Transcript pcmh-2011-webinar-7-3712 - Community Care of North Carolina

Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 7
David Halpern, MD, MPH
March 7, 2012
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Acknowledgements
Let’s Review
• What Is The Record Review Workbook?
• Standard 4 – Self-Care Support &
Community Resources
– PCMH4A: Support Self-Care Process – MUST PASS
– PCMH4B: Provide Referrals to Community
Resources
Let’s Track Our Progress
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Standard 1 – Enhance Access/Continuity
Standard 2 – Identify/Manage Populations
Standard 3 – Plan/Manage Care
Standard 4 – Self-Care Support/Resources
Standard 5 – Track/Coordinate Care
Standard 6 – Measure/Improve Performance
Today’s Agenda
• Standard 3 – Plan & Manage Care
– PCMH3A: Implement Evidence-Based
Guidelines
– PCMH3B: Identify High-Risk Patients
– PCMH3C: Care Management - MUST PASS
– PCMH3D: Medication Management
– PCMH3E: Use Electronic Prescribing
PCMH 3A: Implement
Evidence-Based Guidelines
• Practice implements guidelines through
point of care reminders for patients with:
1) The first important condition *
2) The second important condition
3) The third condition, related to unhealthy
behaviors or mental health or substance
abuse
* Meaningful Use Requirement
PCMH 3A: Implement
Evidence-Based Guidelines
• 4 Points
• Scoring
– 3 factors = 100%
– 2 factors (including factor 3) = 50%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Identification of 3 conditions; (these are not
screening or a single preventive service process)
– Name and source of guidelines
– Demonstration of how guidelines are implemented
PCMH 3A: Choose Conditions
• Examples of eligible conditions include: COPD,
hypertension, hyperlipidemia, HIV/AIDS,
asthma, diabetes, or congestive heart failure.
• One of the 3 conditions (Factor 3) must be
related to unhealthy behavior (e.g. obesity,
smoking), substance abuse (e.g. illicit drug
use, prescription drug addiction, alcoholism),
or a mental health condition (e.g. depression,
anxiety, bipolar disorder, ADHD, dementia).
PCMH 3A: Provide Justification
PCMH 3A: Select
Evidence-Based Guidelines
PCMH 3A: Select
Evidence-Based Guidelines
PCMH 3A: Select
Evidence-Based Guidelines
PCMH 3A: Implement
Evidence-Based Guidelines
• You must adopt AND implement the
guidelines
• Guidelines can be implemented by embedding
them into the EMR or using paper-based
supporting documentation (flow sheets or
templates used to document treatment plans
or patient progress)
PCMH 3A: Implement
Evidence-Based Guidelines
Diabetes Management Flow Sheet
PCMH 3A: Implement
Evidence-Based Guidelines
PCMH 3A: Implement
Evidence-Based Guidelines
PCMH 3B: Identify
High-Risk Patients
• The practice does the following to
identify high-risk patients:
1) Establishes criteria and a process to
identify high-risk or complex patients
2) Determines the percentage of high-risk
patients in the population
PCMH 3B: Identify
High-Risk Patients
• 3 Points
• Scoring
– 2 factors = 100%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Process to identify patients
– Report showing number and percentage of
high-risk patients
PCMH 3B: Explanation of Factor 1
• The practice should have specific criteria and a process
for identifying complex or high-risk patients who need
care planning and management services.
• This may be based on (alone or in combination):
– High resource use (e.g. visits, medications, treatments,
other cost measures)
– Frequent visits for urgent or emergent care
– Frequent hospitalizations
– Multiple comorbidities (including mental health)
– Non-adherence with prescribed treatments/meds
– Terminal illness (palliative care/hospice involvement)
– Barriers to care (e.g. lack of social/financial support)
– Advanced age and frailty
– Multiple risk factors (smoking, family history, obesity, etc)
PCMH 3B: Explanation of Factor 2
• The practice may identify patients through a
billing or practice management system,
through the EMR, through key staff members,
or through profiles from health plan (as long
as these encompass 75% or more of patients)
• The factor requires a report that shows a
number and percentage of patients identified
as high risk, meaning you need to show a
numerator (# of high risk patients) and
denominator (total # of patients)
PCMH 3C &3D: REMEMBER!
• The patients you use for the review in 3C and 3D
are those who have one of the 3 conditions listed
in 3A, or are designated “high-risk” as described
in 3B
• You should only use visits that are “relevant” (i.e.
related to the chronic condition in question or a
combination of the factors which make them
“high risk”)
• NCQA does NOT expect you to care manage every
patient in your practice.
PCMH 3C: Care Management
• Care team performs the following for at least
75% of patients from Elements 3A and 3B:
1) Conducts pre-visit preparations
2) Collaborates with patient to develop care plan,
including treatment goals
3) Gives patient written care plan
4) Assesses and addresses barriers to treatment goals
5) Gives patient clinical summary at relevant visits
6) Identifies patients who need more care
management support
7) Follows up with patients who have not kept
important appointments
PCMH 3C: Care Management
• MUST PASS
• 4 Points
• Scoring
– 6-7 factors = 100%
– 5 factors = 75%
– 3-4 factors = 50%
– 1-2 factors = 25%
– 0 factors = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook
PCMH 3C: Record Review Workbook
PCMH 3C: Example – Factor 1
PCMH 3C: Example – Factor 3
PCMH 3C: Example – Factor 4
PCMH 3C: Example – Factor 7
PCMH 3D: Medication Management
• Practice manages medications in the following ways:
1) Reviews and reconciles medications for more than 50% of
care transitions * - CRITICAL FACTOR
2) Reviews and reconciles medications for more than 80% of
care transitions
3) Provides information about new prescriptions to more
than 80% of patients
4) Assess patient understanding of medications for more
than 50% of patients
5) Assesses patient response to medication and barriers to
adherence for more than 50% of patients
6) Documents OTCs, herbal/supplements, for more than 50%
of patients, with date of update
* Meaningful Use Requirement
PCMH 3D: Medication Management
• 3 Points
• Scoring
– 5-6 factors (including factor 1) = 100%
– 3-4 factors (including factor 1) = 75%
– 2 factors (including factor 1) = 50%
– Factor 1 = 25%
– 0 factors or does not meet Factor 1 = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook
PCMH 3D: Record Review Workbook
PCMH 3D: Example – Factor 2
PCMH 3D: Example – Factor 2 & 6
PCMH 3D: Example – Factor 2
PCMH 3E: Use Electronic Prescribing
• Practice uses e-prescribing system with the
following capabilities:
1) Generates and transmits at least 40% of
prescriptions to pharmacies *
2) Generates at least 75% of eligible prescriptions *
3) Integrates with patient medical records
4) Performs patient-specific checks for drug-drug and
drug-allergy interactions *
5) Alerts prescribers to generic alternatives
6) Alerts prescribers to formulary status *
* Meaningful Use Requirement
PCMH 3E: Use Electronic Prescribing
• 3 Points
• Scoring
– 5-6 factors (including factor 2) = 100%
– 4 factors = (including factor 2) = 75%
– 2-3 factors = (including factor 2) = 50%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Reports showing percent of electronic prescriptions
written and transmitted, and demonstrating the
system’s capabilities
PCMH 3E: Example – Factors 1 & 2
EXPLANATION
 January to March 2009 prescribing method is documented in the table.
 Certain prescriptions (Schedule II) must be printed on special paper
prescription pads in our state.
 96% of prescriptions were generated from our electronic medical record.
PCMH 3E: Example – Factors 1 & 2
PCMH 3E: Example – Factors 3 & 4
Drug-Allergy
Interaction
PCMH 3E: Example – Factor 4
PCMH 3E: Example – Factors 3, 5, 6
PCMH 3E: Example – Factors 3, 5, 6
Capturing A Screenshot
• Press the Print Screen key on your keyboard. It may be labeled
[PrtScn].
• Open a word processing program like Microsoft Word.
• Go to the Edit tab and choose Paste (or press control V).
• Optional: Use your image editor's crop tool to crop out
unnecessary portions of the screen shot.
• Annotate the image by typing above or below.
• Go to the File tab and choose Save As.
• Navigate to the folder where you want to save the image.
• Type a file name for the image.
• Click the Save button.
Screenshot Demo
Community Care PCMH Team
• David Halpern, MD, MPH
Community Care of North Carolina (CCNC)
• R.W. “Chip” Watkins, MD, MPH, FAAFP
Community Care of North Carolina (CCNC)
• Brent Hazelett, MPA
North Carolina Academy of Family Physicians
(NCAFP)
• Elizabeth Walker Kasper, MSPH
North Carolina Healthcare Quality Alliance (NCHQA)
Questions?
Feel free to contact me:
David Halpern, MD, MPH
(215) 498-4648
[email protected]