Part 2: PCMH 2014 Standards Heather Russo, CCE PCMH Consultant September 15, 2015 Advancing Healthcare Improving Health
For Practices Recognized at Level 2 or Level 3 under the 2011 Standards Your Guide to Streamlined Renewal Requirements Note: If you are Renewing as a Level 1 organization, or are otherwise not eligible for the Streamlined Renewal process, you will provide documentation on all Elements for which you intend to receive points. Consider doing an Add-On to become eligible! 2
Let s dive into the details! 3
PCMH Standard 1: Patient-Centered Access Elements: 1A: Patient-Centered Appointment Access (MP) 1B: 24/7 Access to Clinical Advice 1C: Electronic Access Stage 2 MU incorporated into Element 1C 4
PCMH 1A: Patient-Centered Appointment Access (Must Pass) What s New: Providing alternative types of clinical encounters Availability of appointments (wait times) Monitoring no-show rates Acting on identified opportunities to improve access Same-Day Appointments Critical Factor (CF) Extended hours appt. access 5
PCMH 1A: Patient-Centered Appointment Access (Must Pass) Factor 3: Providing alternative types of clinical encounters Scheduled meeting between patient and clinician, e.g. telephone, secure instant messaging, group visits Factor 4: Availability of Appointments Standards for availability for timely appointment availability of appointment types (e.g., third next available appointment is X far out, or, 14 calendar days for routine care) 6
PCMH 1A: Patient-Centered Appointment Access (Must Pass) Factor 5: Monitoring no-show rates # of patients who did not keep pre-scheduled appointments / # of patients who were pre-scheduled to come to the center for appointments Factor 6: Acting on identified opportunities to improve access Uses information in factors 1-5 to improve access 7
PCMH 1B: 24/7 Access to Clinical Advice Focus on providing clinical advice during and afterhours Making medical records available to patients and staff after-hours Advice by telephone (CF) Advice by secure electronic message Documenting advice in the medical record 8
Factors: PCMH 1B: 24/7 Access to Clinical Advice 1. Making medical records available to patients and staff afterhours Secure access to EHR from home; patient portal Printed care plan/clinical summary to patient to convey medical information 2. Advice by telephone (CF) Report that covers 24/7 3. Advice by secure electronic message Report that covers 24/7 4. Documenting advice in the medical record 9
PCMH 1C: Electronic Access Patient portal, or equivalent capabilities required Factors 1-4 align with Stage 2 MU Factors 5-6 screen shots of system capabilities (two-way communication, request information) 10
MU Crosswalk PCMH 1C Stage 2 EP MU Core Measure Patient Electronic Access Measure 1: More than 50 percent of patients are provided timely (within 4 business days) online access to their health information, with the ability to view, download, and transmit. Measure 2: More than 5 percent of patients view, download, or transmit to a third party their health information. NCQA PCMH 2014 Factor 1C-1: More than 50 percent of patients have online access to their health information within four business days of when the information is available to the practice 1C-2: More than 5 percent of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. Tip Sheet: http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/PatientElecAccTipsheet_06182014-.pdf For MU: Report with numerator and denominator for both measures 11
V/D/T What can we do NOW? ALREADY HAVE A PORTAL Collect email addresses as part of check-in/demographics Ensure it is patient-friendly sign up and access to information Identify and share the workflow with all staff and patients Track usage Promote the portal this works best if clinicians promote it in the exam room! Find creative ways to help patients V/D/T DON T HAVE A PORTAL Start collecting email addresses NOW Explore options (certified?) and cost Implement portal ASAP Draft policies and procedures Ensure HIPAA-compliance Review what your patient experience is like on the portal Know which fields flow to the portal Learn how vendor reports calculate these the two V/D/T measures 12
MU Stage 2 Patient Electronic Access View, Download and Transmit Availability: More than 50% of all unique patients seen by the EP during the reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information Utilization: More than 5% of all unique patients seen by the EP during the reporting period (or their authorized representatives) view, download, or transmit to a 3rd party their health information 13
MU Crosswalk PCMH 1C Stage 2 EP MU Core Measure Clinical Summaries: Clinical summaries provided to patients or patient-authorized representatives within one business day for more than 50 percent of office visits. NCQA PCMH 2014 Factor 1C-3: Clinical summaries are provided within one business day(s) for more than 50 percent of office visits. For MU: Report with numerator and denominator 14
MU Crosswalk PCMH 1C Stage 2 EP MU Core Measure Use Secure Electronic Messaging: A secure message was sent using the electronic messaging function of CEHRT by more than 5 percent of patients. (NEW) NCQA PCMH 2014 Factor 1C-4: A secure message was sent by more than 5 percent of patients. (NEW) For MU: Report with numerator and denominator 15
Secure Messaging What can we do NOW? If possible, start secure messaging NOW. Things to think about... How will the patient know they have a message to read? Will the clinician/care team receive notification if the patient doesn t read the email by a certain date? How will the message stream get documented in the EHR? Do you have policies and procedures in place around secure messaging (e.g., NO emailing from personal, unsecured, unencrypted email account) Who receives and reads the messages? What is the required response time? What if someone is out of the office? What caveats and conditions will you specify how and where (e.g., If this is an emergency, you must call 911; we will respond to your message within two working days; there are certain topics and issues we will not be able to cover in an email; etc.) 16
PCMH 1C: Electronic Access Factors 5: two-way communication with the practice Factor 6: patients can request appointments, prescription refills, referrals and test results 17
PCMH Standard 2: Team-Based Care 4 Elements; all familiar from 2011 with enhanced requirements 2A: Continuity 2B: Medical Home Responsibilities 2C: Culturally and Linguistically Appropriate Services 2D: The Practice Team (MP) No MU alignment in Standard 2 18
PCMH 2A: Continuity 2A-1: Assisting patients in the selection process for their assigned PCP and care team 2A-2: Monitor continuity percentages 2A-3: Process for orienting new patients to the practice 2A-4: Transition care plan from pediatric to adult care 19
PCMH 2A: Continuity Solo-doc offices may mark Yes for Factors 1 and 2 In the Text/Notes section of the ISS tool, indicate your solo-doc status Emphasis: patients select a personal clinician who works with a care-team Everyone in the practice is aware of that assignment and can work to accommodate visits and communications with the assigned team (documented in the record) 20
PCMH 2A: Continuity Who is the Care Team? Team: primary personal clinician and associated clinical staff (includes behavioral health) Primary personal clinician may be: Physician or mid-level Residency groups under a supervising clinician, who share a panel of patients 21
PCMH 2A: Continuity 2A-1: Assisting patients/families to select a personal clinician and documenting the selection in practice records. Assist in the process of selection (What does this look like at your practice?) Provide the patient/family with information about the importance of having a personal clinician and care team DOCMENT the choice If needed, the practice may document a team or pairing of clinicians NCQA will review a documented process and an example from a patient record of the documented choice of clinician or team 22
PCMH 2A: Continuity 2A-2: Monitoring the % of patient visits with selected clinician/team Includes structured e-visits and phone visits (remember factor 1A-3!) The practice may determine the appropriate rate NCQA does not specify a threshold that needs to be met Communicate your standard to NCQA what is your goal? NCQA reviews a report 5 days worth of data Show: Total # of patient visits during reporting period where the patient was seen by selected clinician/team Total # of patient visits during reporting period (five business days) % of visits with selected clinician or team 23
PCMH 2A: Continuity 2A-3: Process to orient new patients to the practice. Orientation process includes education on: Medical home model Medical Home responsibilities Patient responsibilities (expectations) NCQA will review your documented process for orientation 24
PCMH 2A: Continuity 2A-4: Collaborating with the patient/family to develop/implement a written care plan for transitioning from pediatric care to adult care. The written plan may include: Summary of medical information List of providers, medical equipment and medications for patients with special health needs Obstacles to transitioning to adult care Special health care needs Patient response to transition Information provided to patient about transition Arrangements for release and transfer of medical records to adult care clinician 25
PCMH 2A: Continuity For Family Medicine practices that do not transition pediatric patients, the practice should instead provide education on: Importance of the medical home and having a primary care clinician Sensitivity to teen privacy concerns should be incorporated for teens NCQA will review: If you re a pediatric practice: an example of a written transition to from your practice to adult care If you re a family medicine practice: documented process and materials for outreach to adolescent and young adult patients If you re an internal medicine practice: documented process and materials for receiving adolescent and young adult patients that ensures continued care 26
PCMH 2B: Medical Home Process for informing patients/families about the role of the medical home Give patients materials covering several responsibilities (enhanced from 2011) Responsibilities 27
As a Medical Home, we provide 2B-1: Coordination of care across settings 2B-2: Instructions for receiving care and advice during and after-hours 2B-3: Effective care when patients provide a complete medical history 2B-4: Access to evidencebased care, selfmanagement support and education 2B-5: Scope of services including behavioral health 2B-6: Equal access regardless of payment source 2B-7: Information about obtaining coverage 2B-8: Instructions on transferring records to your medical home 28
PCMH 2B Documentation Materials may include one or more of: Patient brochure Letter to the patient/family Website information Patient compact Documented Process Who is responsible for ensuring these materials are available to patients How are these provided? Process steps. 29
PCMH 2C: Culturally and Linguistically Appropriate Services Assessing diversity (2C-1) and language needs (2C-2) of patient population (may include race, ethnicity, gender identity, sexual orientation and disability) 2C-3: Providing interpretation or bilingual services 2C-4: Providing printed materials in languages of patient population 30
PCMH 2D: The Practice Team (Must Pass) Emphasis is on on-going interactions of the team to: Understand each member s role Define each team member s responsibilities Provide efficient and sufficient communication Provide effective patient-hand off Ultimately, working together to enhance the care provided to patients 31
PCMH 2D: The Practice Team (Must Pass) 2D-1: Define roles for clinical and non-clinical team members Job Descriptions 2D-2: Identify the team structure and staff who lead and sustain teambased care Overview of the staffing structure for team-based care How will you ensure your team structures and functions stay in place? 32
PCMH 2D: The Practice Team (Must Pass) 2D-3: Hold care team meetings or a structured communication process to focus on individual patient care (CF) Informal daily meetings Review daily schedules with follow-up tasks Structured communication process including the clinician or team leader 2D-4: Use standing orders E.g., testing protocols, defined triggers for Rx orders, vaccinations 33
PCMH 2D: The Practice Team (Must Pass) Training and assigning care team members to: 2D-5: Coordinate care for individual patients 2D-6: Support patients in self-management, selfefficacy and behavior change 2D-7: Manage the patient population 34
PCMH 2D: The Practice Team (Must Pass) Job descriptions and training materials for care team members to MA s Coordinate care for individual patients (Factor 5) Mid- Levels Support patients/families in selfmanagement, self-efficacy and behavior change (Factor 6) RN s Manage the patient population (Factor 7) Physicians CNA s Referral Coordinators Front Desk Staff Behavioral Health Providers Patient Educators 35
PCMH 2D: The Practice Team (Must Pass) 2D-8: Hold scheduled team meetings to address practice functioning Must be routine (monthly, quarterly, etc.) Addressing improving care for all patients (factor 3 addresses specific patients) Include clinical and nonclinical staff What is working well? What needs improvement? 36
PCMH 2D: The Practice Team (Must Pass) 2D-9: Involve care teams in QI activities Not just inform, rather, involve 2D-10: Involve patients/families in QI activities or on the practice s advisory council Specify how patients and families are selected Their specific role on the QI team Frequency of team meetings 37
PCMH Standard 3: Population Health Elements: 3A: Patient Information 3B: Clinical Data Management 3C: Comprehensive Health Assessment 3D: Use Data for Population Management (MP) 3E: Implement Evidence- Based Decision Support MU alignment in 3A, 3B, 3D and 3E 38
PCMH 3A: Patient Information Records information for more than 80% of patients looking at 14 data points. What s New? Occupation (NA for pediatrics) Name and contact information of other health care professionals involved in patients care Meaningful Use: Date of birth (Core MU) Sex (Core MU) Race (Core MU) Ethnicity (Core MU) Preferred Language (Core MU) 39
PCMH 3A: Patient Information 3A-1 3A-2 3A-3 3A-4 3A-5 3A-6 3A-7 3A-8 3A-9 3A-10 3A-11 3A-12 3A-13 40
PCMH 3A: Patient Information 3A-14: Name and contact information of other health care professionals involved in patients care This information does not need to be captured in structured data fields. Documentation: Documented process for capturing data and Three examples demonstration implementation of process 41
MU Crosswalk Element 3A Meaningful Use Core Objective Record Demographics: Record the following demographics: preferred language, sex, race, ethnicity, date of birth. Meaningful Use Core Measure More than 80 percent of all unique patients seen by the EP have demographics recorded as structured data. NCQA Factor 3A-1: Date of birth 3A-2: Sex 3A-3: Race 3A-4: Ethnicity 3A-5: Preferred language For MU: Report with numerator and denominator 42
PCMH 3B: Clinical Data Recording clinical information as structured data (11 factors) What s New? Family history recorded as structured data (20%) Electronic progress note created, edited and signed (30%) MU Stage 2 alignment; factors with enhanced thresholds 43
PCMH 3B: Clinical Data 3B-1: Up-to-date problem list with current and active diagnoses for more than 80 percent of patients 3B-2: Allergies, including medication allergies and adverse reactions for more than 80 percent of patients Not listed as explicit criteria in Stage 2 MU Bundled into the Clinical Summary and Summary of Care Record requirements NCQA requires a report showing 80% Ensure you can still run a report for these data fields 44
MU Crosswalk Element 3B MU Core Objective MU Core Measure NCQA Factor Record Vital Signs: Record and chart changes in the following vital signs: height/length and weight (no age limit); blood pressure (ages 3 and over); calculate and display body mass index (BMI); and plot and display growth charts for patients 0-20 years, including BMI. More than 80 percent of all unique patients seen by the EP have blood pressure (for patients age 3 and over only) and/or height and weight (for all ages) recorded as structured data. 3B-3: Blood pressure, with the date of update for more than 80 percent of patients 3 years and older 3B-4: Height/length for more than 80 percent of patients 3B-5: Weight for more than 80 percent of patients 3B-6: System calculates and displays BMI (screen shot) 3B-7: System plots and displays growth charts (length/height, weight and head circumference) and BMI percentile (0-20 years) (screen shot) For MU: Report with numerator and denominator 45
MU Crosswalk Element 3B MU Core Objective MU Core Measure NCQA Factor Record Smoking Status: Record smoking status for patients 13 years old or older. More than 80 percent of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data. 3B-8: Status of tobacco use for patients 13 years and older for more than 80 percent of patients For MU: Report with numerator and denominator 46
MU Crosswalk Element 3B MU Menu Objective MU Menu Measure NCQA Factor Family Health History: Record patient family health history as structured data. (NEW) More than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives. 3B-10: More than 20 percent of patients have family history recorded as structured data. (NEW) For MU: Report with numerator and denominator 47
MU Crosswalk Element 3B MU Menu Objective MU Menu Measure NCQA Factor Electronic Notes: Record electronic notes in patient records. (NEW) Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. 3B-11: At least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of patients with at least one office visit. (NEW) For MU: Report with numerator and denominator 48
PCMH 3C: Comprehensive Health Assessment Comprehensive health assessment is completed and regularly updated (new documentation alert!) New factor: assessment of health literacy No MU alignment 49
PCMH 3C: Comprehensive Health Assessment 3C-1: Age and gender appropriate immunizations and screenings 3C-2: Family/social/cultural characteristics 3C-3: Communication needs 3C-4: Medical history of patient and family 3C-5: Advance care planning (NA for pediatrics) 3C-6: Behaviors affecting health 3C-7: Mental health/substance abuse for patient and family 3C-8: Developmental screening (NA for adult only) 3C-9: Depression screening 3C-10: Assessment of health literacy 50
PCMH 3C: Comprehensive Health Assessment 3C-10: Assessment of health literacy Practice may demonstrate that it is a health literate organization rather than assessing patients Provide health literacy training for staff System redesign to serve patients at different health literacy levels Utilize AHRQ s or Alliance for Health Reform s Health Literacy toolkit NCQA will review materials or processes demonstrating that health literacy is addressed at the practice 51
PCMH 3C: Comprehensive Health Assessment The practice must provide either: 1) System generated report based on 3-month period where more than 50% of patients had an assessment for each factor OR 2) Record Review Workbook review of patient records For factors 8 and 9 (depression screening and health literacy), must also provide the completed form used for the documentation. 52
Bookmark! PCMH 3C: Comprehensive Health Assessment More on The practice must provide either: 2014 Record 1) System generated report based on 3-month period where Review more than 50% of patients had an assessment for each factor Workbook coming soon OR 2) Record Review Workbook review of patient records For factors 8 and 9 (depression screening and health literacy), must also provide the completed form used for the documentation. 53
PCMH 3D: Use Data for Population Management (Must Pass) Proactive identification of patients and notification of needed care What s New? At least two different immunizations At least three chronic or acute care services MU Alignment patient lists 54
PCMH 3D: Use Data for Population Management (Must Pass) 3D-1: At least two different preventive care services 3D-2: At least two different immunizations 3D-3: At least three different chronic or acute care services 3D-4: Patients not recently seen by the practice 3D-5: Medication monitoring or alert 55
PCMH 3D: Use Data for Population Management (Must Pass) Documentation: Reports/lists of patients needing services (run within the last 12 months) and Materials showing how patients were notified for each service Renewing practices: Provide evidence for at least two factors showing annual outreach for two years If unable to show evidence of ongoing population management (annually for at least two years) for at least two factors, you must submit as an initial applicant and may not use the streamlined renewal process. 56
MU Crosswalk Element 3D MU Core Objective MU Core Measure NCQA Factor Patient Lists: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one report listing patients of the EP with a specific condition. 3D-1: At least two different preventive care services. 3D-2: At least two different immunizations. 3D-3: At least three different chronic or acute care services. For MU: Respond with yes/no 57
PCMH 3E: Implement Evidence-Based Decision Support Implement clinical decision support following evidencebased guidelines for: Mental health or substance abuse (CF) Chronic medical condition Acute condition Condition related to unhealthy behaviors Well child or adult care Overuse/appropriateness issues NCQA reviews name and source of guidelines, examples of guideline implementation These patients are NOT used as the patient sample for the Record Review Workbook MU Alignment for all factors (although MU reports will not be used for NCQA) 58
PCMH 3E: Implement Evidence-Based Decision Support When selecting conditions, consider: What diseases or risk factors are prevalent within your patient population? Availability of EBG s: www.choosingwisely.org (American Board of Internal Medicine) www.uptodate.com www.guideline.gov Embed them into your daily workflows Clinical Decision Support Registries Health Maintenance Templates 59
MU Crosswalk Element 3E 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 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. 3E-1: A mental health or substance use disorder 3E-2: A chronic medical condition 3E-3: An acute condition 3E-4: A condition related to unhealthy behaviors 3E-5: Well child or adult care 3E-6: Overuse/ appropriateness issues Tip Sheet: http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalDecisionSupport_Tipsheet-.pdf For MU: Respond with yes/no 60
Questions Heather Russo, CCE PCMH Consultant hrusso@qualishealth.org 800-949-7536 x2059 For more information: www.qualishealth.org 61