PCMH Redesign June 2017 Michele Stanek, MHS Transfrmatin Changes in Healthcare Delivery System Changes in Payment Systems Changes in Culture 1
Care Crdinatin Better verall care Advanced Access Three- Part Aim Imprved health Lwer per capita csts Team-Based Care Chrnic Care Mdel Enhancing Health and the Patient Experience Medical Hme Mdel Team-Based Healthcare Delivery Access t Care Ppulatin Health Advanced IT Systems Patient is the center f the Medical Hme Patient-Centered Care Decisin Supprt Tls Patient & Physician Feedback Refcused Medical Training Mdel adapted frm the NNMC Medical Hme 2
Patient Centered Medical Hme PCMH is an enhanced primary-care mdel that delivers cmprehensive and timely care t patients, emphasizing the central rle f teamwrk and engagement between caregivers and patients PCMH is a radmap fr transfrming primary care practice in preparatin fr value-based purchasing PCMH mdel includes the rganizatinal systems and care prcesses shared by high perfrming primary care practices Why PCMH? Radmap fr Transfrmatin Unifying Framewrk Fcus n Primary Care Bully Pulpit Financial Incentives External Seal f Apprval 3
Merit-Based Incentive Prgram Each physician r eligible prfessinal will receive a cmpsite perfrmance scre; rated with a scre f 1-100; scre will determine reimbursement Recgnized PCMH receives maximum pints Final Scre (0-100) Quality 60% MU f Certified EHR 25% Resurce Use 0% QI Activities 15% Surce: https://www.cms.gv/medicare/quality-initiatives-patient-assessment-instruments/value-based- Prgrams/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf 4
PCMH 2014 PCMH 2011 Renew under Get credit fr aspects f 2011 standards applied t standards Cnvert t PCMH 2014 Obtain an additinal year f recgnitin Must submit dcumentatin fr 6 elements Must be a Level III under PCMH 2011 Must have bught PCMH 2014 tl Must submit by September 30, 2017 50% fee Renewal t PCMH 2014 Obtain 3 years f recgnitin under PCMH 2014 Must submit dcumentatin fr 11 elements Must have bught PCMH 2014 tl Must submit by September 30, 2014 100% fee 5
PCMH 2014 Renew/Succeed under Get credit fr aspects f 2011 standards applied t standards Must cmmit 6 mnths prir t expiratin Renewal under PCMH 2014 Obtain 3 years f recgnitin under PCMH 2014 Must submit dcumentatin fr 11 elements Must have bught PCMH 2014 tl Must submit by September 30, 2014 100% fee 6
PCMH Redesign - 2017 Prvide mre guidance t practices Assignment f practice navigatr/supprt Live supprt and interactive web-based tl Receive and assess peratinal and clinical data t supprt quality measurement, benchmarking and recgnitin Expand HIT pre-validatin Replaces ISS system - New web-based management tl (Q-PASS) Annual check-in rather than 3-year term 18 elements Reprt ecqms N lnger Level 1-3 PCMH Recgnitin Reduces requirements frm 167 t 100 Recgnitin achieved by meeting 45 Cre Requirements + 25/60 f elective requirements Distinctin mdules: Behaviral health Patient experience reprting Perfrmance reprting 7
Q-PASS Surce: https://qpass.ncqa.rg/hme/welcme 8
Standards Elements Factrs Cncepts Cmpetencies Criteria 9
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Team-Based Care & Practice Organizatin Prvides cntinuity f care, cmmunicates rles and respnsibilities and trains staff t practice t the tp f their license and ability t prvide teambased care TC 01 (Cre): Designate a clinical leader that supprts PCMH TC 09 (Cre): Has at least ne care manager qualified t identify and address behaviral health needs Knwing & Managing Patients Captures and analyzes infrmatin abut patients & cmmunity it serves and uses infrmatin t delivery evidence based care KM02 (Cre): Cmprehensive health assessment that includes: Scial functining Scial determinants f health KM04 (1 ptinal credit) Cnducts behaviral health screening using standardized assesment tl (must implement 2 r mre) Anxiety PTSD KM05 (1 ptinal credit) Assess ral health needs and prvide services r crdinates services KM07 (2 ptinal credits) Understands scial determinates f health and implements interventins 11
Knwing & Managing Patients Captures and analyzes infrmatin abut patients & cmmunity it serves and uses infrmatin t delivery evidence based care KM18 (1 ptinal credit) Reviews cntrlled substance database KM19 (2 ptinal credits) Systematically btains prescriptin claims data KM23 (1 ptinal credit) Prvides ral health educatin resurces KM25 (1ptinal credit) Engages with schls r interventin agencies KM28 (2 ptinal credits) Has regular case cnferences invlving parties utside the practice team Patient Centered Access & Cntinuity Patients have 24/7 access t clinical advice and apprpriate care AC01 (Cre): Assesses the access needs ad preferences f patients AC09 (1 ptinal credit) Uses infrmatin abut the patient ppulatin served t assess health equity and cnsider health disparities AC13 (1 ptinal credit): Demnstrates systematic prcess fr mnitring and balancing patient panels AC14 (1 ptinal credit): Reviews and recnciles panels based n health plan r utside panel assignment 12
Care Management & Supprt Practice identifies patient needs at the individual and ppulatin level; emphasis is placed n supprting patients at highest risk CM03 (2 ptinal credits): Reprt demnstrating risk stratificatin CM09 (1 ptinal credit): Care plan is integrated and accessible acrss settings Care Crdinatin & Transitins Tracks tests, referrals, care transitins t ensure cmprehensive care crdinatin and cmmunicatin with medical neighbrhd CC03 (2 ptinal credits): Uses clinical prtcls t determine when imaging studies are necessary CC06 (1 ptinal credit): Uses clinical prtcls t determine when a referral t a specialist is necessary CC06 (1 credit): Mnitrs referrals by specialty type CC11 (1 credit): Mnitrs timeliness and quality f referral CC13 (2 credits): Engages with patients regarding cst implicatins f treatment ptins CC17 (1 credit): Systematically ability t crdinate with acute care settings after hurs 13
Perfrmance Measurement & QI Practice cllects, reprts and uses perfrmance data t identify pprtunities fr imprvement, set gals and acts t imprve Triple Aim measures and engages staff and patients in imprvement 5 measures acrss 4 clinical quality categries (immunizatin, preventive, chrnic/acute, BH) 2 measures f resurce stewardship (crdinatin & csts) 1 access measure 1 patient experience measure QI19 (2 ptinal credits) Is engaged in Value-Based Agreement QUESTIONS? 14
Michele Stanek, MHS Directr, SCORH Center fr Practice Transfrmatin Assistant Prfessr, Univ. f Suth Carlina SOM Department f Family & Preventive Medicine stanek@scrh.net michele.stanek@uscmed.sc.edu 15