Transcript Title

DCO-ON0056-20090404-njPP1
TITLE
Quality Improvement Program
Patient-Centered Medical Home
2010
Printed
Quality Improvement Team
Primary Care Information Project
NYC Department of Health & Mental Hygiene
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What is a Patient Centered Medical Home and Who is NCQA?
Specialist
Patient Centered Home
VNS
PCP/
Patient
Hospital
Printed
Pharmacy
COORDINATION OF CARE
“There is a clear consensus that primary care needs to be at the center of a reformed US
health care system. The Patient-centered Medical Home (PCMH) has emerged as the key
strategy for the redesign of primary care. The PCMH model builds upon the core concepts of
primary care that include accessible, accountable, coordinated, comprehensive, and
continuous care in a healing physician-patient relationship over time. Added to these
basic primary care concepts are features that improve quality of care, improve patient
centeredness, organize care across teams, and reform the payment system to support this
enhanced model of primary care.”
doi: 10.1370/af
Annals of Family Medicine 8:88-89 (2010)
© 2010 Annals of Family Medicine, Inc.
m.1087
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NCQA PCMH Nine Focus Areas
PPC1: Access and Communication
PPC2: Patient Tracking and Registry Functions
PPC3: Care Management
PPC4: Patient Self-Management Support
PPC5: Electronic Prescribing
Printed
PPC6: Test Tracking
PPC7: Referral Tracking
PPC8: Performance Reporting and Improvement
PPC9: Advanced Electronic Communication
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THERE ARE 10 MUST-PASS ELEMENTS IN PCMH SCORING
= Must pass elements
Elements
Points
1: Access & Communication (9 pts)
1A: Access & communication
processes
1B: Access & communication results
2: Patient Tracking & Registry Functions (21 pts)
2A: Basic system for managing patient data
2B: Electronic system for clinical data
2C: Use of electronic clinical data
2D: Organizing clinical data
2E: Identifying important conditions
2F: Use of system for population management
4: Patient Self-Management Support (6 pts)
4A: Documentation of communication
needs
4B: Self-management support
4
5
2
3
3
6
4
3
3
4
3
5
5
2
4
Points
5: Electronic prescribing (8 pts)
5A: Electronic prescription writing
5B: Prescribing decision support-safety
5C: Prescribing decision supportefficiency
6: Test tracking (13 pts)
6A: Test-tracking and follow-up
6B: Electronic system for managing tests
7: Referral tracking (4 pts)
7A: Referral tracking
3
3
2
7
6
4
8: Performance Reporting & Improvement (15 pts)
8A: Measures of performance
8B: Patient experience data
8C: Reporting to physicians
8D: Setting goals and taking action
8E: Reporting standardized measures
8F: Electronic reporting- external entities
9: Advanced Electronic Communications (4 pts)
9A: Availability of interactive website
9B: Electronic patient identification
9C: Electronic care management support
Printed
3: Care Management (20 pts)
3A: Guidelines for important
conditions
3B: Preventive service clinician
reminders
3C: Practice organization
3D: Care management of important
conditions
3E: Continuity of care
Elements
3
3
3
3
2
1
1
2
1
TOTAL POINTS 100
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Source: NCQA Overview Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH)
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PPC-PCMH STRUCTURE DETAIL

Description

Achievement
levels
•
•
•


Level 1
25-49 points; Must-pass elements = 5 of 10, with performance of at least 50%
Level 2
50-74 points; Must-pass elements = 10 of 10, with performance of at least 50%
Level 3
75 points or more; Must-pass elements = 10 of 10, with performance of at least 50%
Basic: Requires electronic practice management
Intermediate: Requires EHR or e-prescribing
Advanced: Requires interoperable IT capabilities
IT
requirements
Steps for
evaluation
Printed
• Practice conducts self-scoring assessment
• Practice completes on-line Survey Tool
• NCQA evaluates all data and documents & provides score
• At least 5% of practices receive additional, onsite audit by NCQA
• NCQA provides final information to the practice
• NCQA reports information on the practice, the providers and level of
performance to NCQA & data users (health plans & physician directories) for
practices that pass a level

Pricing
charged by
NCQA
•
•
•
Initial fee Survey Tool license -$80
Initial Application fee
-$450-$2700 for 1-6 non-sponsored provider
-$360-$2700 for 1-6 sponsored providers
Add-on Survey Application fee to advance to next level
-Ranges from $225-$1350 for 1-6 providers
PCIP RATE- HALF OF THE RATE NOTED ABOVE$225/PHYSICIAN – benefit of participating with PCIP
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PCIP QUALITY IMPROVEMENT ACTIVITIES – WHAT DO WE DO?
–Provide technical assistance to physicians to help them improve the health
outcomes of patients,
–Focus on 4 priority TCNY areas (ABCS)
–Help providers get to meaningful use
–Provide CME/CNE credits for participating with QI
–Provide support for office redesign (e.g., workflows, documentation, standard
processes) to improve office efficiency
–if desired, prepare for NCQA Patient Centered Medical Home (PCMH)
Printed
–Provide additional coaching on preventive-health features & how to use
them for QI
–Provide a forum for discussing performance feedback and sharing best
practices for QI efforts
–Provide feedback to the teams at PCIP on what we observe during site visits
(development, IS, Billing, EMR)
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Standard 1- Access and Communication
INTENT OF THE STANDARD
 Practice removes barriers to care by providing improved access for appointments
and on-going patient communication
 Patients have a personal physician, coordinating care and diagnostics during one
visit
 Obtain patient feedback about potential access and communication issues to
reduce barriers to care
Supporting Evidence
▪ Scheduling
▪ Methods to contact MD
▪ Identifying health insurance
▪ Patient feedback
▪ Written telephone triage
▪
▪
Printed
Concepts Addressed
process
Written policy – helping patients
identify insurance options
Job descriptions for each staff
member
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PPC 1 – Access and Communication
Practical Examples:
 Incorporate feedback from patients and staff into office process
Develop policies, procedures, and job descriptions to ensure
that staff understand responsibilities.
 Consider holding monthly staff meetings to discuss staff ideas
and provide training
Printed
Conduct a patient survey and incorporate feedback into the
practice
 Post information in your office or website about how to obtain
insurance for those patients who do not have coverage
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Standard 2- Patient Tracking and Registry Function
INTENT OF THE STANDARD
 Capturing and using data for population management and data driven decision
making to improve outcomes for chronic conditions
• Proactively outreach to patients --identify needed treatment outside of the
normal office visit
 Capture important information for continuity of care if patient sees another
provider
 Promote consistency of patient care
Supporting Evidence
▪ Registry
▪ Capturing patient data
▪ Charting tools/documentation
▪ Conduct a 36 chart review,
▪
▪
Printed
Concepts Addressed
MRR spreadsheet
Chose three disease focus
areas, prove they are clinically
important for the practice
Written description- how often
the registry is used, examples
of preventive outreach efforts
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PPC 2 Patient Tracking and Registry Functions
Practical Examples:
 Identify three chronic clinical conditions to focus on at your
practice
Printed
 Run a billing report of top 10 billed ICD 9 codes
 Identify health conditions prevalent in your zip code through
DOH report
 Run registry query to determine percentage of patients with
condition at your practice
 Select chart sample (36 patients) for medical record review
 Use the registry to identify potential gaps in care for patients, i.e.,
overdue Hgb A1C, HTN patients without an office visit in 12
months
 Use letters function, telephone encounters, and emails to
document outreach efforts
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Standard 3 – Care Management
INTENT OF THE STANDARD
Patients receive coordinated care at the practice according to evidence - based
guidelines
Provide a physician directed, team based approach to managing and coordinating
the patient care – non-physician staff are an important part of the care team
Avoid patient safety errors or duplicative, unnecessary care through coordination
with patient, family and external organizations (hospital, health plan, nursing home)
Supporting Evidence
▪ Care management
▪ Clinical focus areas
▪ Team approach-non-
▪ PCIP Multi-site
▪ Job Descriptions
▪ Policy and Procedures
▪ Create Standing Orders
▪ MRR to assess use of care
physician staff
Printed
Concepts Addressed
plans, review of medication list,
self-monitoring etc
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PPC 3 – Care Management
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Practical Examples:
 Maximize the features of system and delegate to non-physician team
members
•
•
Clear CDSS alerts
Have each staff member practice to the fullest capacity of their license and
use standing orders
 Create a program for patient self management
•
•
Printed
Order FREE educational material from the DOH and distribute to patients
Refer patients to local classes or programs (i.e.: Weight Watchers, HTN,
Diabetes)
 Document all of the coordination work
•
•
•
•
Create a policy and workflow on how to communicate with external agencies
(documenting phone calls using t-encounters in the patient chart)
Document referral follow-up
Customize Preventive medicine section. The doctor can then easily document
(1) Individualized treatment goals; (2) assess patient treatment goals; and (3)
Assess barriers when patient have not met their goals
Use flowsheets and incorporate self-monitoring results into flowsheet.
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Standard 4 – Patient Self-Management
INTENT OF THE STANDARD
 Engaged patients will participate in their care and take responsibility improving
outcomes through self monitoring, community programs, and group classes
 Patients become part of the care team and collaborate with the practice by setting
their own goals and being accountable
 Physicians consider hearing and vision barriers to learning and self management
Concepts Addressed
▪
education
Patient goal setting
▪ 4A – PCIP multi-site 1 point
▪ NYCDOH free educational
▪
▪
Printed
▪ Smart forms
▪ Patient home monitoring
▪ Documentation of patient
Supporting Evidence
materials
Hite site website link
Document referral to community
resources
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PPC 4 – Patient Self-Management
Practical Examples:
 Encourage patients to manage their chronic conditions
• Provide educational materials
• Provide patients with a printed visit summary
 Assess readiness to change
• Use smart forms to screen
Printed
 Assess barriers to achieving clinical and personal goals
• Create and use alerts at the front desk for assessing
hearing and vision barriers
• Customize Preventive medicine section. This allows for
easier documentation of goal assessments
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Standard 5- Electronic Prescribing
INTENT OF THE STANDARD
Electronic prescribing reduces errors through using drug safety checks and
eliminating transcription errors
Recording medications in the EHR helps coordinate care among providers and in
the event of an emergency
Supporting Evidence
▪ Prescribing workflows
▪ Potential incentives and
▪ Screen shots of the practice’s
▪
rewards for eRx
Meaningful use
▪
▪
Printed
Concepts Addressed
schedule (last 5 days)
Screen shots of eRx’s (printing,
faxing or automating success)
Indicate what % of eRx’s the
practice does on a daily or
weekly basis
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PPC 5 – Electronic Prescribing
Practical Examples:
 Encourage coordination of pharmacy care and e-prescribing
Routinely document patient’s preferred pharmacy and
document in EHR
 Compare 5 days of practice schedule with reports of eRx
to determine percentage of patients using service
Printed
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Standard 6- Test Tracking
INTENT OF THE STANDARD
 Timely follow up/tracking of lab tests will assist providers in medical decision
making
 Patients and families can engage in care by understanding the test results and
adhering to treatment plans that improve outcomes
Concepts Addressed
Supporting Evidence
▪ Written process for lab workflow
▪ Using Lab interfaces
▪ Screenshots of letters or
▪ Closing the loop and
telephone encounters that notify
patients of lab results
coordinating care
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Printed
▪ Developing Strong Workflows
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PPC 6- Test Tracking
Practical Examples:
 Use a lab interface
 Develop a strong workflow
 Create written policy for test tracking and follow-up
 Track all tests and document all actions in the telephone
Printed
encounter section
 Notify patients of lab results by either sending letters or calling
the patient
**Remember to document all telephone calls!
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Standard 7-Referral Tracking
INTENT OF THE STANDARD
Coordination of complex care requires the systematic tracking of referrals
and treatment plan from other providers
Concepts Addressed
staff
Printed
▪ Referral workflows
▪ Delegating follow-up items to
Supporting Evidence
Written description of the referral
process
Screen shots of completed
referral and tracking process
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PPC 7- Referral Tracking
Practical Examples:
Develop a strong workflow
 Create policies for tracking outgoing referral
 Use eCW to document all outgoing referrals
 Continuously track referrals until consult notes are received
Printed
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Standard 8- Performance Reporting and Improvement
INTENT OF THE STANDARD
 Practice uses all available data to improve all aspects of care and includes patient
feedback into the process
 Data is shared within the practice to target improvement and with external
agencies (I.e., health plans, PQRI, DOH)
 Practices utilize data-driven decision making
Concepts Addressed
change health outcomes
▪ Patient surveys and score sheet
▪ Written process for survey
▪
distribution
Written plan for performance
assessment and improvement
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Printed
▪ Using the practice’s data to
Supporting Evidence
DCO-ON0056-20090404-njPP1
PPC 8-Performance Reporting and Improvement
Practical Examples:
Develop a strong workflow and delegate items to non physician staff
 Determine which reports will be run, by whom, and how often
Hold monthly staff meetings to discuss results, set goals, and take action
 Review quality measures monthly and identify areas that need
improvement
Printed
 Periodically assess the practice’s performance by distributing patient
surveys
 Use data from registry and patient feedback to drive discussions
Report to CMS through PQRI Measures to satisfy external reporting
requirements
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Standard 9-Advanced Electronic Communication
INTENT OF THE STANDARD
 Patients can communicate with providers in a variety of ways that is convenient
and maximizes coordination of care
- Website, email, patient portal
- Communicate with disease/case mgmt
- Patient web-based education
Concepts Addressed
▪ Written processes of electronic
tool
▪
▪ Must be interactive
Email communication
management
▪
Printed
▪ Using website education as a
Supporting Evidence
communication
Screenshots of direct
communication between
patients and physicians
▪ must be secure
communication- not regular
email
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PPC9- Advanced Electronic Communication
Practical Examples:
Create policies for electronic communication
Implement the patient portal
 Educate patients about how/when to use the portal to
communicate
Printed
Develop an interactive website
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PPC9- Advanced Electronic Communication
Printed
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PPC9- Advanced Electronic Communication
Printed
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GETTING STARTED AT YOUR PRACTICE – WHAT DO WE DO FIRST?
–Visit www.NCQA.org and download the standards
–Read the requirements and determine where you would like to make
changes at your practice to optimize workflows and patient care
–Arrange a visit from QI / EMR / Billing teams to optimize workflows and
documentation
–Organize a plan and timeline for making changes
–Delegate tasks to your staff
Printed
–Involve your entire team in the process
–Get feedback from staff and patients
1) Start by defining policies, procedures and job descriptions
–Use PCIP templates to create these documents
2) Administer a patient satisfaction survey
3) Hold your first staff meeting
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PCMH Project Plan – PDCA CYCLE
PLAN: A QI Specialist performs an onsite assessment with the physician
and other key staff members at the practice. Following the visit, the
practice receives a project plan and timeline along with recommendations
for workflow redesign and toolkit items to help achieve goals.
DO: QI project plan begins; practice purchases NCQA online tool, defines
policies and procedures, job descriptions, distributes /scores patient
surveys, improves EHR documentation, identifies 3 clinically important
conditions to focus PCMH efforts, practice considers advanced
communication techniques ie: portal/website options
•
CHECK: QI assesses workflow changes at practice and suggests
additional changes as needed, practice analyzes data (including patient
survey data and chart audit results)
•
ACT: QI Specialist reviews all documentation and provides feedback--Practice submits application to NCQA
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