2 0 1 7 Attestation PATIENT CENTERED Medical Home of Facility Compliance State of Wyoming, Department of Health, Division of Healthcare Financing Check the Patient Centered Medical Home (PCMH) Programs you would like to be a part of: Any additional future payers Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016
PRACTICE INFMATION To be completed by facility Medical Director 1. PCMH Practice Name 2. PCMH Address (Practice Physical Address): Street: City: State: Zip Code: 3. Primary Contact for PCMH Project * Medical Director Name: Phone: Fax: Email: 4. Practice NPI Number 5. Medicaid Provider Number (Current Wyoming Medicaid enrolled providers only) (Current Wyoming Medicaid enrolled providers only) 6. PCMH Address (Mailing Address): Street: City: State: Zip Code: 7. Practice Manager: Name: Phone: Fax: Email: Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016 2
MEDICAL HOME CE FUNCTIONS If submitting the ISS tool, please skip ahead to page 6. For sections 8 through 17, your practice must attest to implementing core medical home functions as defined by NCQA s Patient-Centered Medical Home Standards or equivalent certification. Practices must attest to achieving at least the identified scoring threshold for each corresponding PCMH element. To verify compliance, please submit, along with this form, your Summary and Detailed Results report from your practice s NCQA PCMH Interactive Survey System (ISS) tool or equivalent certification. This summary report can be generated at any time both prior to being NCQA-Recognized (self-assessment) or after receiving formal Recognition (final score). Formal Recognition is not required for this initiative. The attached instructions (Appendix 1) identify how to: a) obtain access to the tool; b) locate the summary report within the tool; and c) print out or create a PDF of the summary report. The requirements around the CCD and reporting of CQM s will be verified at the State level. Medical Home Core Function A 8. Do you certify that the PCMH provides enhanced access, electronic access, continuity of medical care, and works as a team to provide culturally and linguistically appropriate care? 9. Scoring Threshold Practices must demonstrate at least a 25% score on all elements in their Summary and Detailed Results PCMH Standard 1 Elements A, B, C, D, E, F, G PCMH Standard 1 Elements A, B, C PCMH Standard 2 Elements A, B, C, D Does your practice currently meet the 25% score required on each of these elements? Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016 3
Medical Home Core Function B 10. Do you certify that your PCMH practice will collect and use appropriate demographic and clinical data to support effective care management? 11. Scoring Threshold Practices must demonstrate at least a 50% score on all elements in their Summary and Detailed Results PCMH Standard 2 Elements A, B, C, D PCMH Standard 3 Elements A, B, C, D Does your practice currently meet the 50% score required on each of these elements? Medical Home Core Function C 12. Do you certify that your PCMH practice plans and manages care by using evidence-based guidelines, identifying high-risk patients, developing patient-centered care plans, managing medications, and referring patients to effective community resources? 13. Scoring Threshold Practices must demonstrate at least a 25% score on all elements in their Summary and Detailed Results PCMH Standard 3 Elements A, B, C, D, E PCMH Standard 4 Elements A, B PCMH Standard 3 Element E PCMH Standard 4 Elements A, B, C, D, E Does your practice currently meet the 25% score required on each of these elements? Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016 4
Medical Home Core Function D 14. Do you certify that your PCMH practice tracks and coordinates care for your patients, including tracking labs, tests, referrals, and coordinating with health care facilities, such as hospitals? 15. Scoring Threshold Practices must demonstrate at least a 50% score on all elements in their Summary and Detailed Results PCMH Standard 5 Elements A, B, C PCMH Standard 5 Elements A, B, C Does your practice currently meet the 50% score required on each of these elements? Medical Home Function E 16. Do you certify that your PCMH practice measures and implements continuous quality improvement techniques and reports data externally? 17. Scoring Threshold Practices must demonstrate at least a 50% score on all elements in their Summary and Detailed Results report. 2011 or 2014 may be used in 2017. NCQA PCMH 2011 or 2014 Elements PCMH Standard 6 Elements A, B, C, D, E, F, G Does your practice currently meet the 50% score required on each of these elements? Clinical Quality Measures For 2017, the 9 adult and 12 children measures below are required for reporting to meet PCMH Standard 6 Element A: Adults: 1. Closing the Referral Loop 2. Functional Status Assessment for Total Knee Replacement 3. Documentation of Current Medications in the Medical Record 4. Maternal Depression Screening 5. Diabetes: Hemoglobin A1C Poor Control 6. Breast Cancer Screening 7. Tobacco Use Assessment and Cessation Intervention 8. Controlling High Blood Pressure 9. Use of Imaging Studies for Low Back Pain 10.Cervical Cancer Screening 11. Colorectal Cancer Screening 12.Diabetes: LDL Management and Control Children: 1. Closing the Referral Loop 2. Childhood Immunization Status 3. Use of Appropriate Medications for Asthma 4. ADHD: Follow-Up Care for Children Prescribed Medication 5. Hemoglobin A1C Test for Pediatric Patients 6. Appropriate Treatment for Children with Upper Respiratory Infection (URI) 7. Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents 8. Oncology: Medical and Radiation Pain Intensity Quantified 9. Child & Adolescent Major Depressive Disorder: Suicide Risk Assessment Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016 5
18. Do you agree to report the 21 Clinical Quality Measures listed in section 17 into the State Level Registry (SLR) on a monthly basis? 19. Do you agree to pull CCDs or import CCD-As into your EHR/EMR for Medicaid encounters at least monthly? 20. This attestation is only valid for the current calendar year submitted. Do you understand that you will need a new attestation of compliance annually by January of each year, and also in the event that the facility director is no longer in this position? 21. Do you understand that these requirements are expected to change in future years as Stages 2 and 3 of Meaningful Use are updated and NCQA (or equivalent) PCMH requirements continue to be revised? Form Certification In signing this document you are attesting that you have read, understand and agree to all conditions for participation as a Patient Centered Medical Home and that all statements contained herein are true to the best of your knowledge. Also you are attesting that you understand that failure to abide by the certifications will result in the care management fees being recovered, denied, or withheld. 22. Director s Name: (printed) 23. Director s Signature: Date Signed: F STATE MEDICAID AGENCY USE Date Attestation Received by DHCF: Action Taken: Wyoming Department of Health- PCMH Version 3.0 revised 11/1/2016 6