Transcript LPHI Strategic Planning

Applying NCQA PPC-PCMH Standards
to Primary Care and Behavioral Health
Maria Ludwick, MPH
Harold Pincus, MD
Agenda

PCASG Quality Improvement Program

NCQA Patient Centered Medical Home Basics
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Adaptation to PC - BH

Gaps in Implementation

Strategies to Fill the Gap
Note: This is a participatory session
Goals for the Primary Care Access
and Stabilization Grant
o
Increase access to care on a population basis
o
Develop sustainable business entities
o
Provide evidenced based, quality health care
o
Develop an organized system of care
PCASG Quality Improvement Program

Interprets NoA requirement for a quality improvement
program at the grantee level
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Approved by CMS in June 2008
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Outlines a uniform set of quality standards

Minimum quality requirements

Optional incentive payment program

Encourages maximum participation

Based on National Committee for Quality Assurance (NCQA)
Physician Practice Connections – Patient Centered Medical
Home
Why NCQA PPC-PCMH?

Widely recognized for health care quality standards

Received input from a variety of stakeholders e.g. professional
organizations, insurers, and patient advocacy groups

Standards emphasize use of systematic, patient-centered, coordinated care
management processes

Reinforces partnerships between individual patients, and their personal
physicians, and when appropriate, the family
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Uses of registries, care coordination, information technology, and other
means to assure patients have the right care when they need it
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Standardized survey tool & methodology enables equitable distribution of
PCASG funds
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Encourages grantees to seek NCQA recognition
Optional Quality Incentive Payment (QIP)

5% of PCASG grant funds available for QIP ($3.85M)
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3 opportunities (March, June and Dec 09)
~$1.283M each payment
Round One Awards Ranged from $67k-$135k
Three Payment Tiers
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Based on NCQA levels but less stringent
Graduated tiers/Graduated payments
NCQA Scoring
Must
Qualifying
Points
Pass
Level
(50%)
Level 3
75
10 of 10
Level 2
50
10 of 10
Level 1
25
5 of 10
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PCASG Scoring
Must
Qualifying
Payment
Points
Pass
Tier
Factor
(50%)
Tier 3
50
8 of 10
6x
Tier 2
25
5 of 10
3x
Tier 1
20
4 of 10
1x
Half of an organization’s eligible service delivery sites must pass
to obtain a specific tier
PPC-Patient Centered Medical Home Basics
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Measures evaluate:
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Use of systems
Effectiveness in prevention
Management of chronic illness and patient safety
Measures are “actionable” at practice level
Measures are validated by relating them to
performance
Score is based on:
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Responses in Web-based Survey Tool
Supporting documentation attached to Survey Tool
Each element specifies type of documentation: Reports;
Documented processes; Records or files
Data Sources & Guidance

Data sources and documentation are required
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Each element indicate type of HIT required to perform functions

Basic – (HIT) Basic
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Paper-based or administrative electronic system
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Intermediate – (HIT) Intermediate
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Electronic system for clinical functions
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Advanced – (HIT) Advanced

Electronic system for connectivity or interoperability
Practices can achieve a passing score on All Must Pass
Elements with Basic Health Information Technology
PPC-PCMH Content and Scoring
Standard 1: Access and Communication
A. Has written standards for patient access and patient
communication**
B.
Uses data to show it meets its standards for patient
access and communication**
Pts
Standard 2: Patient Tracking and Registry Functions
A. Uses data system for basic patient information
(mostly non-clinical data)
B.
Has clinical data system with clinical data in
searchable data fields
C. Uses the clinical data system
D. Uses paper or electronic-based charting tools to
organize clinical information**
E.
Uses data to identify important diagnoses and
conditions in practice**
F.
Generates lists of patients and reminds patients and
clinicians of services needed (population
management)
Pts
Standard 3: Care Management
A. Adopts and implements evidence-based guidelines
for three conditions **
B.
Generates reminders about preventive services for
clinicians
C. Uses non-physician staff to manage patient care
D. Conducts care management, including care plans,
assessing progress, addressing barriers
E.
Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pts
3
Standard 4: Patient Self-Management Support
A. Assesses language preference and other
communication barriers
B.
Actively supports patient self-management**
Pts
2
4
4
5
9
2
3
3
6
4
3
21
4
3
5
5
20
6
Standard 5: Electronic Prescribing
A. Uses electronic system to write prescriptions
B.
Has electronic prescription writer with safety
checks
C. Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
A. Tracks tests and identifies abnormal results
systematically**
B.
Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts
7
Standard 7: Referral Tracking
A. Tracks referrals using paper-based or electronic
system**
PT
4
Standard 8: Performance Reporting and
Improvement
A. Measures clinical and/or service performance
by physician or across the practice**
B.
Survey of patients’ care experience
C. Reports performance across the practice or by
physician **
D. Sets goals and takes action to improve
performance
E.
Produces reports using standardized measures
F.
Transmits reports with standardized measures
electronically to external entities
Pts
Standard 9: Advanced Electronic Communications
A. Availability of Interactive Website
B.
Electronic Patient Identification
C. Electronic Care Management Support
Pts
1
2
1
**Must Pass Elements
Physician Practice Connections and Patient-Centered Medical Home
2
8
6
13
4
3
3
3
3
2
1
15
4
8
NCQA PPC – PCMH Requirements:
Must pass criteria
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1A – Written standards for patient access
1B – Data to show it meets access standards
2D – Use charting tools to organize clinical info
2E – Data to identify 3 important conditions
3A – EBG for 3 conditions – 2 to pass
4B – Supports patient self management
6A – Test tracking
7A – Referral tracking
8A – Measure performance
8C – Report performance
Evidence-Based Chronic (Planned) Care Approaches
for Treating Depression Are Effective
Community
Health System
Resources and Policies
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Productive Interactions
Patient-Centered
Informed, Empowered
Patient and Family
Timely and
Efficient
Coordinated
EvidenceBased and Safe
Improved Outcomes
Prepared, Proactive
Practice Team
Chronic Disease Clinical Models
Hypertension
 Congestive heart failure (CHF)/Coronary
artery disease (CAD)
 Stroke
 COPD (Chronic Obstructive Pulmonary
Disease)
 DM (Disease Management)
 Asthma
 Multiple comorbidities
 Transitional care management

Depression Clinical Models
Chronic (planned) care model – Wagner
• Collaborative care – Katon
• Partners in Care (AHRQ) – Wells
• PROSPECT – Alexopoulous, Katz, Reynolds
• Telephone care management – Simon, Hunkeler
• IMPACT (Hartford) – Unutzer
• RESPECT (MacArthur) – Dietrich
• Quality Improvement for Depression (NIMH) – Rost,
Ford, Rubenstein
• Child models – Campo, Asarnow, GLAD-PC
• Other models for anxiety/PTSD
•
Clinical Model: Major Components
Leadership
Accountability
Vision
Resources
Practice design
Patient registry
Protocols
Care manager
Clinical
information
systems
Red flags
Feedback to provider on clinical progress
Support care manager
Decision support
Guidelines
Provider training
Expert/specialist consultation
Referral pathways
Self management
support
Patient preferences, cultural competency
Information on depression, medications, skills
Community
resources
Information on and for consumer groups and other services
Access to non-provider sources of care
Leadership
Component
Leadership
Key Principles
Description
There must be a
A team of primary care, mental health, and
senior administrative personnel that:
leadership team
composed of
•
Garners resources (personnel, space,
financial)
organizational
partners with overall • Incorporates and coordinates
stakeholder interests
program
accountability for
•
Promotes adherence to treatment
guidelines and protocols
implementation
across partnering
•
Sets target goals for key process
organizations
measures and outcomes
•
Encourages efforts at continuous
quality improvement
A Clinical Framework for Depression Treatment in Primary Care;
Psychiatric Annals 32:9; September 2002
Delivery System Design
Component
Delivery System
Design
Key Principles
The delivery system is
available to implement
all aspects of decision
support. It consists of:
•Access to guidelines
and protocols
•A depression patient
registry
•A care manager
responsible for
implementing
coordinated care in
conjunction with primary
care providers and, when
necessary, mental health
specialists
•A systematized
A Clinical Framework for Depression
Treatmentto
in Primary
Care;
approach
obtaining
Psychiatric Annals 32:9; September 2002
access to mental health
specialists for referral,
consultation, and
feedback
Description
1)
•
•
•
•
•
2)
Care manager, either on or off site,
implements protocols for:
Systematically identification of patients at
elevated risk for depression
Screening of patients at elevated risk for
major depression using a structured
assessment tool
Stratification of treatment intensity by
episode severity and patient preference
Monitoring and promotion of adherence to
guideline-based treatment(s) for
depression
Routing follow-up at intervals specific to a
patient’s phase of depression treatment
(acute, continuation, or maintenance)
Structure is in place to ensure facilitated
access to mental health specialists
Clinical Information System
Component
Clinical
Information
System
Key Principles
The clinical information
system consists of tools
to facilitate the roles of
the primary care
providers and care
managers
Note: The clinical
information system
does not necessarily
need to be interactive
with other computer
systems
A Clinical Framework for Depression Treatment in Primary Care;
Psychiatric Annals 32:9; September 2002
Description
Enables the primary care physician and
care manager to establish a registry to
identify, manage, and track depressed
patients
•
Tracks key process and program
measures (e.g. percent of patients who
received a structured assessment for
depression, percent of patients continuing
pharmacotherapy after 3 months, percent of
patients who achieved a 50% decrease in
depression scores)
•
Decision Support
Component
Decision Support
Key Principles
Evidence-based
depression treatment
guidelines and care
protocols are
available to improve
recognition and
treatment of
depression
Description
1)
•
•
•
•
•
2)
3)
4)
A Clinical Framework for Depression Treatment in Primary Care;
Psychiatric Annals 32:9; September 2002
There are evidence-based treatment
guidelines and care protocols for:
Systematically identifying patients at
elevated risk for depression
Case identification using a structured
assessment tool
Stratification of treatment intensity by
severity
Treatment by provider and care manager
Mental health specialist referral
Staff are trained in using decision
support tools
Materials receive periodic review and
updating
Mental health specialists are readily
available for decision support and patient
referral
Self-Management Support
Component
SelfManagement
Support
Key Principles
Materials, tools, and
processes are
available to promote
patient activation and
self-care for
depression
A Clinical Framework for Depression Treatment in Primary Care;
Psychiatric Annals 32:9; September 2002
Description
Self-management support consists of:
•Shared decision making between
patient and provider(s), taking into
account patient preferences for
treatment and family involvement
•Culturally appropriate patient
information available in a variety of
formats (e.g. print, audio, and
videotape)
•Self-study materials including such
self-care techniques as goal setting
and problem solving, as well as
promotion of adherence to
pharmacotherapy
•CM follow-up on a patient’s progress
with advice and acquisition of skills
described in self-study materials
Community Resources
Component
Community
Resources
Key Principles
Description
Patient information
and education about
depression are
available from
organizations that
are independent of
providers and health
plan
Patients and families are informed of
nonprogram information and other
resources designed to assist in their
understanding of depression and the
various treatments available from
such entities as:
•Local/national organizations
•Clergy, employee assistance
programs, and support groups
Functions of Care Managers
Patient-Focused Support
•Develop and maintain rapport
•Help access psychosocial treatment (e.g.
interpersonal therapy or problem-solving
therapy)
Education/Self Management
•Educate about illness, treatments, side
effects
•Communicate, customize, and maintain
self-action plan for patient
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Functions of Care Managers
Follow-up
•Encourage adherence to medications and
education on their side effects
•Facilitate and remind patient about
telephone or personal visits
•Facilitate communication and linkages
with mental health specialist and primary
care provider
•Intervene in crisis
Clinical
•Systematically monitor depressive
symptoms, comorbidities, adherence
•May provide psychosocial therapy or
counseling (e.g. interpersonal therapy or
problem-solving therapy)
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Phases of Depression Treatment
Remission
Recovery
Relapse
No Depression
Symptoms
Recurrence
Response
Syndrome
Treatment Phases
Acute
Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.
Continuation
Maintenance
Top Ten Issues
General Health/Mental Health Relationships
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Partnerships
Formalize
Accountability
Referral
Consultation/Evaluation
Information Flow
Money
Quid Pro Quo
Maintenance
Generalize
Gaps (1)
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Participant comments
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NCQA Reports
RESULTS FROM
Round One NCQA Surveyed Sites
36 Sites Total
34 Primary Care
2 Behavioral Health
Where QIP Participants Did Well
PPC1A: Access & Communication Processes
e.g. Written Standards*
MUST PASS
4 POINTS
PPC2A: Patient Data e.g. Practice Management
System or Registry*
Not MUST
PASS
2 POINTS
PPC2E: Identify Important Conditions*
MUST PASS
4 POINTS
PPC3A: Implement EBG*
MUST PASS
3 POINTS
PPC3B: Guideline-based Reminders When
Seeing Patient
Not MUST
PASS
4 POINTS
PPC8A: Measures clinical and service
performance*
MUST PASS
3 POINTS
TOTAL
20 POINTS
* PCASG Quality Minimum Requirement
Where QIP Participants Didn’t Do Well
PPC2F: System for Population Management
Generates lists of patients needing appts or follow-up,
reminders for follow, on particular meds, chronic condition
PPC3E: Continuity of Care
Identifies patients receiving care in facilities; routinely sends
info to facilities; contacts patients after discharge
PPC4B: Actively Supports Self-Management:
Readiness for change, language appropriate educational resources,
self-monitoring tools, support programs, written care plan
Not MUST
PASS
3 POINTS
Not MUST
PASS
5 POINTS
MUST PASS
4 POINTS
Where They Didn’t Do Well (cont)
PPC6A: Test Tracking and Follow-up:
MUST PASS
7 POINTS
MUST PASS
4 POINTS
Track lab and imaging tests until results return; flags overdue and
abnormal results; notify patients of abnormal results; paper
based or electronic
PPC7A: Referral Tracking and Follow-up
For referral to specialist or consultant: origination: referring
clinician; reason for referral; status; insurance/preapproval
Where Results Were Variable
PPC1B: Report on Access & Communication
Visits with assigned physician; Response times; Same day
appointment access; Language services available
PPC2B & C: Has and Uses Clinical Data System
(SEARCHABLE)
MUST
PASS
5 POINTS
Not MUST
PASS
3 POINTS
each
MUST
PASS
6
POINTS
Not MUST
PASS
3 POINTS
Not MUST
PASS
5 POINTS
Age appropriate preventive services (immunizations, screening,
counseling); Allergies; Vitals (BP, weight, BMI); Labs, imaging and
path results
PPC2D: Charting Tools
Problem lists, medications, structured templates
PPC3C: Care Team
Non-clinician provides reminders, standing orders, education,
coordination
PPC3D: Care Management
Care plans, treatment goals, assess progress
Behavioral Health Organizations
Challenges & Successes
Successes
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Reporting on Access
& Communication
Charting Tools
Care Management
Challenges
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Clinical Data
System for Population
Management
Self Management
Support
Test Tracking
Primary Care Organizations
Challenges & Successes
Successes
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Processes for Access &
Communications
Charting Tools
Challenges
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Reporting on Access &
Communication
Clinical Data Systems
System for Population
Management
Care Management
Continuity of Care
Self Management Support
Test Tracking
Gaps (2)
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Organizing care management
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Tasks/Roles/People
Incorporating self management
Disease registries
Referral tracking
Communication/HIPAA
Test tracking
Guideline-based reminders
Using data for QI
Continuity of care
Anticipation of needs
Care Management Functions
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Patient engagement/rapport
Screening/Assessment
Education/Planning
Self management support
Clinical monitoring/Tracking
Reminders (patient/provider)
Accessing resources/referrals
Coordination/Continuity
Problem solving/counseling/therapy
Top Ten Issues
General Health/Mental Health Relationships
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Partnerships
Formalize
Accountability
Referral
Consultation/Evaluation
Information Flow
Money
Quid Pro Quo
Maintenance
Generalize