Patient Centered Health HomeOverview and Preparation

February 2013Dawn Gentsch, MPH, MCHES

PCHH Practice Transformation FacilitatorGreat Basin Primary Care Association

Objectives for Webinar

• Overview of the principles and benefits of patient centered medical home (PCMH) recognition.

• Understand the basic elements of the PCMH standards, self-assessment and survey application process for the National Committee for Quality Assurance 2011 standards.

• Identify the next steps for your primary care practice regarding the PCMH transformation journey.

Principles for the Patient-Centered Medical Home

• Personal physician/clinician• Team-based care• Whole person orientation• Enhanced access (with continuity)• Coordinated & integrated care• Quality & safety prioritized• Payment for the value provided

Medical Home: What it Looks Like• A health care setting that provides patients with:

– well-organized & on-time visits– enhanced access with their own provider & care team for continuity (same

day appointment availability, 24/7 telephone access, alternatives to the 1:1 visit)

– proactive care management (evidence-based clinical care, panel management, reminder systems, registries)

– care coordination across settings (assistance with referrals, tracking for tests & referrals; care during transitions)

– patient activation, engagement & participation in decisions on care (patient centered customer driven)

– connections to community resources to extend resources for care– focus on health outcomes & goals for improvement– use of Health IT as tool to support the achievement of advanced primary

care practice

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System:Community

Medical Home: Aligned with (Chronic) Care Model

Health Care OrganizationResources and Policies

From Purpose To Practice: A Continuing Journey Of Commitment

• PCMH focus is a continuation of the purpose-driven journey of FQHCs

• Opportunity: continue our work to transform practice to the highest levels of performance and to obtain recognition for this achievement

• Recognition as a medical home is increasingly associated with opportunities for enhanced payment for the value created.

KyPCA Applied PCMH Webinar #1 01.16.13

Suma Nair, MS, RD; Director Office of Quality and Data HRSA BPHC

810 ‘12-’13grant

NCQA 2011 Standards

• NCQA released its latest standards, PCMH 2011 in January 2011

• The new standards direct practices to organize care according to patients’ preferences and needs, and reinforce federal “meaningful use” incentives for primary care practices to adopt health information technology– Meaningful use criteria (all 25) are in the standards– Creates virtuous cycle for PCMH & MU

2011 NCQA PCMH Standards

1. Enhance Access and Continuity2. Identify and Manage Patient

Populations3. Plan and Manage Care4. Provide Support for Self-Care5. Track and Coordinate Care6. Measure and Improve Performance

2011 NCQA PCMH Structure & Relationships

PCMH Joint Principles

6 Standards

28 Elements (6 MPE)

147 Factors (8 CF)

Reflect core principles of primary care.

Evaluate practice’s ability to function as a PCMH

Scored component of standards

Provide details for performance expectations

Scored items for each element

They reflect specific capabilities for PCMH

Documentation is developed to demonstrate the capability as described by Factors

NCQA 2011 – Standards & Intent• Access and Continuity: Provide team-based care with access and

advice during and after hours and patient/family information about medical home

• Identify and Manage Patient Populations: Acquire and use data for care of the practice’s population

• Plan and Manage Care: Use evidence-based guidelines for preventive, acute and chronic care management for chronic, frequent and behavior-based conditions, including medication management

• Self-Care: Support patient and family in self-care with information, tools and community resources

• Track and Coordinate Care: Track and coordinate tests, referrals and transitions of care

• Performance Measurement and Quality Improvement: Use performance and patient experience data for continuous quality improvement

Important Parts of the Structure

• Must Pass Elements• Critical Factors• Meaningful Use• Documentation

Critical Factors -- central to capability being assessed; important impact on scoring

• 1A1: Provide same day appointments [MPE]• 1B3: Provide timely clinical advice by phone after hours• 1G2: Have regular team meetings and communication processes• 3A3: 3rd important condition for MH/SA or unhealthy behavior• 3D1: Review & reconcile medications with patients/families for more

than 50% of care transitions** • 3E2: Generate at least 75% of eligible prescriptions electronically*• 4A3: Develop & document self-management plans and goals in

collaboration w/ at least 50% of patients/families** [MPE]• 5A1: Track labs until results are available, flagging and following-up on

overdue results• 5A2: Track imaging tests until results are available, flagging and

following-up on overdue resultsNOTE: items in blue are must pass elements

* and ** are meaningful use items (3D1, 3E2, 4A3)

Anatomy of a StandardStandard Name, Points &

Intent

Element Name, Points, Description of Performance

Expectation

Scoring Description

Explanation: Additional info on what NCQA is looking for

Documentation Examples

Factor: Scored item in an Element

NOTE: * and ** indicate MU criteria

Source: NCQA See pg 19 of NCQA Standards & Guidelines, March 28, 2011 for definitions

Source: NCQA

Element 6B: relates to MPE 6C

Recognition & Transformation

“Recognition… is only the beginning of a journey for continuous improvement and cultural transformation.

NCQA’s rigorous standards challenge a practice to examine nearly

every aspect of its operations. The evolution to a PCMH is a serious undertaking — one that rewards patients with more coordinated, focused and safer care, and rewards providers

with greater satisfaction in practicing medicine.”

- Marjie Harbrecht, MDCEO, HealthTeamWorks, Colorado

RRWB is the Supplemental Worksheet

Click here

Click here

• 2011 Elements PCMH 3C, 3D, 4A − Require medical record abstraction of data− Need % of patients for each factor based on

numerator and denominator

• Two methods to collect and submit patient data– Method #1 - report from the electronic system– Method #2 – Record Review Workbook

• Excel workbook in the Survey Tool• Tool to identify sample of patients and abstract data

The Chart Review Using the Record Review Workbook

PCMH 3C: Care Management

Response Options Yes No Not Used Not applicable

Entering NOT USED in row 1“grays” out the column for all

entries

Questions - PCMH Standards

Which PCMH standard is of greatest interest to you, where will your clinic start? What QI goal do you think you will start with?

NCQA PCMH 2011 Self-Assessment

PCMH-A

PCMH-A Background & Context• Developed to measure a site’s progress

towards achieving the 8 Change Concepts• Self-administered assessment• Aids in the identification of improvement

opportunities• Stimulates conversations with other sites to

learn, share, & transform• Serves as a standardized measure of progress

PCHH Timeline General Planning

1

2

3

4

5

The settingfor a

BIG Idea

Understand

AssessDecide/Plan

Take Action

Support & Sustain

Next Steps (Homework)• Review the requirements for each standard,

element and factor– What does the practice already do?– What does the practice need to create?– Are there elements the practice clearly does not

have in place but does not wish to implement in the near-term?

• Complete the NCQA PCMH Baseline Self Assessment tool in excel– Complete the PCMH-A

• Complete a gaps analysis– Timeline and work plan

• Form the Lead Team• Get Ready • Assess IT Requirements• Know Your Deadlines• Set Your Goals and Timeline for Recognition• Order Interactive Survey System and On-Line

Application from NCQA• Determine Eligibility for the Multi-site Survey Option• Complete Your Survey • Prepare & Submit Survey (you know when!)• Receive Recognition Decision from NCQA (TBD)

Steps in the Process – You have (will need to) taken!

Develop Your Action Plan• Identify resources available for this project• Refine the timeframe• Identify roles and tasks for each of your team members• Include key activities to facilitate the process:

– System to organize documentation– Attend NCQA training courses, other courses– Multi-Site network and survey or single sites

• Develop a schedule for completing your submission using ISS

• Be as specific as possible– Key deliverables and set completion deadlines– Active verbs: identify, develop, review, draft, complete,

convene

GBPCA Website

• PCMH Resources– Readiness Tools– Planning/Preparation– Standards/Guidelines– Training– Research, evidence-based

www.gbpca.org

Contact Information – TA and Coaching through GBPCA

Dawn Gentsch, MPH, MCHESGreat Basin Primary Care AssociationPCMH Practice Transformation Facilitatordgentsch@gbpca.org515.360.1731