NCQA s Patient-Centered Medical Home (PCMH) 2011 Johann Chanin, Director, Product Development Mina Harkins, Assistant Vice President, Recognition Programs All materials 2011, National Committee for Quality Assurance
National Committee for Quality Assurance NCQA Private, independent non-profit health care quality oversight organization founded in 1990 MISSION To improve the quality of health care. VISION To transform health care through quality measurement, transparency, and accountability. ILLUSTRATIVE PROGRAMS: * HEDIS Healthcare Effectiveness Data and Information Set * Health Plan Accreditation * Clinician Recognition * Disease Management * Wellness & Health Promotion Accreditation * Consumer Union s Health Plans Rankings * Quality Dividend Calculator 2
PCMH Value Encourages practices to adopt proven systems for improving care Provides mechanism for incentivizing investment in quality infrastructure and processes Complements evaluation of clinical effectiveness, patient experiences, and efficiency 3
Research Shows: Medical Homes Work Higher quality of care, reduced cost of care on some measures (Patient-Centered Primary Care Collaborative, 2010) Reduced hospitalization and ER visits, overall savings (Fields, Leshen, Patel, 2010) In integrated group practice, improvements in quality of clinical care, patient and provider experiences (Reid, 2009) Relationship between practices with established practice systems/processes and a decreased use of inpatient and emergency care by diabetic patients (Flottemesch, under review) 4
1. Enhance Access and Continuity A. Access During Office Hours * B. After-Hours Access C. Electronic Access D. Continuity (with provider) E. Medical Home Responsibilities F. Culturally/Linguistically Appropriate Services G. The Practice Team 2. Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management * 3. Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management * D. Medication Management E. Use Electronic Prescribing PCMH 2011 Standards (6 standards/28 elements) 4. Provide Self-Care and Community Resources A. Support Self-Care Process * B. Provide Referrals to Community Resources 5. Track/Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up * C. Coordinate with Facilities/Care Transitions 6. Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Feedback C. Implement Continuous Quality Improvement * D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology (not scored Optional Patient Experiences Survey * Must-pass element for any level of PCMH Recognition 5
Level of Qualifying PCMH Scoring 6 standards = 100 points 6 Must Pass elements NOTE: Must Pass elements require a 50% performance level to pass Points Must Pass Elements at 50% Performance Level Level 3 85-100 6 of 6 Level 2 60-84 6 of 6 Level 1 35-59 6 of 6 Not Recognized 0-34 < 6 Practices with a numeric score of 0 to 34 points and/or achieve less than 6 Must Pass Elements are not Recognized. 6
Practice Needs for PCMH Survey Process 1. Computer system with: Email Internet access Microsoft Word Microsoft Excel Adobe Acrobat Reader (available for free online) 2. Staff skill in using above listed computer systems and 3. Access to the electronic systems used by the practice, e.g. billing system, registry, practice management system, electronic prescription system, EHR, Web portal, etc. 7
Documentation 1. Documented process Written procedures, protocols, processes, workflow forms (not explanations) 2. Reports Aggregated data showing evidence 3. Records or files Patient files or registry entries documenting action taken 4. Materials Information for patients or clinicians, e.g. clinical guidelines, self-management and educational resources 5. Screen shots Electronic copy may be used as examples (EHR capability), materials (Web site resources) or records; helps to show specific to the practice and not a vendor demo page 8
The NCQA PCMH Recognition Process Practice Steps: Obtains PCMH 2011 Standards and Guidelines Participates in NCQA trainings Obtains survey tool and online application account Self-assesses current performance on survey Completes online application information: electronic agreements, practice site, clinician details, and application for survey Submits application Receives email confirmation that practice can submit Survey Tool and documentation Submits Survey Tool and application fee when ready 9
Practical Tips from Practice #1 Establish Medical Home Recognition Team Physician Champion Team members adopted a standard to assess operational compliance Standing meetings scheduled Selected important conditions for evidence-based guidelines requirements Established Clinical Practice Committee to develop guidelines Analysis of Practice Determine standards that could not be met with current processes Identify deficiencies and focus on areas that can be achieved Be Realistic Complex process to collect examples and reports Ballpark administrative time 0.5 FTE for six months 10
Practical Tips from Practice #2 Lessons Learned Start early it takes longer than you think Evaluate where you are and be realistic Answer the specific question asked in each element It s okay if you don t meet every element Watch the timeline, you don t have forever Dedicate time away from general duties, difficult to do piecemeal Considerations Include both clinical and technical savvy person on team Implement changes in practice with lead time, so that data will reflect the change in methods You already do more than you think 11
Practical Tips from Practice #3 Need to change traditional physician values Heroism, autonomy, visit-based care, prevention on request System that treats acute infections/injuries PCMH is a different approach Clinician-led team: our way versus my way Use of evidence-based guidelines to support a population Simplified scheduling to enhance access Outreach for primary and secondary prevention 12
PCMH 2011 Key Components Access Evening/weekend hours, agreement with facility for after-hours care Coordination of care Information to/from specialists/facilities/patient, update care plan Team-based care Defined roles and responsibilities, training, communication Role of medical home Discuss roles/expectations for medical home and for patients Care management Pre-, post-visit planning, care planning during visit, patient self-care Medication management Include mental health/substance abuse/behaviors affecting health Community resources/referrals Identify/address population needs/risks Quality improvement Performance measurement Patient experience 13
PCMH 1: Access and Continuity Intent: Access to care/advice during/after hours to meet patient need Access During and After Office Hours: Same day access; appointments outside normal office hours; timely advice documented in patient record Electronic Access: Patient access to medical record information; visit summaries, communication with practice; request appointments/rx/referrals/results Continuity Patient/family choose clinician; monitor visits with clinician/team Medical Home Responsibilities Explains medical home to patient/family Culturally and Linguistically Appropriate Services (CLAS) Assess patient diversity/language; meets language needs Practice Organization Team-based care with defined roles/responsibilities; standing orders; training for self-care and population management; team involved in QI 14
PCMH 2: Identify and Manage Patient Populations Intent: Collect data to manage populations of patients Patient Information Searchable demographic data includes: race/ethnicity/language; current/past diagnoses and prior visits; legal guardian/proxy/caregiver; advance directives Clinical Data Structured data: immunizations; screenings; allergies; BMI; growth chart information; medications with dates of update Comprehensive Health Assessment Assess risks/needs: social/cultural/language; unhealthy behaviors/ mental health/substance abuse; screen for depression (chronic illness/teens) Population Management Lists and reminders to manage populations of patients: screenings/ immunizations; chronic care services; absentee patients 15
PCMH 3: Plan and Manage Care Intent: Identify and manage patient care using evidence-based guidelines Guidelines for Important Conditions Identify 4 important conditions including unhealthy behavior, mental health or substance abuse and high risk/complex condition; use evidence-based guidelines for care Care Management Plan and manage care: pre-visit planning; care plan/treatment goals; visit summaries; assess barriers to not meeting treatment goals; assess need for care management Medication Management Review/reconcile medications Electronic Prescribing Generate, transmit prescriptions electronically; e-system integrated with EMR 16
PCMH 4: Self-Care Support Intent: Support patient self-management with resources, materials and self-care tools Self-Care Process Assess self-management abilities; document self-care plan; provide tools and resources; counsel on healthy behaviors; assess/provide/arrange for mental health/substance abuse treatment 17
PCMH 5: Track and Coordinate Care Intent: Track, follow-up on and coordinate tests, referrals and patient care in other facilities Test Tracking Track and flag overdue test results; identify abnormal results; provide test results to patients; order tests and retrieve results electronically and integrate into medical record Referral Tracking Track status of referrals; obtains report back; has agreements with specialists; tracks self-referrals Coordinate with Facilities/Care Transitions Identify hospitalized patients and ER visits and exchange clinical information; follow up with discharged patients; transition plan from pediatric to adult care 18
PCMH 6: Performance Measurement and Quality Improvement Intent: Practice performance data used to identify and take action on clinical and patient experience areas for improvement Measures of Performance Preventive care measures; chronic or acute care clinical measures; utilization measures; data by vulnerable populations Patient/Family Experience Patient experience survey (at least 3 of 6 possible categories); CAHPS-CG medical home survey tool optional; identify vulnerable populations Quality Improvement Set goals/act on preventive/chronic measures; improves care for vulnerable populations Report Performance Report physician/practice level data to physician/practice Report Data Externally Public health data; measures to CMS/states 19
QUESTIONS? 20