Part 3: NCQA PCMH 2014 Standards

Part 3: NCQA PCMH 2014 Standards Heather Russo, CCE PCMH Consultant September 15, 2015 Advancing Healthcare Improving Health

PCMH Standard 4: Care What s New? Management and Support Combined 2011 Standards 3 and 4 (Care Planning and Self Management Support) Elements: 4A: Identify Patients for Care Management Support 4B: Care Planning and Self-Care Support (MP) 4C: Medication Management 4D: Use Electronic Prescribing 4E: Support Self-Care and Shared Decision Making MU alignment in 4C, 4D, 4E 2

PCMH 4A: Identify Patients for Care Management Systematic process for identifying patients who may benefit from care management, considering: 4A-1: Behavioral health 4A-2: High cost/high utilization 4A-3: Poorly controlled or complex conditions 4A-4: Social determinants of health 4A-5: Referrals by outside organizations, practice staff or patient/family/caregiver Specific Criteria for identifying patients which may include: Substance abuse Psychiatric hospitalizations Diagnosis of behavioral issue Positive screening result for behavioral health issue Pediatrics: at risk for chronic physical, developmental, behavioral or emotional conditions 4

PCMH 4A: Identify Patients for Care Management Systematic process for identifying patients who may benefit from care management, considering: 4A-1: Behavioral health 4A-2: High cost/high utilization 4A-3: Poorly controlled or complex conditions 4A-4: Social determinants of health 4A-5: Referrals by outside organizations, practice staff or patient/family/caregiver Specific criteria, which may include: ER visits Hospital readmissions Unusually high numbers of imaging or lab tests Unusually high number of prescription medications High-cost medications 5

PCMH 4A: Identify Patients for Care Management Systematic process for identifying patients who may benefit from care management, considering: 4A-1: Behavioral health 4A-2: High cost/high utilization 4A-3: Poorly controlled or complex conditions 4A-4: Social determinants of health 4A-5: Referrals by outside organizations, practice staff or patient/family/caregiver Consider: Patients who consistently fail to meet treatment goals Patients with multiple comorbid conditions Continued abnormal results (A1C or blood pressure) 6

PCMH 4A: Identify Patients for Care Management Systematic process for identifying patients who may benefit from care management, considering: 4A-1: Behavioral health 4A-2: High cost/high utilization 4A-3: Poorly controlled or complex conditions 4A-4: Social determinants of health 4A-5: Referrals by outside organizations, practice staff or patient/family/caregiver Conditions in the environment that affect a wide range of health and quality-of-life outcomes. Availability of resources to meet needs Access to educational opportunities Access to job opportunities Public safety Social support Exposure to crime 7

PCMH 4A: Identify Patients for Care Management Systematic process for identifying patients who may benefit from care management, considering: 4A-1: Behavioral health 4A-2: High cost/high utilization 4A-3: Poorly controlled or complex conditions 4A-4: Social determinants of health 4A-5: Referrals by outside organizations, practice staff or patient/family/caregiver Intention is to allow nominations for care management by those closest to the patient. Practice should have a process for this. 8

PCMH 4A: Identify Patients for Care Management Behavioral health High cost/ high utilization Poorly controlled or complex conditions Social determinants of health Referrals by outside organizations, staff or patient How do we identify these patients? Data from the comprehensive health assessment (3C) Billing or practice management system Data from the EHR Through key staff members Can use different processes to identify different groups of patients A patient may fall into more than one category/factor 9

PCMH 4A: Identify Patients for Care Management 4A-6: Monitor percentage of patients identified (CF) Required to receive a score above 0 on this Element Combination of all factors results in a subset of the practice s entire panel Intent of this Element is to identify vulnerability A single indicator, such as cost, may not be enough of an indication for care management needs Patients identified in this Element will be used to draw a sample for the Record Review Workbook 10

PCMH 4A: Identify Patients for Care Management Documentation Requirements For factors 1-5 Documented process that describes the criteria for identifying patients for each factor For factor 6 Report showing the number and percentage of total patient population identified as likely to benefit from care management Can be a report of one of the factors Can be a report of all factors combined Can be any combination of the factors Percentage = Patients identified as likely to benefit from care management All active patients in practice 11

PCMH 4B: Care Planning and Self-Care Support (Must Pass) Care Plan that includes: Patient preferences and lifestyle goals Treatment goals Barriers to meeting goals Self-management plan Care Plan provided to patient 12

PCMH 4B: Care Planning and Self-Care Support (Must Pass) Care team and patient collaborate at relevant visits to develop and update a care plan that addresses whole-person care. Must include, for 75% of patients: 4B-1: Patient preferences and lifestyle goals 4B-2: Treatment goals 4B-3: Assess and address barriers to meeting goals 4B-4: Self-management plan 4B-5: Care Plan provided to patient in writing 13

PCMH 4B: Care Planning and Self-Care Support (Must Pass) Documentation: Method 1: Reports from the practice s electronic system for the patients identified in Element 4A. Denominator = # of patients identified through criteria in Element 4A seen at least once for a relevant visit within a recent 3-month period Numerator = # of patients identified in the denominator for whom each item is entered in the medical record Method 2: Record Review Workbook (RRWB) Choose a sample of patients from Element 4A and check for relevant items within their medical records Provide examples for each factor met 14

Behavioral health PCMH 4B: Care Planning and Self-Care Support (Must Pass) Documentation: Method 1: Reports from the practice s electronic system for High the cost/ patients identified in Element 4A. high utilization Denominator = # of patients identified through criteria in Poorly controlled Element 4A seen at least once for a relevant visit within a recent or complex 3-month period conditions Numerator = # of patients identified in the denominator for whom Social each item is entered in the medical record determinants Method of health 2: Record Review Workbook (RRWB) Choose a sample of patients from Element 4A and check for Referrals relevant by outside items within their medical records organizations, staff or patient Provide examples for each factor met 16

Bookmark NCQA PCMH 2014 Record Review Workbook (Method 2) Review sample of 30 records (use NCQA s sampling method) Assesses Elements 3C, 4B, 4C 50% threshold for 3C Comprehensive Health Assessment 75% threshold for 4B Care Planning and Self-Care Support Threshold varies by factor for 4C Medication Management May use reports instead (Method 1) Must also provide examples of how each factor is demonstrated for 4B and 4C (new documentation alert!) 17

Bookmark NCQA PCMH 2014 Record Review Workbook (Method 2) 18

Bookmark NCQA PCMH 2014 Record Review Workbook (Method 2) Yes No Not Used See Report 19

PCMH 4C: Medication Management What s new? Documentation requirements! Record Review Workbook or reports AND examples demonstrating how each factor is documented Factor 1 (CF) aligns with MU 20

PCMH 4C: Medication Management 4C-1: Reviews and reconciles medications for more than 50% of care transitions (CF) 4C-2: Reviews and reconciles medications for more than 80% of care transitions 4C-3: Provides information about new prescriptions for more than 50% 4C-4: Assess understanding of medications for more than 50% 4C-5: Assess response to medications and barriers to adherence for more than 50% 4C-6: Documents OTC medications, herbal therapies and supplements for more than 50% 21

MU Crosswalk Element 4C MU Core Objective MU Core Measure NCQA Factor Medication Reconciliation: The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The EP who performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. 4C-1: Reviews and reconciles medications for more than 50 percent of patients received from care transitions. Report with numerator/denominator 22

PCMH 4D: Use Electronic Prescribing Combined electronic transmission and use of formulary into one factor MU Alignment for 3 of the 4 factors Still includes CPOE, drug-drug and drugallergy, generic alternatives 23

PCMH 4D: Use Electronic Prescribing 4D-1: More than 50% of eligible prescriptions written by the practice are compared to formulary and electronically sent to pharmacies 4D-2: Enters electronic medication orders into medical record (CPOE) for more than 60% 4D-3: Patient specific checks for drug-drug and drug-allergy 4D-4: Alerts prescribers to generic alternatives 24

MU Crosswalk Element 4D MU Core Objective MU Core Measure NCQA Factor e-prescribing (erx): Generate and transmit permissible prescriptions electronically (erx). More than 50 percent of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using certified electronic record technology (CEHRT). 4D-1: More than 50 percent of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies. For MU: Report with numerator/denominator 25

MU Crosswalk Element 4D MU Core Objective MU Core Measure NCQA Factor CPOE for Medication, Laboratory and Radiology Orders: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE. 4D-2: Enters electronic medication orders in the medical record for more than 60 percent of medications. For MU: Report with numerator/denominator 26

MU Crosswalk Element 4D MU Core Objective MU Core Measure NCQA Factor Clinical Decision Support: Use clinical decision support to improve performance on high-priority health conditions. (2 Measures) Measure 2: The EP has enabled and implemented the functionality for drugdrug and drug-allergy interaction checks for the entire EHR reporting period. 4D-3: Performs patientspecific checks for drug-drug and drugallergy interactions. For MU: Respond with yes/no 27

PCMH 4E: Support Self-Care and What s New? Shared Decision Making Providing shared decision making aids Assess usefulness of identified community resources MU Alignment Factor 1 The same: self management tools, educational materials, list of community resources 28

PCMH 4E: Support Self-Care and Shared Decision Making 4E-1: Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients Aligns with MU; provide report 4E-2: Provides educational materials and resources to patients Provide at least 3 examples 4E-3: Provides self-management tools to record self-care results Provide at least 3 examples 29

PCMH 4E: Support Self-Care and Shared Decision Making 4E-4: Adopts shared decision making aids For complex decisions with options that people might value differently; helping patients make informed, values-based decisions with their care team NCQA will review at least three examples of materials Resources: International Patient Decision Aid Standards Collaboration (IPDASC) http://ipdas.ohri.ca/ Examples of Shared Decision Making Aids for Diabetes by the Mayo Clinic: http://diabetesdecisionaid.mayoclinic.org/ http://shareddecisions.mayoclinic.org/decision-aid-information/decision-aids-for-chronicdisease/diabetes-medication-management/ Philosophy on Shared Decision Making Aids by the Mayo Clinic: http://shareddecisions.mayoclinic.org/decision-aid-information/decision-aids-for-chronicdisease/ Helping Patients Make Better Treatment Choices with Decision Aids by the Commonwealth Fund: http://www.commonwealthfund.org/publications/newsletters/qualitymatters/2012/october-november/in-focus 30

PCMH 4E: Support Self-Care and Shared Decision Making 4E-5: Offers or refers patients to health education programs Peer-led discussion groups or shared medical appointments Allows patients to interact with the care team and each other NCQA will review materials for offering/conducting classes/groups 4E-6: Maintains current resource list on five or more topics or key community service areas important to the patient population Specific to the entire patient population (not a specified group of patients) Topics may include: dental, smoking cessation, weight management, etc. NCQA will review materials demonstrating that the practice offers at least five resources 31

PCMH 4E: Support Self-Care and Shared Decision Making 4E-7: Assesses usefulness of identified community resources Reviews and requests feedback from patients and families about community referrals Evaluate whether there are sufficient and appropriate resources for the patient population NCQA will review a survey or other materials showing how the practice collects information from patients on usefulness of referrals to community resources 32

MU Crosswalk Element 4E MU Core Objective MU Core Measure NCQA Factor Patient-Specific Education Resources: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. 4E-1: Uses an EHR to identify patientspecific education resources and provide them to more than 10 percent of patients. For MU: Report with numerator/denominator 33

PCMH Standard 5: Care Coordination Elements: and Care Transitions 5A: Test Tracking and Follow-Up 5B: Referral Tracking and Follow-Up (MP) 5C: Coordinate Care Transitions MU alignment in all Elements 34

PCMH 5A: Test Tracking and Follow-Up Content is the same from 2011 except for alignment with MU Stage 2 measures (factors 7-10) Tracks until results are available, flagging and following up, flag abnormal, notify patients, new born hearing and blood spot 35

PCMH 5A: Test Tracking and Follow-Up Factors 1 AND 2 are Critical Factors Both factors must be met in order to receive any score for this Element (6 point Element) Factors 1-6 are familiar from 2011 Standards Factors 7-10 reflect updated alignment with MU Stage 2 measures (factors 7-10) 36

PCMH 5A: Test Tracking and Follow-Up 5A-1: Tracks lab tests until results are available, flagging and following up on overdue results (CF) 5A-2: Tracks imaging tests until results are available, flagging and following up on overdue results (CF) Documentation: Documented process and Evidence showing how the process is met (must be for multiple patients, e.g. a log or report) 37

PCMH 5A: Test Tracking and Follow-Up 5A-3: Flags abnormal lab results, bringing them to the attention of the clinician 5A-4: Flags abnormal imaging results, bringing them to the attention of the clinician 5A-5: Notifies patients/families of normal and abnormal lab and imaging test results Documentation: Documented process and Evidence showing how the process is met (must be for multiple patients, not just a single patient record) 38

PCMH 5A: Test Tracking and Follow-Up 5A-6: Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (NA for adults) Documentation: Documented process and Evidence showing how the process is met (must be for multiple patients, not just a single patient record) 39

MU Crosswalk PCMH 5A MU Core Objective MU Core Measure NCQA Factor CPOE for Medication, Laboratory and Radiology Orders: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE. 5A-7: More than 30 percent of laboratory orders are electronically recorded in the patient record. 5A-8: More than 30 percent of radiology orders are electronically recorded in the patient record. For MU: Report with numerator/denominator 40

MU Crosswalk PCMH 5A MU Core Objective MU Core Measure NCQA Factor Clinical Lab-Test Results: Incorporate clinical lab-test results into CEHRT as structured data More than 55 percent of all clinical lab tests results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in CEHRT as structured data. 5A-9: Electronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record. For MU: Report with numerator/denominator 41

MU Crosswalk PCMH 5A MU Core Objective MU Core Measure NCQA Factor Imaging Results: Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT. More than 10 percent of all tests whose result is one or more image. 5A-10: More than 10 percent of scans and tests that result in an image are accessible electronically. For MU: Report with numerator/denominator 42

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) What s New under the 2014 Standards? Emphasis on coordination with behavioral health providers. Considering performance information on consultants/specialists when making referrals More information sent to the specialist with the referral Alignment with MU Stage 2 43

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-1: Considers available performance information on consultants/specialists when making referral recommendations Examples: state physician report cards, health plan directories, CMS website Documentation: NCQA reviews examples of the type of information your practice has available on specialist performance 44

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-2: Maintains agreements with a subset of specialists based on established criteria May be formal OR informal May embed expectations in a referral request form Criteria may include timeliness and content of response Documentation: at least one example 45

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-3: Maintains agreements with behavioral healthcare providers Must have at least one; meets the requirement if a facility is shared or service is integrated Documentation: at least one example 5B-4: Integrates behavioral health providers within practice site May fully or partially integrate See Evolving Models of Behavioral Health Integration in Primary Care for more information on types of integration http://www.milbank.org/uploads/documents/10430evolvingcare/10430evolvingcare.html Documentation: Materials that explain how behavioral health is integrated with physical health 46

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-5: Gives the consultant/specialist: 5B-6: Gives the consultant/specialist: Documentation: Documented process and Demonstration that the process is followed 47

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-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 Documentation: Screen shot showing the test of capability and report showing numerator and denominator. 48

MU Crosswalk Element 5B MU Core Objective MU Core Measure NCQA Factor Summary of Care: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Measure 1: The EP who transitions or refers provides a summary of care record for more than 50 percent of transitions of care and referrals. Measure 2: The EP who provides a summary of care record for more than 10 percent AND referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by...ehealthexchange. Measure 3: An EP must satisfy one of the following criteria: Conducts one or more successful electronic exchanges of a SCD, as part of which is counted in "measure 2"... Conducts one or more successful tests with the CMS designated test EHR. 5B-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 percent of referrals. For MU: Measures 1 and 2, report with numerator/denominator For MU: Measure 3, respond with yes/no 49

SCD Must-Have Resources The Medicare and Medicaid EHR Incentive Meaningful Use Education Module: Transitions of Care from CMS http://www.healthit.gov/policy-researchersimplementers/video/meaningful-use-education-module-transitionscare Go to http://www.healthit.gov/providers-professionals/achievemeaningful-use/menu-measures/transition-of-care ; scroll down to Care Transition Summary Toolkit; select Download this will bring you to NLC_Meeting the Transition of Care Measures for Eligible Professionals a document that is a checklist to meet the Summary of Care Document measures This is a complex MU objective, which deserves its own webinar! We just can t do it justice today or provide ALL the must-have resources. 50

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-8: Tracking referrals until the results are available, flagging and following up on overdue results (Critical Factor) Tracking should include: Date referral was initiated Timing indicated for receiving the report If report is not received within stated parameters, practice must contact the specialist and document this contact/effort to retrieve in log/tracking system Documentation: documented process and report/log showing tracking 51

PCMH 5B: Referral Tracking and Follow-Up (Must Pass) 5B-9: Documents co-management arrangements in the patient's medical record For patients who are regularly seen by both their PCP and a specific specialist Documentation: Three examples 5B-10: Asks patients/families about self-referrals and requests reports from clinicians Routine, proactive asking of patients If patient has self-referred, must follow-up with specialist Documentation: Documented process and demonstration that process is followed 52

PCMH 5C: Coordinate Care Transitions New factor: obtain consent for release of information and have secure exchange of information for coordination of care Content is the same from 2011 except for alignment with MU Stage 2 measures (factor 7) Identify patient with hospital/er stay, share information with hospitals, obtain patient discharge summaries, exchange information with hospital during patient stay 53

PCMH 5C: Coordinate Care Transitions 5C-1: Proactively identify patients with unplanned hospital admissions and ED visits Documentation: documented process and a log of patients 5C-2: Shares clinical information with admitting hospitals and emergency departments Documentation: documented process and three examples 5C-3: Obtains patient discharge summaries Documentation: documented process and three examples 54

PCMH 5C: Coordinate Care Transitions 5C-4: Contacts patients/families for follow-up care within an appropriate period following hospital admission or ED visit Practice defines appropriate contact period Documentation: Documented process and three examples or log of consistent follow-up 5C-5: Exchanges information with the hospital during a patient s stay Two-way communication Documentation: Documentation process and one example 55

PCMH 5C: Coordinate Care Transitions 5C-6: Obtains proper consent for release of information and has a process for secure exchange of information with community partners Detention centers, foster care, juvenile justice facilities, etc., to coordinate with those legally responsible for the patient Documentation: Documented process 5C-7: Exchanges key clinical information with facilities and provides SCD to facilities for more than 50% of referrals Documentation: Report See resources on Summary of Care Document (slide 24) 56

MU Crosswalk Element 5C MU Core Objective MU Core Measure NCQA Factor Summary of Care: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Measure 1: The EP who transitions or refers provides a summary of care record for more than 50 percent of transitions of care and referrals. Measure 2: The EP who provides a summary of care record for more than 10 percent AND referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by...ehealthexchange. Measure 3: An EP must satisfy one of the following criteria: Conducts one or more successful electronic exchanges of a SCD, as part of which is counted in "measure 2"... Conducts one or more successful tests with the CMS designated test EHR. 5C-7: Exchanges key clinical information and provides an electronic summaryof-care record for more than 50 percent of referrals. For MU: Measures 1 and 2, report with numerator/denominator For MU: Measure 3, respond with yes/no 57

PCMH Standard 6: Performance Measurement and Quality Improvement Elements: 6A: Measure Clinical Quality Performance 6B: Measure Resource Use and Care Coordination 6C: Measure Patient/Family Experience 6D: Implement CQI (MP) 6E: Demonstrate CQI 6F: Report Performance 6G: Use CEHRT Stage 2 MU incorporated into Element 6G 58

PCMH 6A: Measure Clinical Quality Performance Review performance to understand strengths and opportunities for improvement. Data may be from internal or external source. If external, must represent at least 75% of the population. Each measure may be used only once within this Element. For all factors, must provide reports for each measure that include: Period of measurement Number of patients in the data Rate (%), based on numerator and denominator For MULTI-SITES Reports must show data for each individual site (rather than an example site) 59

PCMH 6A: Measure Clinical Quality Performance 6A-1: At least two immunization measures Immunizations as recommended by the ACIP, CDC or USPSTF 6A-2: At least two other preventive care measures Routine health care that includes screenings, checkups and patient counseling to prevent illness, disease or other problems CMS definition Additional immunizations do not meet the intent Examples: Cancer screening Mammograms Depression screening ADHD screening Assessment of behaviors affecting health 60

PCMH 6A: Measure Clinical Quality Performance 6A-3: At least three chronic or acute care clinical measures May choose one measure from each of three conditions May choose three or more measures related to the same condition 6A-4: Performance data stratified for vulnerable populations (to assess disparities in care) Must stratify data from one or more measures from factors 1-3 May stratify by race, ethnicity, age, gender, language needs, education, income, type of insurance, disability or health status 61

PCMH 6A: Measure Clinical Quality Performance For streamlined renewal surveys the practice may attest to the factors, in addition: Be prepared to provide reports showing that the practice has measured at least annually for two years If the practice cannot demonstrate this, they must complete a full survey 62

PCMH 6B: Measure Resource Use and Care Coordination Two factors: 1. At least two measures related to care coordination 2. At least two utilization measures affecting health care costs (renewal surveys must show reporting on this factor annually for the past 2 years) No MU alignment For MULTI-SITES Reports must show data for each individual site (rather than an example site) 63

PCMH 6B: Measure Resource Use and Care Coordination 6B-1: At least two measures related to care coordination Examples: Timely transmission of transition of care record Transition record with specified elements contained within Reconciled medication list received for transitions of care 64

PCMH 6B: Measure Resource Use and Care Coordination 6B-2: At least two utilization measures affecting health care costs Measures the practice using resources judiciously. Examples: ER visits, readmissions, redundant tests, May not use no-show rate Streamlined renewal surveys must be prepared to show reporting on this factor annually for the past 2 years 65

PCMH 6C: Measure Patient/Family Experience Content is the same from 2011 (2011 Element 6B) 6C-1: Patient experience survey covering three of four areas: Access, Communication, Coordination of care and Whole-person care/self-mgmt. support 6C-2: PCMH Version of CAHPS 6C-3: Obtains experiences of vulnerable patient groups 6C-4: Obtains qualitative feedback (comments at the end of your patient survey do not meet the intent) For renewal surveys Be prepared to provide reports showing that the practice has measured at least annually for two years For MULTI-SITES Reports must show data for each individual site (rather than an example site) 66

PCMH 6D: Implement Continuous Quality Improvement (Must Pass) 6D-1: Set goals and analyze at least three measures from 6A. 6D-2: Act to improve at least three measures from 6A. 6D-3: Set goals and analyze at least one measure from 6B. 6D-4: Act to improve at least one measure from 6B. 6D-5: Set goals and analyze at least one measure from 6C. 6D-6: Act to improve at least one measure from 6C. 6D-7: Set goals and address at least one identified disparity in care/service for vulnerable populations (making a comparison to the general population). 67

PCMH 6D: Implement Continuous Quality Improvement (Must Pass) Set goals, analyze and act to improve: Clinical Measures (3 from 6A) Utilization or Coordination of Care Measure (from 6B) Patient Experience Measure (from 6C) Disparity in care/service for a vulnerable group (any) 68

PCMH 6E: Demonstrate Continuous Quality Improvement Measuring effectiveness of actions Achieving improved performance on: Two clinical quality measures One utilization or coordination measure One patient experience measure 69

PCMH 6E: Demonstrate Continuous Quality Improvement 6E-1: Measure the effectiveness of the actions taken to improve measures selected in 6D. 6E-2: Achieve improved performance on at least two clinical quality measures. 6E-3: Achieve improved performance on at least one utilization or care coordination measure. 6E-4: Achieve improved performance on at least one patient experience measure. 70

You will complete this form for: Measure 1 from 6A Measure 2 from 6A Measure 3 from 6A Measure 1 from 6B Measure 2 from 6C Identify Vulnerable Population 72

PCMH 6F: Report Performance Use measures from Elements 6A, 6B, 6C (clinical outcomes, utilization/coordination and patient experience) Show how you share data by clinician, across the practice, publically and with patients 73

PCMH 6F: Report Performance The practice produces data reports using measures from Elements 6A, 6B and 6C and shares: 6F-1: Individual clinician performance results with the practice. 6F-2: Practice-level performance results with the practice. 6F-3: Individual clinician or practice-level performance results publicly. 6F-4: Individual clinician or practice-level performance results with patients. 74

PCMH 6G: Use Certified Purpose: Meeting designated factors to align with Stage 2 MU and use CEHRT This element is for data collection purposes and will not be scored on the NCQA PCMH Survey 8 out of 10 factors align with Stage 2 MU EHR Technology 75

MU Crosswalk PCMH 6G MU Core Objective MU Core Measure NCQA Factor Protect Electronic Health Information: Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. Conduct or review a security risk analysis, including addressing the encryption/security of data stored in CEHRT, and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process for EPs. 6G-2: The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies. Respond with yes/no 76

MU Crosswalk PCMH 6G MU Core Objective MU Core Measure NCQA Factor Reminders: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminders, per patient preference. More than 10 percent of all unique patients who have had 2 or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available. 6G-10: The practice generates lists of patients and, based on their preferred method of communication, proactively reminds more than 10 percent of patients/families/ caregivers about needed preventive/ follow-up care. Report with numerator/denominator 77

MU Crosswalk PCMH 6G MU Core Objective MU Core Measure NCQA Factor Immunization Registries Data Submission: Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period. 6G-7: The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. Respond with yes/no 78

MU Crosswalk PCMH 6G MU Menu Objective MU Menu Measure NCQA Factor Syndromic Surveillance Data Submission: Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. 6G-3: The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. Respond with yes/no 79

MU Crosswalk PCMH 6G MU Menu Objective MU Menu Measure NCQA Factor Report Cancer Cases: Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period. 6G-4: The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically. Respond with yes/no 80

MU Crosswalk PCMH 6G MU Menu Objective MU Menu Measure NCQA Factor Report Specific Cases: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period. 6G-5: The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically. Respond with yes/no 81

Immunization Registries, Syndromic Surveillance Submission, Report Cancer Cases, Oh my! Washington State Department of Health http://www.doh.wa.gov/forpublichealthandh ealthcareproviders/healthcareprofessionsan dfacilities/datareportingandretrieval/electr onichealthrecordsmeaningfuluse 82

Action Planning in Teams Identify the TOP THREE areas of concern for you today 1. 2. 3. What is one action step you can do NOW for each item? Who will do each of those action steps? By when? What do you need to take back and share with your teams? How will this communication take place? 83

Share Ideas 84

Resources From NCQA Download Standards and Guidelines Includes Policies and Appendices Eligibility and Scoring Crosswalk from 2014 Standards to MU Stage 2 PCMH 2011-PCMH 2014 Crosswalk Glossary Summary of Updates (Updated 3x annually Mark your calendars! End of March, end of July, end of November.) Free Trainings on NCQA s website Start-to-Finish Pathway 85

NCQA s Start-to- Finish Pathway http://www.ncqa.org/progr ams/recognition/practices /PatientCenteredMedicalH omepcmh.aspx 86

Resources From Qualis Health (what you are leaving with today!) Available electronically: NCQA PCMH 2014 Self-Assessment Tool NCQA PCMH 2014 Renewal Planning Tool MU Stage 2 Crosswalk with NCQA PCMH 2014 Recognition Roadmap Safety Net Medical Home Implementation Guides for Practice Transformation http://www.safetynetmedicalhome.org/resourcestools/implementation-guides 87

Final Thoughts Design, develop and lead the process to maintain what you ve already accomplished and continue to move forward by: Assign roles and tasks, use a team Pay close attention to deadlines, plan accordingly Utilize tools to plan for the work ahead Be proactive about the work, don t wait! 88

Questions Heather Russo, CCE PCMH Consultant hrusso@qualishealth.org 800-949-7536 x2059 For more information: www.qualishealth.org 89