All materials © 2011, National Committee for Quality Assurance

NCQA’s Patient-Centered Medical Home (PCMH)

Program

February 15 and 28, 2012Florida CHIPRA Pediatric Medical Home Demonstration Project

2NCQA PCMH Overview February 2012

Goals for Today’s Meeting

• Understand rationale for NCQA’s PCMH recognition program and requirements for practices to demonstrate the patient-centered medical home model

• Identify resources for NCQA’s PCMH 2011 program

• Review information about quality, cost savings and pay-for-recognition initiatives

• Identify PCMH components specific to pediatric practices

3NCQA PCMH Overview February 2012

Support for NCQA’s PCMH • Most widely used tool in PCMH

demonstrations with payment reform (Bitton et al 2010)

• Endorsed for Recognition by American Academy of Pediatrics, National Quality Forum, et al.

• Federal initiatives (CMS, HRSA, Military)

• State initiatives (NYS Medicaid, multi-payor efforts that include Medicaid in VT, RI, CO, ME, and more )

4NCQA PCMH Overview February 2012

Positive Impact on Practices

• Better care management programs

• Greater attention to patient compliance

• Improved patient outreach (patient reminders, increased screenings, educational materials)

• Increased data collection and reporting

• Significant adoption of patient registries

5NCQA PCMH Overview February 2012

Of the >3500 Recognized Practices

• 15% are pediatrics only, >30% serve children

• 38% have only 1-2 physicians• 60% are Level 3• 48 states & DC have recognized

practices (91 in FL, 85 Level 3)• EMR is not required to achieve

recognition– Level 1 recognition is achievable

without EMR– Higher levels require more health IT

6NCQA PCMH Overview February 2012

NUMBER OF PPC-PCMH & PCMH SITES BY STATE

ME

VT

RI

NJ

MD

MA

DE

NY

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PAOH

VAMO

HI

OK

GA

SC

TN

MT

KY

WV

AR

LA

AL

INIL

SD

ND

TX

ID

WY

UT

AK

CA

CT

NH

61-200 Sites

*As of 1/31/12

MS

21-60 Sites

0 Sites

1-20 Sites

201+ Sites3571 PPC-PCMH SITES

7NCQA PCMH Overview February 2012

Initiatives Supporting NCQA Recognition Programs

• National/Multi-state – CMS, HRSA, MHS, Anthem, Aetna,

• Maine – Patient Centered Medical Home Pilot

• Vermont - Vermont “Blueprint for Health”

• North Carolina – Community Care of North Carolina (N3CN), BCBSNC

• Pennsylvania – Chronic Care Commission, PAFP

• Rhode Island – Rhode Island Quality Institute

• Minnesota – Primary Care Coordination Program – Facilitated by Office of the Commissioner of Securities and Insurance

• Maryland – Maryland Health Care Collaborative (MHCC)

• Michigan – Priority Health, Health

Plan of Michigan and Medicaid Health Plan

• Massachusetts – State Medicaid PCMH Initiative

• New York – Adirondack Medical Home Demonstration , State Medicaid

• Ohio – Cincinnati Health Improvement Collaborative

• Colorado – Colorado Clinical Guidelines Collaborative

• Louisiana – Through DHH the Louisiana Health Care Quality Forum

• Florida– BCBSFL Care Management and P4P Quality Initiative

• Connecticut - Connecticut Department of Social Services– Medicaid Initiative

8NCQA PCMH Overview February 2012

2011 PCMH Content and ScoringStandard 1: Enhance Access and

Continuity

A. Access During Office Hours**B. After-Hours AccessC. Electronic AccessD. ContinuityE. Medical Home ResponsibilitiesF. Culturally and Linguistically

Appropriate ServicesG. Practice Team

Pts

442222

4

20

Standard 2: Identify and Manage Patient Populations

A. Patient InformationB. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population

Management**

Pts

3445

16

Standard 3: Plan and Manage Care

A. Implement Evidence-Based GuidelinesB. Identify High-Risk PatientsC. Care Management**D. Medication ManagementE. Use Electronic Prescribing

Pts

43433

17

Standard 4: Provide Self-Care Support and Community Resources

A. Support Self-Care Process**B. Provide Referrals to Community

Resources

Pts

63

9

Standard 5: Track and Coordinate Care

A. Test Tracking and Follow-UpB. Referral Tracking and Follow-Up**C. Coordinate with Facilities/Care Transitions

Pts

666

18

Standard 6: Measure and Improve Performance

A. Measure Performance B. Measure Patient/Family ExperienceC. Implement Continuously Quality

Improvement**D. Demonstrate Continuous Quality

ImprovementE. Report PerformanceF. Report Data ExternallyG. Use of Certified EHR Technology

Pts

444

3

320

20**Must Pass Elements

9NCQA PCMH Overview February 2012

PCMH Scoring

Level of Qualifying

PointsMust Pass Elementsat 50% Performance

Level

Level 385 - 100 6 of 6

Level 2 60 - 84 6 of 6

Level 1 35 - 59 6 of 6

Not Recognized 0 - 34 < 6Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.

6 standards = 100 points6 Must Pass elements

NOTE: Must Pass elements require a ≥ 50% performance level to pass

10NCQA PCMH Overview February 2012

Must Pass ElementsRationale for Must Pass Elements • Identifies critical concepts of PCMH• Helps focus Level 1 practices on most important

aspects of PCMH• Guides practices in PCMH evolution and continuous

quality improvement• Standardizes “Recognition”

Must Pass Elements• 1A: Access During Office Hours• 2D: Use Data for Population Management• 3C: Manage Care• 4A: Self-Care Process• 5B: Referral Tracking and Follow-Up• 6C: Implement Continuous Quality Improvement

11NCQA PCMH Overview February 2012

NCQA Survey Process ComponentsStandards and Elements – basis for scoring, each

described with type of documentation required and level of health information technology required

Important conditions – basis for data responses in multiple elements

Survey Tool – software to record and score practice responses and file documentation

Record Review Workbook - requires data from selected medical records

Documentation –identify and organize documents needed for evidence of compliance with each element

Readiness – practice uses the Survey Tool to assess readiness to meet the standards and submit

12NCQA PCMH Overview February 2012

Training• NCQA provides free web-based

training www.ncqa.org/rptraining.aspx– Twice a month

• Getting On Board• Instruction for the online application system and

multi-site submission process– Once per month

• Overview of standards and requirements given in 2 sessions

• Overview of the Survey Tool and the Interactive Survey System (ISS)

– Recorded• Getting On Board• Record Review Workbook

13NCQA PCMH Overview February 2012

Focus on Pediatrics• Goal for PCMH 2011 to enhance applicability to pediatric

practices• AAP participated on the PCMH Advisory Committee• Throughout the Standards

– “Patients/Families” has been incorporated where appropriate – “NA for pediatric practices” has been used where appropriate – Pediatric examples and explanations have been added– References to Bright Futures have been included

• PCMH 1: Enhance Access and Continuity – Explanation addresses unique pediatric issues, such as teen privacy

and guardianship• PCMH 2: Identify and Manage Patient Populations

– Includes pediatric clinical data, health assessment requirements and age appropriate immunizations and screenings

– Includes age appropriate screenings, e.g. developmental and adolescent depression screening

14NCQA PCMH Overview February 2012

Focus on Pediatrics (cont.)• PCMH 3: Plan and Manage Care

– Explanation specifies relevant pediatric clinical conditions, including well-child care and children/youth with special health care needs

• PCMH 4: Provide Self-Care and Community Resources– Population specific referrals includes parenting and respite care

• PCMH 5: Track and Coordinate Care – Communicate with facilities for newborn lab test results– Collaborate to develop a written care plan for patients transitioning

from pediatric care to adult care• PCMH 6: Measure and Improve Performance

– Preventive measures include developmental screening, immunizations and depression screening

15NCQA PCMH Overview February 2012

Using NCQA’s PCMH:Steps for the Practice

1. Review PCMH program information

2. Participate in a free standards webinar

3. Obtain a web-based Survey Tool

4. Participate in a free WebEx ISS demonstration of the Survey Tool

5. Use Survey Tool to self-assess current performance

6. To apply for recognition (optional), submit completed application, agreements, discounted application fee, and survey with documentation to NCQA when ready

16November 30, 2010

Overview of NCQA Recognition Process

• Review requires Survey Tool, application information:NCQA Agreement and Business Associate Addendum (BAA), Application, Clinician Information

• Licensure check of all clinicians• Evaluation includes Survey Tool responses,

documentation, and explanations by trained reviewers• 5% audit by email, teleconference, or on site visit• Executive review by NCQA for consistency• Peer review by trained Review Oversight Committee

(ROC) member • Final decision and status to the practice within 30 – 60

days• Results reported - Recognition posted on NCQA Web site

and distributed on monthly data feeds

• Recognition packet provided - Certificate, press release and advertising guidelines

17NCQA PCMH Overview February 2012

Best Practices: What We Have Learned

• Roadmap for quality improvement• Recognizes roles of every care

team member, physicians and mid-level practitioners

• Coordinated teamwork• Patient/family engagement• Enables practice system change• Share benefits with patients and

payors• Connection to community resources

18NCQA PCMH Overview February 2012

NCQA Contact Information

Contact NCQA Customer Support to:• Acquire standards documents, application materials,

and survey tools• Questions about your user ID, password, access• 1-888-275-7585

Visit NCQA Web Site to:• View Frequently Asked Questions• View Recognition Programs Training Schedule

Submit to questions to pcmh@ncqa.org

Or direct questions to your assigned team contacts:• Ask about interpretation of standards or elements• Request technical assistance with the application

process

19NCQA PCMH Overview February 2012

Questions?