capability 2.2 - Fr all established patients in the registry, the perfrmance reprts are expected t include treatment infrmatin pertinent t standard quality metrics (e.g., use f beta blckers fllwing AMI) but are nt expected t cntain cmprehensive treatment infrmatin as this level f infrmatin is ften cntained in detailed narrative text in clinical ntes. - Reprtable items culd include diagnsis, and assciated labs, physilgic parameters such as bld pressure, medicatins r diagnstic services prvided during the encunter. 3.9 Perfrmance reprts include infrmatin n services prvided by specialists - Reference Guidelines under 3.0 - Infrmatin n key preventive r disease specific services prvided by specialists (e.g., b-gyn, phthalmlgists, pdiatrists, endcrinlgists) is incrprated int perfrmance reprts. 3.10 Perfrmance reprts are generated fr the ppulatin f patients with: Asthma - Reference Guidelines under 3.0 3.11 Perfrmance reprts are generated fr the ppulatin f patients with: Crnary Artery Disease [nt applicable t pediatric practices] - Reference Guidelines under 3.0 3.12 Perfrmance reprts are generated fr the ppulatin f patients with: Cngestive Heart Failure [nt applicable t pediatric practices] - Reference Guidelines under 3.0 3.13 Perfrmance reprts are generated fr the ppulatin f patients with: Pediatric ADHD - Reference Guidelines under 3.0 BCBSM PCMH Interpretive Guidelines September 2010 11
4.0 Individual Care Management 4.1 Practice Unit leaders and staff have been trained/educated and have cmprehensive knwledge f the Patient Centered-Medical Hme mdel, the Chrnic Care mdel, and practice transfrmatin cncepts - Training cntent shuld include cmprehensive infrmatin abut the Chrnic Care Mdel Reference infrmatin prvided at the Imprving Chrnic Illness Care website: http://www.imprvingchrniccare.rg - Training/educatinal activity is dcumented in persnnel r training recrds, and cntent material used fr training is available fr review. 4.2 Practice Unit has ability t deliver crdinated care management services with an integrated team f multi-disciplinary prviders and a systematic apprach is in place t deliver cmprehensive care that addresses patients' full range f health care needs - The integrated team f multi-disciplinary prviders must include an RN and at least 2 f the fllwing: certified diabetes educatr, nutritinist, respiratry therapist, PharmD, scial wrker, certified asthma health educatr r ther certified health educatr, r an NP and/r PA with training/experience in health educatin wh is actively engaged in care crdinatin/selfmanagement training separate frm their ffice visit E&M duties When they are unable t include RNs r PharmDs n the multidisciplinary care management team, individual practices may use LPNs r PharmD students, in which case these ancillary prviders with lesser training must be actively supervised by the physician and/r by a supervising RN r PharmD, respectively, with regard t the educatinal and care management interventins prvided t each individual patient. This supervisin may be prvided directly in the practice (e.g., by the primary care physician) r by staff emplyed by the Physician Organizatin. - Practice unit team members hld regular team meetings. - All members f the team d nt have t be at the same lcatin r at the practice site, but care delivered by the team must be crdinated and integrated with the PCMH practice. Care may be delivered by travel teams r at sites ther than the PCMH practice, prvided that: BCBSM PCMH Interpretive Guidelines September 2010 12
the care is fully crdinated by a PCMH practice team member r a health navigatr wh has nging cmmunicatin with the practice the PCMH practice is invlved in nging mnitring, fllw-up and reinfrcement f health educatin/training received by patients at ther sites mnitring includes practive utreach t patients t engage the patient in actively addressing nging health needs and health care gals n a lngitudinal basis The multi-disciplinary prviders are nt required t be emplyees f the PCMH practice, but must have an nging relatinship with, and cmmunicatin with, the practice team members Cmmunicatin can be a cmbinatin f verbal, written, and electrnic methds, preferably including sme direct verbal cmmunicatin and participatin in in-persn team meetings, althugh individual team members wh are nt n-site at a practice can make their infrmatin and perspective knwn t specific team members s that their infrmatin abut individual patients is actively cnsidered by the team as a rutine part f case review and planning The care management services must be crdinated and integrated with the patient s verall care plan Standard referrals t hspital-based diabetes educatrs with summary reprts sent back t the PCP d nt cnstitute care that is crdinated and integrated, and wuld nt meet the requirements fr capability 4.2 Referrals t hspital-based diabetes educatrs that take place in the cntext f an verall crdinated, integrated care plan and include cmmunicatin between the diabetes educatr and physician, as well as nging patient utreach and cmmunicatin, wuld meet the requirements fr capability 4.2 4.3 Systematic apprach is in place t ensure that evidence-based care guidelines are established and in use at the pint f care by all team members f the Practice Unit - Guidelines are available and used at the pint f care by all clinical staff in the Practice Unit Guidelines are activated and used regularly t prvide alerts abut gaps in care n the Pint f Care reprt r in the EMR - All members in the practice, including frnt ffice staff wh wrk with clinicians and patients, are knwledgeable abut the type and length f appintments t bk and their respnsibilities fr preparing resurces fr visits, based n the guidelines Guidelines are actively used t mnitr, track, and cnduct utreach t patients t schedule care as needed BCBSM PCMH Interpretive Guidelines September 2010 13
- Guidelines are used by PO t evaluate perfrmance f physicians, Practice Units, and PO. 4.4 At least ne chrnic cnditin has been identified fr initial fcus, and practice has assembled and is mnitring all key clinical data, clinical utcmes measures, prcess measures, and patient satisfactin/ffice efficiency measures - Key clinical indicatrs relevant t the chrnic cnditin are tracked in the patient registry - Prcess f care measures relevant t evidence-based standards fr the chrnic cnditin are mnitred. - Patient satisfactin and ffice efficiency measures (e.g., patient waiting time t btain appintment, ffice visit cycle time, percentage f n-shw appintments) are mnitred May be based n surveys cnducted by the ffice r infrmatin prvided by health plans, the PO, r ther surces Surveys d nt need t fcus n single specific chrnic cnditin, prviding they are capturing infrmatin relevant t all chrnic cnditins, such as asking abut whether the primary practitiner discusses health care gals, diet and exercise, and supprts the patient in achieving health management gals Reference infrmatin at Institute fr Healthcare Imprvement: http://www.ihi.rg/ihi/tpics/officepractices/access/measures/ - Evidence-based care clinical utcmes measures are used t track patient health care status 4.5 Develpment f written actin plan and self-management gal-setting is systematically ffered t all patients with the chrnic cnditin selected fr initial fcus, with patient-friendly dcumentatin prvided t the patient - Physicians and ther practice team members are actively invlved in wrking with patients t use self-management gal-setting techniques and develp actin plans Gal-setting shuld fcus n specific changes in behavir (e.g., walking arund the blck nce a day) r cncrete, tangible results (e.g., lsing 2 punds) rather than general clinical gals (such as lwering bld pressure r reducing LDL levels) - Reference infrmatin prvided at the Imprving Chrnic Illness Care website: http://www.imprvingchrniccare.rg/index.php?p=selfmanagement_supprt&s=39 The gal f self-management supprt is t assist and sustain the patient's ability t engage in self-management behavirs that fit within their wn life patterns. The creatin f a persnal actin plan is an BCBSM PCMH Interpretive Guidelines September 2010 14
imprtant way in which prviders can supprt their patients selfmanagement gals. Anther key skill is t help patients learn t slve prblems. Patients with chrnic cnditins must manage the illness (such as learning t take medicatins and mnitr the cnditin) carry n nrmal rles and activities manage the emtinal impact f the illness 4.6 A systematic apprach is in place fr appintment tracking and generatin f reminders fr all patients with the chrnic cnditin selected fr initial fcus - Evidence-based guidelines are used systematically as a basis fr: Cnducting tracking and fllw-up regarding missed appintments Prviding patients with mail and/r telephne reminders f upcming appintments 4.7 A systematic apprach is in place t ensure that fllw-up fr needed services is prvided fr all patients with the chrnic cnditin selected fr initial fcus - Evidence-based guidelines are used systematically as a basis fr: Fllwing up with patients t ensure that needed services, whether at the PCMH practice site r at anther care site, are btained by the patients 4.8 Planned visits are ffered t all patients with the chrnic cnditin selected fr initial fcus - Planned visits cnsist f a practive, cmprehensive, dcumented apprach t ensure that patients receive needed care in an efficient and effective manner. Planned visits include the well-rchestrated, team-based apprach t managing the patient s care during the visit, all perfrmed n a rutine basis, as well as the tracking and scheduling f regular visits, and the guideline-based preparatin that ccurs prir t the visit. - Reference infrmatin prvided at the Imprving Chrnic Illness Care website: http://www.imprvingchrniccare.rg/index.php?p=planned_visits&s=48 - Many healthcare prviders believe themselves t already be ding planned visits. They nte that their patients with chrnic cnditins cme back at defined intervals. Yet upn clser inspectin, these visits may lk a lt like acute care: the prvider might lack necessary infrmatin abut the patient s BCBSM PCMH Interpretive Guidelines September 2010 15
care needs; prvider and patient might have different expectatins fr the visit; and staff may nt be fully utilized t help with the rganizatin f the visit and delivery f care. These check-back visits, while scheduled in advance, are ften nt efficient nr prductive fr the prvider and patient. - Key Cmpnents f a Planned Visit Assign Team Rles and Respnsibilities Fr example, the fllwing questins might need t be addressed: wh is ging t call the patient t schedule the visit? Wh will rm the patient? If the patient has diabetes, wh will remve her/his shes and scks? Wh will examine the feet? Wh will prepare the patient encunter frm fr use during the visit? All tasks need t be delegated t specific team members s that nthing is left t chance. Call a Patient In Fr a Visit Develp a script fr the call, and decide which team member will make the call. Set the tne and expectatins fr the issues addressed in the visit. If yu chse t mail an invitatin t patients, be sure t track respndents. Typically, less than 50% f patients respnd t a letter. Yu will need t plan an alternative methd f cntacting nn-respnders. Deliver Clinical Care and Self-Management Supprt In preparatin fr the visit, print an encunter frm frm yur registry r pull the chart in advance s that yu can review the patient s care t date. Dcument what clinical care needs t be dne during the visit. Until new rles are well integrated int the nrmal wrk flw, many practices have team huddles fr 5-10 minutes t review the schedule and identify chrnic care patients cming in that day fr an acute care visit. Decide hw best t meet as a team t manage these patients. Determine the best intervals and timing fr these meetings, and stick t them. The brief get-tgethers help the team stay fcused n practice redesign and create a spirit f ne fr all. 4.9 Grup visit ptin is available fr all patients in the practice unit with the chrnic cnditin selected fr initial fcus (as apprpriate fr the patient) - Reference AAFP infrmatin n grup visits at: http://www.aafp.rg/fpm/20060100/37gru.html - Grup visits are a frm f ffice visit. (They are nt the same as care crdinatin/care management services, which are fllw-up services delivered by nn-physician clinicians antecedent t an ffice visit at which individual treatment and/r health behavir gals have been established.) - Grup visits include nt nly grup educatin and interactin but als all essential elements f an individual patient visit, including but nt limited t the cllectin f vital signs, histry taking, relevant physical examinatin and clinical decisin-making. BCBSM PCMH Interpretive Guidelines September 2010 16
Grup visits differ frm ther frms f grup interventins, such as supprt grups, which are generally led by peers and d nt include ne-n-ne cnsultatins with physicians. - The clinician is directly invlved and meets with each patient individually - Members f the care management team may take vital signs and ther measurements and assist with individual encunters - Dietitians r pharmacists may lead educatinal sessins. Tpics such as medicatin management, stress management, exercise and nutritin, and cmmunity resurces, may be suggested by the grup facilitatr r by patients, wh raise cncerns, share infrmatin and ask questins. In prgrams emphasizing self-management, physicians and patients wrk tgether t create behavir-change actin plans, which detail achievable and behavir-specific gals that participants aim t accmplish by the next sessin. Once plans are set, the grup discusses ways t vercme ptential bstacles, which raises patients' self-efficacy and cmmitment t behaviral change. Patients' family members can als be included in these grup sessins. - Grup visits generally last frm tw t 2.5 hurs and include n mre than 20 patients at a time. - Grup visits may be cnducted in cllabratin with ther Practice Units 4.10 Medicatin review and management is prvided at every visit fr all patients with chrnic cnditins - Chrnic cnditins under 4.10 are defined as any cnditin requiring maintenance drug therapy. - During every patient encunter, a list f all medicatins currently taken by the patient is reviewed and updated, and any cncerns regarding medicatin interactins r side effects are addressed. 4.11 Actin plan develpment and self-management gal-setting is systematically ffered t all patients with chrnic cnditins r ther cmplex health care needs prevalent in practice s patient ppulatin - See guidelines fr 4.5 4.12 A systematic apprach is in place fr appintment tracking and generatin f reminders fr all patients - See guidelines fr 4.6 BCBSM PCMH Interpretive Guidelines September 2010 17
4.13 A systematic apprach is in place t ensure fllw-up fr needed services fr all patients - See guidelines fr 4.7 4.14 Planned visits are ffered t all patients with chrnic cnditins prevalent in practice ppulatin - See guidelines fr 4.8 4.15 Grup visit ptin is available t all patients with chrnic cnditins prevalent in practice ppulatin - See guidelines fr 4.9 5.0 Extended Access 5.1 Patients have 24-hur access t a clinical decisin-maker by phne, and clinical decisin-maker has a feedback lp within 24 hurs r next business day t the patient's PCMH - Clinical decisin-maker must be an M.D., D.O., P.A., r N.P. If nt M.D. r D.O., clinical-decisin maker must have ability t cntact supervising M.D. r D.O. n an immediate basis if needed Clinical decisin-maker may be, but is nt required t be, the patient s primary care prvider - Clinical decisin-maker has the ability t direct the patient regarding self-care r t an apprpriate level f care. - Clinical decisin-maker cmmunicates all clinically relevant infrmatin via phne cnversatin directly t patient s primary physician, by email, by autmated ntificatin in an EMR system, r by faxing directly t primary physician regarding the interactin within 24 hurs (r next business day) f the interactin - Clinical decisin-maker respnds t patient inquiry in a timely manner (generally 15-30 minutes, and n later than 60 minutes after initial patient inquiry) BCBSM PCMH Interpretive Guidelines September 2010 18
5.2 24-hur patient access t clinical decisin-maker (as defined in 5.1) is enhanced by enabling clinical decisin-maker t access and update patient's EMR r registry inf during the phne call - Clinical decisin-maker shuld rutinely have access t patient s EMR r registry infrmatin fr all calls Occasinal technical prblems, such as failure f internet service in rural areas, may ccur and wuld nt cnstitute failure t meet the requirements f 5.2 as lng as access t the EMR r registry is typically and rutinely available 5.3 Prvider has made arrangements fr patients t have access t nn-ed after-hurs prvider fr urgent care needs during at least 8 after-hurs per week and, if different frm the PCP ffice, after-hurs prvider has a feedback lp within 24 hurs r next business day t the patient's PCMH - After-hurs is defined as ffice visit availability during weekday evening (e.g., 5-8 pm) and/r early mrning hurs (e.g., 7-9 am) and sme weekend hurs (e.g., Saturday 9-12), sufficient t reduce patients use f ED fr nn-ed care - After-hurs prvider may be at Practice Unit site r may be in a physically separate lcatin (e.g., an urgent care lcatin r a separate physician ffice) as lng as it is within 30 minutes travel time f the PCMH Services prvided by the after-hurs prvider must be billable as an ffice visit r an urgent care visit, nt as an ER visit - If after-hurs prvider is different frm Practice Unit (e.g., they are an urgent care center r a physician wh shares n-call respnsibilities), there must be an established arrangement fr after-hurs cverage, and the after-hurs prvider must be able t prvide feedback regarding care encunter t the patient's Practice Unit within 24 hurs r n the next business day - Practice Units may team with ther practice units/physicians t prvide afterhurs urgent care 5.4 A systematic apprach is in place t ensure that all patients are fully infrmed abut after-hurs care availability and lcatin, at the PCMH site as well as ther after-hurs care sites, including urgent care facilities, if applicable 5.5 Practice Unit has made arrangements fr patients t have access t nn- ED after-hurs prvider fr urgent care needs (as defined under 5.3) during at least 12 after-hurs per week - See guidelines fr 5.3 BCBSM PCMH Interpretive Guidelines September 2010 19
5.6 After-hurs care prvider is enhanced by enabling nn-ed after-hurs prvider fr urgent care needs t access and update the patient s EMR r patient s registry recrd during the visit - Reference 5.3 fr definitin f nn-ed after-hurs prvider fr urgent care needs - Clinical decisin-maker shuld rutinely have access t patient s EMR r registry infrmatin fr all visits Occasinal technical prblems, such as failure f internet service in rural areas, may ccur and wuld nt cnstitute failure t meet the requirements f 5.6 as lng as access t the EMR r registry is typically and rutinely available 5.7 Advanced access scheduling is in place, reserving at least 30% f appintments fr same-day appintments fr acute and rutine care (i.e., any elective nn-acute/urgent need, including physical exams and planned chrnic care services, fr established patients) - 30% f the day s appintments shuld be available at the start f business fr same-day appintments fr bth acute and rutine care needs In unusual, extenuating circumstances (such as a sl practice in a rural r urban under-served area), practice units may meet the requirements f capability 5.7 by having a rutine, systematic prcedure that practice unit clinicians remain after-hurs as necessary t see the majrity f patients requesting rutine r acute care Written plicy fr advanced access is available Patients are aware f plicy and d nt feel that they must self-screen t avid impsing n practice unit staff Patients can be accmmdated thrughut the day (nt nly during lunch r after-hurs) Patients are seen n a timely basis with n excessive waiting time Patients can be seen by PAs/NPs r by any physician in practice If practices des nt have an apprach t scheduling that clsely fllws the structure and prcess f frmal pen access scheduling cnsistent with the surces cited herein, then must have dcumented plicy and prcedures demnstrating that the practice s advanced access apprach has the fllwing attributes referenced at the fllwing sites: http://www.aafp.rg/fpm/20000900/45same.html. Reference Institute fr Healthcare Imprvement articles at http://www.ihi.rg/ihi/tpics/officepractices/access/changes/i H fr infrmatin n implementing advanced access BCBSM PCMH Interpretive Guidelines September 2010 20
5.8 Advanced access scheduling is in place reserving at least 50% f appintments fr same-day appintment fr acute and rutine care (i.e., any elective nn-acute/urgent need, including physical exams and planned chrnic care services, fr established patients) - 50% f the day s appintments shuld be available at the start f the business day fr same-day appintments fr acute and rutine patient needs - Reference 5.7 5.9 Practice unit has telephnic r ther access t interpreter(s) fr all languages cmmn t practice s established patients. 6.0 Test Results Tracking & Fllw-up 6.1 Practice has test tracking prcess/prcedure dcumented, which requires tracking and fllw-up fr all tests and test results, with identified timeframes fr ntifying patients f results - Test tracking prcedure must be in writing and identify all steps in prcess and timeframes 6.2 Systematic apprach and identified timeframes are in place fr ensuring patients receive needed tests and practice btains results - Fllw-up ccurs with patients t ensure necessary tests are perfrmed - Cmmunicatin prcess are in place with testing entities as necessary t ensure results are received - Result are reviewed, signed, and dated by the physician and filed in the patient s medical recrd 6.3 Prcess is in place fr ensuring patient cntact details are kept up t date - Patients are asked at every visit t cnfirm that address and phne numbers are current 6.4 Mechanism is in place fr patients t btain infrmatin abut nrmal tests BCBSM PCMH Interpretive Guidelines September 2010 21
- Patients are infrmed abut hw t access nrmal test results - Prcess may use any f the fllwing mechanisms: Patient phne call t specific phne number at practice Phne call frm practice t patient Mail frm practice Patient access via secure web prtal (in cnjunctin with ne f the abve ptins fr patients withut internet access) 6.5 Systematic apprach is used t infrm patients abut abnrmal test results - Systematic apprach is in place t flag as high pririty results where fllw-up is essential and the risk f nt fllwing up is high, i.e., tissue bipsies, diagnstic mammgrams, INR tests - Fr high pririty results, patient is cntacted by phne (repeated attempts at different times f day, n different days if necessary; if necessary and acceptable t patient, email r patient prtal may be used t request the patient call ffice; as a last resrt, results may be sent by registered mail) Fr lw pririty results, such as minr lab abnrmalities, cntact may be by letter - Systematic apprach is in place t ensure cmmunicatin prcess is clear and patients understand implicatins f test results 6.6 Systematic apprach is used t ensure that patients with abnrmal results receive the recmmended fllw-up care within defined timeframes. - Patients requiring fllw-up are flagged and fllw-up timeframes are specified - Cancellatins and n-shw appintments are tracked and assessed t determine whether any patients require fllw-up - Outcmes f fllw-up actin are filed in patient s medical recrd 6.7 Systematic apprach is used t dcument all test tracking steps in the patient s medical recrd - All phne calls, letters, and ther cmmunicatins with patient regarding testing and test results are dcumented in the patient s medical recrd 6.8 All clinicians and apprpriate ffice staff are trained t ensure adherence t the test-tracking prcedure; all training is dcumented either in persnnel file r in training lgs r recrds BCBSM PCMH Interpretive Guidelines September 2010 22
- Practice unit r PO maintains recrd f training and can prvide training cntent fr review 6.9 Practice has Cmputerized Order Entry integrated with autmated test tracking system - Test-tracking system has Cmputerized Order Entry system structured t lg all test rders and is linked t autmated tracking system that supprts caregiver fllw-up - Test tracking system has the ability t electrnically receive and track results 9.0 Preventive Services 9.1 Primary preventin prgram is in place that fcuses n identifying and educating patients abut persnal health behavirs t reduce their risk f disease and injury. - Primary preventin is defined as inhibiting the develpment f disease befre it ccurs. Secndary preventin, als called "screening," refers t measures that detect disease befre it is symptmatic. Tertiary preventin effrts fcus n peple already affected by disease and attempt t reduce resultant disability and restre functinality. - Patient questinnaire r ther mechanism is used t elicit infrmatin abut persnal health behavirs that may be cntributing t disease risk During well-visit exam and initial intake fr new patients During ther visits when behavir may be relevant t acute cncern (e.g., tbacc use when patient presents with cugh) - Patient assessment addresses persnal health behavirs and disease risk factrs, based n age, gender, health issues Behavirs and risks assessed shuld include a majrity f the fllwing, as apprpriate t the patient ppulatin: Alchl and Drug Use, Breast Self-Examinatin, Awareness f Lead Expsure, Lw Fat Diet and Exercise, Use f Sunscreen, Safe Sex, Testicular Self- Examinatin, and Tbacc Avidance 9.2 A systematic apprach is in place t prviding preventive services - Preventive care guidelines are integrated int clinical practice (e.g., Michigan Quality Imprvement Cnsrtium - www.mqic.rg/guid.htm). Examples f apprpriate Guidelines include: Adult Preventive Services Guideline 18-49 Yrs BCBSM PCMH Interpretive Guidelines September 2010 23
Adult Preventive Services Guideline 50-65 Yrs Childhd Overweight Preventin Guideline Preventin f Unintended Pregnancy in Adults Preventive Service fr Children & Adlescents Ages Birth 24 Mnths Preventive Service fr Children and Adlescents Ages 2-18 Yrs Tbacc Cntrl Guideline - Systematic appintment tracking system (implemented as part f Individual Care Management Initiative) is in place 9.3 Strategies are in place t prmte and cnduct utreach regarding nging well care visits and screenings fr all ppulatins, cnsistent with guidelines fr such age and gender-apprpriate services prmulgated by credible natinal rganizatins - Systematic reminder system is in place and incrprates the fllwing elements: Age apprpriate health reminders (e.g., annual physicals). Age apprpriate immunizatin infrmatin cnsistent with mst current evidence-based guidelines If reminders are generated by PO, ffices shuld have knwledge f the prcess/ - Fr children and adlescents frm birth t 18 years f age examples f utreach strategies may include birthday reminders fr well-visits, kindergarten rund-up, flu vaccine reminders, health fairs, brchures, schl physical fairs. - Fr adults, examples f utreach strategies may include annual health maintenance examinatin reminders, and age and gender-apprpriate reminders abut recmmended screenings (e.g., mammgrams) - Outreach shuld be systematic and cnsistent with evidence-based guidelines 9.4 Practice has prcess in place t inquire abut a patient s utside health encunters and has capability t incrprate infrmatin in patient tracking system r medical recrd - Outside health encunter infrmatin includes services such as immunizatins prvided at health fairs - Practice unit shuld include actual/estimated date f service in the medical recrd whenever pssible - Infrmatin may be included in histrical sectin f recrd BCBSM PCMH Interpretive Guidelines September 2010 24
9.5 Practice has a systematic apprach in place t ensure the prvisin/dcumentatin f tbacc use assessment tls and advice regarding smking cessatin - Examples may include yearly assessment sheet, tbacc use interventin prgrams 9.6 Written standing rder prtcls are in place allwing Practice Unit care team members t authrize and deliver preventive services accrding t physician-apprved prtcl withut examinatin by a clinician - Examples include vaccinatins, fecal ccult bld tests and mammgram rders, medicatin intensificatin algrithm fr patients with lipid disrder r high bld pressure 9.7 Secndary preventin prgram is in place t identify and treat asymptmatic persns wh have already develped risk factrs r preclinical disease, but in whm the disease itself has nt becme clinically apparent. - System with guideline-based reminders fr age-apprpriate risk assessment and screening tests is in place. Practice Unit may chse t implement tls such as checklists attached t the patient chart, tagged ntes, cmputer generated encunter frms and prmpting stickers. - Mechanisms are established t identify asymptmatic at-risk patients and prvide apprpriate treatment - Examples include metablic syndrme, steprsis, crnary artery disease, depressin, alchlism, STDs, accelerated regimen fr cln and breast cancer screening in high risk patients 9.8 Staff receives regular training and/r cmmunicatins in health prmtin and disease preventin and incrprates preventive-fcused practices int nging administrative peratins - Practice unit staff has received training r educatinal material has been psted r circulated regarding a full range f preventive services and health prmtin issues New hires receive apprpriate training BCBSM PCMH Interpretive Guidelines September 2010 25
Educatinal material is circulated r psted when guidelines change Fr example, PO r practice unit staff persn may be assigned t update clinical persnnel n standards and guidelines such as AHRQ newsletter updates, the immunizatin schedule & standards issued by the Advisry Cmmittee n Immunizatin Practices, Alliance f Immunizatin in Michigan, r Centers fr Disease Cntrl and Preventin. Fr example, infrmatin may be prvided t practice units educating them n apprpriate billing and ICD-9 cdes in rder t ensure accurate reprting fr preventive medicine services (including use f the crrect ICD-9 cde fr a physical) - Staff is trained (as apprpriate t patient ppulatin) regarding cnsistently using and entering infrmatin int the Michigan Care Imprvement Registry (MCIR) 10.0 Linkage t Cmmunity Services 10.1 PO has cnducted a cmprehensive review f cmmunity resurces fr the gegraphic ppulatin that they serve, in cnjunctin with Practice Units - The review may take place within the cntext f a multi-po effrt - Review shuld include health care, scial, pharmaceutical, mental health, and rare disease supprt assciatins If cmprehensive cmmunity resurce database has already been develped (e.g., by hspital, United Way) then further review by PO is nt necessary Review may include survey f practice units t assist in identifying lcal cmmunity resurces 10.2 PO maintains a cmmunity resurce database based n input frm Practice Units that serves as a central repsitry f infrmatin fr all Practice Units. - The database may include resurces such as the United Way s 2-1-1 htline, and links t nline resurces. - At least ne staff persn in the PO is respnsible fr cnducting a semiannual update f the database and verifying lcal resurce listings (PO may crdinate with Practice Unit staff t ensure resurce reliability) It is acceptable fr staff t nt verify aggregate listings (such as 2-1-1) if they are able t dcument hw ften the listings are updated by the resurce administratr - Resurce databases are shared with ther POs, particularly in verlapping gegraphic regins BCBSM PCMH Interpretive Guidelines September 2010 26