Practice Transformation: Patient Centered Medical Home Overview Megan A. Housley, MBA Business Development Director Kentucky Regional Extension Center
The Triple Aim Population Health TRIPLE AIM Per Capita Cost Experience of Care
Policy Framework For Achieving Triple Aim Quality & Efficiency Care Delivery & Innovation Provider Feedback & Measurement Payment Reform HIT Foundation: Meaningful Use of EHRs and HIE
A journey of a thousand miles begins with a single step Payment Innovation Meaningful Use Care Delivery Innovation (PCMH) Health IT & HIE + Quality Improvement
What is Patient-Centered Medical Home? What is Patient-Centered Medical Home? PCMH is a model that provides specific standards for transforming the organization and delivery of primary care to be more: Comprehensive Patient-Centered Coordinated Accessible Safe
Other Other Common Common PCMH PCMH Descriptors: Descriptors a vision of healthcare as it should be a framework for organizing systems of care at both the micro (practice) and macro (society) level a model to test, improve, and validate political construct that includes new ways of organizing and financing care, while attempting to remain true to the proven value of primary care part of the healthcare reform agenda
Patient PCMH: Centered Extreme Medical Makeover Home Extreme Makeover Uncoordinated care Over-loaded schedule Physician & practice-centric Arbitrary quality improvement projects Lack of clear leadership & support Team-based approach Open access Patient engagement & empanelment Data directed quality improvement efforts Engaged leadership
5 Functions of PCMH Five Functions of a PCMH 1. Comprehensive Care 2. Patient-Centered 3. Coordinated Care 4. Accessible Services 5. Quality and Safety
PCMH Benefits PCMH Benefits Long-term partnerships, not hurried visits Care that is coordinated among providers Better access Shared decision-making Lower costs Fewer EH visits/hospitalizations Practices get paid for doing the right things More satisfied providers and patients
Even Bigger Picture: Medical Neighborhood Primary Care Specialty Care Inpatient Care Emergency Care Urgent Care Laboratory Services Physical Therapy / Rehabilitation Mental Health Home Health Services Pharmacy Durable Medical Equipment Social Work Community Support Agencies
Patient-Centered Medical Neighborhood HIT Sub-Specialty PCMH/ Medical Home Neighbor HIT HIT Hospital HIT HIT Pharmacy HIT PCMH HIT Sub-Specialty Procedural Practice Lab
Meaningful Use So How Do We Get There? How Do We Get There? Primary Care-PCMH Recognition Care Coordination Agreements Define type of interaction Responsibility for elements of care Expectations for HIE Population Health Management focus (work with ACO/Medical System with this focus)
How To Achieve PCMH Recognition Many PCMH recognition programs National Committee for Quality Assurance (NCQA) Private, non-profit health care quality organization offering clinical & practice process programs Gold Standard for Primary Care Transformation By far the most widely used method for Medical Home Recognition (Each month 150+ practices apply) Partnering with Department of Defense, Department of Health & Human Services, state programs and insurance companies
NCQA PCMH Recognition NCQA PCMH Recognition For outpatient primary care Practice-site level NCQA defines practice as a clinician or clinicians practicing together at a single geographic location Recognizes PCPs at the site, including NPs and Pas who can be designated as a personal clinical with their own panel of patients 3-year Recognition period Practice may add/remove clinicians
Who Is Eligible? Who Is Eligible? Clinicians with intention of serving as the personal, primary care clinician Physicians, NPs and Pas who practice in Internal Medicine, Family Medicine, or Pediatrics Must have license as MD, DO, NP or PA
6 NCQA PCMH Standards Standard 1: Enhance Access and Continuity of Care Standard 2: Identify and Manage Patient Populations Standard 3: Plan and Manage Care Standard 4: Self-Care Support & Community Resources Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance
NCQA PCSP Recognition For non-primary care specialists Practice-site level Recognizes clinicians at the site, including NPs and PAs with own/shared patient panel 3-year Recognition period May be multi-site and/or multi-specialty May add/remove clinicians
Who Is Eligible? Clinicians who typically receive referrals from PCPs and other nonprimary care specialists including : MDs, DOs, NPs/PAs with own/shared patient panel CNMs Behavioral health specialists: Psychologists, licensed clinical social workers, marriage and family counselors
6 NCQA PCSP Standards Standard 1: Track and Coordinate Referrals Standard 2: Provide Access and Communication Standard 3: Identify and Coordinate Patient Populations Standard 4: Plan and Manage Care Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance
Meaningful Use Overlap PCMH reinforces the use of HIT through the involvement of an EHR, registries, and HIEs MU practices wellprepared for PCMH MU language embedded in PCMH Standards
Connect with Kentucky REC! Phone: (859) 323-3090 Email: Kyrec@uky.edu Follow us on Twitter: @KentuckyREC Like us on Facebook: facebook.com/ehrresource Follow us on LinkedIn: linkedin.com/company/kentucky-rec Check out our website: www.kentuckyrec.com
Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director Northeast KY Regional Health Information Organization www.nekyrhio.org
NCQA Program Setup Standards Six Standards Outline Program Elements Six Must Pass Factors Must meet 50% AND ALL Critical Factors
2014 NCQA Standards PCMH 1 PCMH 2 PCMH 3 PCMH 4 PCMH 5 PCMH 6 Patient Centered Access Team Based Care Population Health Management Care Management and Support Care Coordination and Care Transition Performance Measurement and Quality Improvement
Sample Element P C M H 3 : P o p u l a t i o n H e a l t h M a n a g e m e n t Element D: Use Data for Population Management At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including: 1) At least two different preventive care services 2) At least two different immunizations 3) At least three different chronic or acute care services 4) Patient not recently seen by the practice 5) Medication monitoring or alert 100% The practice meets 4-5 factors 75% The practice meets 3 factors 50% The practice meets 2 factors 25% The practice meets 1 factor 0% The practice meets 0 factors 5 Points 3.75 Points 2.5 Points 0 Points 0 Points
Stage 2 Core MU Measures 1) CPOE 2) erx 3) Demographics 4) Vital Signs 5) Smoking Status 6) Clinical Decision Support 7) View, Download and Transmit 8) Clinical Summaries 9) Privacy and Security 10) Lab-test Results 11) List of Patients 12) Patient Reminders 13) Patient Education 14) Medication Reconciliation 15) Summary of Care/Transitions of Care 16) Immunization Registry 17) Secure Electronic Messaging
MU Core Measure 1 CPOE - 60% Medications - 30% Lab - 30% Radiology PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.
MU Core Measure 2 erx - 50% Generate and transmit prescriptions electronically PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives 100% The practice meets 4 factors 75% The practice meets 3 factors 50% The practice meets 2 factors 25% The practice meets 1 factor 0% The practice meets 0 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points
MU Core Measure 3 Record Demographics - 80% -Language -Sex -Race -Ethnicity -DoB PCMH 3: Population Health Management Element A: Patient Information 3.0 Points Practice records as structured data for more that 80% of patients the following: 1. Date of Birth 2. Sex 3. Race 4. Ethnicity 5. Preferred Language 6. Telephone numbers 7. E-mail address 8. Occupation 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives 13. Health insurance information 14. Name and contact information of other health care professionals involved in patients care. 100% The practice meets 10-14 factors 75% The practice meets 8-9 factors 50% The practice meets 5-7 factors 25% The practice meets 3-4 factor 0% The practice meets 0-2 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points
MU Core Measure 4 Record Vitals - 80% -Height/length -Weight -Blood Pressure -BMI -Display growth chart PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.
MU Core Measure 5 Record Smoking Status - 80% -Patients age 13 and up PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.
MU Core Measure 6 -Implement 5 Clinical Decision Support Rules -Enable drug-drug and drug to allergy interaction checks PCMH 4: Care Management and Support Element D: Use Electronic Prescribing 3.0 Points 1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more that 60 percent of medications 3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives 100% 75% 50% 25% 0% The practice meets 4 factors The practice meets 3 factors The practice meets 2 factors The practice meets 1 factor The practice meets 0 factors 3 Points 2.25 Points 1.5 Points.75 Points 0 Points
MU Core Measure 7 Provide patients ability to View, Download and Transmit their ephi - 50% available - 5% viewed PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.
MU Core Measure 8 Provide clinical summaries to patients for each office visit within one business day -50% PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.
MU Core Measure 9 Protect electronic health information (Privacy and Security) PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. The practice uses an EHR system that has been certified and issued a CMS certification ID. 2. The practice conducts a security risk analysis and implement updates as necessary. 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
MU Core Measure 10 Incorporate clinical lab-test results into EHR as structured data. - 55% PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.
MU Core Measure 11 Generate lists of patients by specific condition PCMH 3: Population Health Management Element D: Use data for Population Management (MUST PASS) 5.0 Points At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers of needed care based on patient information. 1. At least two different preventive care services 2. At least two different immunizations 3. At least three different chronic or acute care services 4. Patients not recently seen by the practice 5. Medication monitoring or alert.
MU Core Measure 12 Send reminders to patients for preventive/followup care - 10 % PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. The practice uses an EHR system that has been certified and issued a CMS certification ID. 2. The practice conducts a security risk analysis and implement updates as necessary. 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
MU Core Measure 13 Identify and provide patient specific education resources to patient - 10% PCMH 4: Care Management and Support Element E: Support Self-Care and Shared Decision Making 5.0 Points The practice has, and demonstrates us of, materials to support patients and families/caregivers in self-management and shared decision making. 1. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients. 2. Provides educational materials and resources to patients. 3. Provides self-management tools to record self-care results. 4. Adopts shared decision making aids. 5. Offers or refers patients to structured health education programs, such as group classes or peer support. 6. Maintains a current resource list of five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates. 7. Assesses usefulness of identified community resources.
MU Core Measure 14 Perform Medication Reconciliation as relevant - 50% PCMH 4: Care Management and Support Element C: Medication Management 4.00 Points The practice has a process for managing medications, and systematically implements the process in the following ways. 1. Reviews and reconciles medications for more than 50% of patients received from 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/caregivers. 4. Assesses understanding of medications for more than 50% of patients/families/caregivers, and dates the assessment. 5. Assesses response to medications and barriers to adherence for more than 50% of patients, and dates the assessment. 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients, and dates updates.
MU Core Measure 15 Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document 50% b) Provide summary of care document electronically 10% c) Provide summary of care document to another provider on different EHR - Once PCMH 5: Care Coordination and Care Transitions Element B: Coordinate Care Transitions (MUST PASS) 6.00 Points The practice: 1. Considers available performance information on consultants/specialists when making referral recommendations. 2. Maintains formal and information agreements with a subset of specialists based on established criteria 3. Maintains agreements with behavioral healthcare providers. 4. Integrates behavioral healthcare providers within the practice site. 5. Gives the consultant or specialist the clinical question, the required timing and the type of referral. 6. Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan. 7. Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50% of referrals. 8. Tracks referrals until the consultant or specialist's report is available, flagging and following up on overdue reports. (CRITICAL FACTOR) 9. Documents co-management arrangements in the patients medical record 10. Asks patients/families about self-referrals and requesting reports from clinicians.
MU Core Measure 15 Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document 50% b) Provide summary of care document electronically 10% c) Provide summary of care document to another provider on different EHR - Once PCMH 5: Care Coordination and Care Transitions Element C: Coordinate Care Transitions 6.00 Points The practice: 1. Proactively identifies patients with unplanned hospital admissions and emergency department visits. 2. Shares clinical information with admitting hospitals and emergency departments. 3. Consistently obtains patient discharge summaries from the hospital and other facilities 4. Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit. 5. Exchanges patient information with the hospital during a patient s hospitalization. 6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners. 7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.
MU Core Measure 16 Submit electronic data to state Immunization Registry PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. The practice uses an EHR system that has been certified and issued a CMS certification ID. 2. The practice conducts a security risk analysis and implement updates as necessary. 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
MU Core Measure 17 Use Secure Electronic Messaging to communicate with Patients - 5% PCMH 1: Patient-Centered Access Element C: Electronic Access 2.0 Points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results.
Stage 2 Menu MU Measures 1) Syndromic Surveillance 2) Electronic Notes 3) Imaging Results 4) Family Health History 5) Cancer Registry 6) Specialized Registry
MU Menu Measure 1 Submit Syndromic Surveillance data to public health agency PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. The practice uses an EHR system that has been certified and issued a CMS certification ID. 2. The practice conducts a security risk analysis and implement updates as necessary. 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
MU Menu Measure 2 Record Electronic Notes in patient records - 30% PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.
MU Menu Measure 3 Imaging Results are available in the EHR system - 10% PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up 6.0 Points 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.
MU Menu Measure 4 Record Family Health History as structured data - 20% PCMH 3: Population Health Management Element B: Clinical Data 4.0 Points The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of patients 2. Allergies, including medication allergies and adverse reactions for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible professional for more than 30 % of patient with at least one office visit.
MU Menu Measure 5 Capability to identify and report cancer cases to public health cancer registry MU Menu Measure 6 Capability to identify and report specific cases to public health specialized registry PCMH 6: Performance Measurement and Quality Improvement Element G: Use Certified EHR Technology 0.0 Points 1. The practice uses an EHR system that has been certified and issued a CMS certification ID. 2. The practice conducts a security risk analysis and implement updates as necessary. 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. 4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically. 6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Care Coordination Within a Patient Centered Medical Home Practice Angie Ross, RnCC Catholic Health Partners
Planned and Purposeful Care Between visits Riskbased out reach post visit Pre-visit visit Identify high risk population Pre-visit planning During patient s office visit Following patient s office visit or specialty appointment Between visits
Identifying Patients for Care Coordination Practice Risk Report Produced quarterly or monthly, pulls from claims data on our population health patients in our physician practices that are based on historical claims history Daily Census Produced daily, pulls from Meditech and lists all patients in our physician practices who have been admitted, are in observation or are at the ER by hospital A1C greater than 8 Report Input from Physician and Physician Staff Produced real time, from Explorys and lists all patients by practice who have A1C greater than 8 as well as patient s next visit to the practice During office visit, recognizing patient in need of further clinical support and management of care beyond the physician s office
Initial Assessment Initial Evaluation Living situation Type of support Mental status Self care deficits Durable medical equipment Financial assessment Health literacy Anticipated needs Fall risk assessment Develop Care Plan Patient input Physician input Assist with goal setting
Ongoing Workflow Follow up monthly calls/visits, or can be as often as several times a week based on patient needs such as: Active medication adjustments-weekly calls for 3-4 weeks, then decreased to biweekly Post hospitalization initial call within 24-72 hours follow up weekly for 4 weeks New referrals or tests ordered facilitate scheduling; follow up post appointment to facilitate getting consult or results in patient chart
Care Coordination: Pre Visit Pre-visit Review needs prior to visit; ie are labs, retinal exam, podiatrist visit ect. due Communicate to physician what is due. Make sure patient knows if need to be fasting Was patient referred to another provider since last visit-if so, was appointment made and are visit results in the chart
Care Coordination: Office Visit Update physician on patient goals, progress toward goals, barriers, social issues effecting treatment plan, compliance issues, patient concerns Participate in setting and explaining plan/orders/goals Let patient know when to expect next follow up
Care Coordination: Post Visit Follow up calls-frequency based on individual needs Face to face visits either in office or at patient s home Continued education/support
Care Coordination: Patient Outcome Goals set during initial visit: Weight less than 400 lbs. HgbA1C less than 7 Will walk 3 times a week for 3-5 minute increments Initial Current WEIGHT 432 lbs 408 lbs A1C 10.3 8.5 LDL 76 75 TG S 314 231 CHOL 142 130
Key Takeaways Care coordination is a key part of our success in a value-based delivery system and will help ensure an overall better experience and outcome for our patients Care coordination is a vital asset to our practices to ensure our eyes are on the patient during, after, and between visits with PCP and specialty Care coordination is vital within our practices to support and implement patient centered medical home standards
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