HRSA’s Quality Initiatives – Many Paths to a Patient Centered

Medical Home

May 31, 2012

Alyson Roby – AAAHC

Lon Berkeley – The Joint Commission

William Tulloch – National Committee for Quality Assurance

Harriet McCombs – HRSA/BPHC/OQD

Nina Brown – HRSA/BPHC/OQD

Learning Objectives

1. Identify the difference between the Accreditation and the PCMHH Initiatives;

2. Identify the difference between the Patient Centered Medical Home recognition conducted by the three recognizing organizations;

3. Identify resources on the HRSA webpage that are available to help grantees select the recognition organization that best meets their health center needs; and

4. Understand the process for enrolling in the initiative and the timelines involved with medical home recognition.

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Session Outline

• Introduction – 5 minutes

• Purpose of PCMH Recognition – 10 minutes

• Contractor Presentations – 45 minutes

• Summary – 5 minutes

• Question & Answer – 25 minutes

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• An approach to providing comprehensive, patient centered, and coordinated primary care for health center patients.

• HHS Priority Recognition Goal

– Goal: 25% of grantees recognized by 9/30/2013

– Goal: 13% of grantees recognized by 12/31/2012

• HRSA investments in quality

– Patient-Centered Medical Health Home Initiative o Covers survey costs and fees

– Accreditation Initiativeo Covers survey costs and fees

– PCMH Supplemental funds

– Partnership with the CMS Primary Care Demonstration

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The Patient Centered Medical Home

• Demonstrates the quality of care provided in health centers.

• Positions health centers at an advantage for the changing health care landscape.

• Transforms patient care to help health centers achieve the three part aim of: Better Care, Healthy People and Communities, and Affordable Care.

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Why PCMH?

Many Paths to PCMH

• Many entities across the country are embracing the PCMH model:

– Private Payers: Blue Cross Blue Shield, United Health Care, etc.

– States: Oregon and Minnesota

o Initiatives to provide TA and lead to 3rd party recognizing organization, i.e., NCQA, AAAHC, TJC

• HRSA supports two initiatives to assist grantees with the survey costs and assistance in achieving PCMH recognition

– The Accreditation Initiative: Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission

– The Patient Centered Medical Health Home Initiative: National Committee for Quality Assurance (NCQA)

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Agenda

• Brief History of Organization

• Organization Surveyors

• The Handbook of Standards

• Education Opportunities and Pre-Survey Activities

• Overview of the Survey

• Certification/Recognition

• Post-Survey Activities and Resources

• Organization Contacts

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Contractor Presentations

1. Alyson Roby – Accreditation Association for Ambulatory Health Care

2. Lon Berkeley – The Joint Commission

3. William Tulloch – National Committee for Quality Assurance

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Accreditation Association for Ambulatory Health Care (AAAHC)

Accreditation Initiative

Alyson Roby, MD

AAAHC Surveyor

Family Practice Physician

AAAHC is committed to maintaining its position as the preeminent leader in

developing standards to advance and promote patient safety, quality, value and measurement of performance for ambulatory health care through peer

based accreditation processes, education, and research.

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AAAHC Mission

Brief History of the AAAHC

• AAAHC has been conducting surveys since 1979.

• Not-for-profit and governed by 18 member organizations.

• AAAHC is recognized by many third-party payors including Medicare, Medicare Advantage plans, HRSA, Indian Health Services, and Department of Energy.

• In 1983, AAAHC began accrediting managed care organizations.

• CMS granted AAAHC deemed status for Medicare certification for ambulatory surgery centers.

• AAAHC currently accredits more than 5,100 organizations, and is the largest accreditor of ambulatory settings.

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Who We Accredit

• Community health centers (Internal Medicine, Family Practice, and Pediatrics)

– Medical Home

– Women’s health

– Laboratory and x-ray facilities

– Behavioral health

– Dental

• School-based health centers

• Walk-in clinics

• Indian Health Centers12

Why choose AAAHC?

• Emphasis on education and consultation to organizations

• Not “inspectors”

• Peer-based accreditation program

• Nationally-recognized standards

• 325 surveyors (physicians, dentists, Advanced Practice Registered Nurses and other nurses, pharmacists, health care administrators, etc.)

• CHC-specific surveyors who will perform your surveys are selected, trained, and privileged to conduct FQHC surveys

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How are AAAHC StandardsAssessed?

• Substantial Compliance (SC) – Current operations are acceptable and meet the Standards

• Partial Compliance (PC) – A portion of the standard is met in an acceptable manner, but area(s) need to be addressed

• Non-Compliance (NC) – Current operations do not meet the Standard

• Not Applicable (NA) – This Standard does not apply to this organization

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Handbook of Standards: Core Chapters

• Chapter 1 – Rights of Patients

• Chapter 2 – Governance

• Chapter 3 – Administration

• Chapter 4 – Quality of Care Provided

• Chapter 5 – Quality Management and Improvement

• Chapter 6 – Clinical Records and Health Information

• Chapter 7 – Infection Prevention and Control and Safety

• Chapter 8 – Facilities and Environment

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Handbook of Standards:Adjunct Chapters

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• Medical Home

• Pharmaceutical Services

• Pathology and Medical Laboratory Services

• Diagnostic and Other Imaging Services

• Dental Services

• Health Education and Health Promotion

• Behavioral Health Services

• Teaching and Publication Activities

• Immediate/Urgent Care Services

Medical Home

• Transformation to a Medical Home is a journey worthy of the investment of time and resources.

‒ Stronger relationships = higher treatment plan compliance

‒ Fewer hospital days, fewer ER visits

‒ Higher satisfaction levels for patient, providers, staff

• Foundation of the Medical Home model of care focuses on:

‒ Patient and provider relationship

‒ Continuity of care

‒ Comprehensiveness of care

‒ Accessibility

‒ Quality

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Educational Opportunities/Pre-Survey Activities

• Technical Assistance

• Mock Surveys

• Pre-Survey Calls with Surveyors

• Achieving Accreditation

• Dedicated Staff Availability

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Pre-Survey Activities:Application Process

• Select AAAHC on your NOI (Notice of Interest) and submit it to AccreditInit@hrsa.gov

• Once the NOI is approved, AAAHC will be notified and they will send you a welcoming letter containing instructions on the online application for the survey

• Application supporting documents:

‒ Brief organization history and current org chart

‒ Statement of Patient Rights and Responsibilities

‒ Governing Body meeting minutes

‒ Patient satisfaction survey results

‒ Quality improvement plan and studies

‒ Emergency preparedness plan19

Overview: Day of the Survey

• Opening conference with senior leaders and Board members

• Tour of facility and introduction to staff

• Review of select clinical records, policies, and other documentation to support compliance

• Review and discussion of QI plan and studies

• Interaction with staff and patients

• Summation conference, including consultative advice for improving quality of care and safety for patients, staff, and others

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Recognition

• Public recognition of National recognized accreditation

• Consultative guidance

• Quality improvement

• Increase consumer awareness

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Post-Survey Activities and Resources

• FQHCs are eligible to sign-up for participation in one complimentary six-month QI study with the Institute for Quality Improvement (IQI)

• Information on http://www.aaahc.org/institute

• Primary care/non-surgical studies are designed to examine processes and outcomes at the point of care

• A “QI Toolkit” of educational publications provides:‒ A step-by-step Workbook

‒ Examples of award-winning studies

‒ Basic information and examples of important QI topics

‒ IQI staff available to assist and answer QI questions22

• Commonly-asked questions:

‒ Estimated length of time to prepare for survey

‒ Common areas for improvement

‒ Estimated length of time to complete survey

‒ How long will it take to get the survey report

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Questions about Survey Preparation

Keep in Mind

AAAHC is about:AAAHC is about:

Discovery………………vs. inspection

Consultation…………vs. prescription

Collaborative……..……vs. dictatorial

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In Conclusion

• Focus - Quality of care at the provider/patient level

• Goal - Improve and enhance health care in ambulatory settings

• Standards - Designed to promote excellence, professionalism and patient safety

• Survey Process - Assure compliance with published standards through education and consultation

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Visit us Online

http://www.aaahc.org

• Michon Villanueva• mvillanueva@aaahc.org• (847) 853-6063

• Gina Stepuncik Prus, MHA• gstepuncik@aaahc.org• (847) 324-7700

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AAAHC Contacts

The Joint Commission’s

Accreditation &

Primary Care Medical Home (PCMH)

Certification Option

Lon M. Berkeley

Project Co-Lead, Primary Care Medical Home Initiative

Project Director, Community Health Center Accreditation

The Joint Commission

May 30 & 31, 2012

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Joint Commission Background

• General customer base

‒ Accredits or certifies over 19,000 total organizations (hospitals/critical access hospitals, labs, behavioral health, home care/Durable Medical Equipment, long term care, ambulatory care/office-based surgery)

• Accrediting Ambulatory Care since 1975:

‒ Ambulatory Care program accredits over 2,000 organizations with 6,400 sites of care

‒ Wide variety of ambulatory settings, including Medical/Dental settings such as:

• Federally Qualified Health Centers (almost 300)

• Medical Group Practices29

• Applies to an accredited ambulatory care organization (or one seeking accreditation)

• On-site survey process to evaluate compliance with both existing ambulatory care and PCMH requirements

• No special application requirements

• No additional on-site survey time

• No jeopardy to accreditation

• Organization-wide certification for up to 3 years

• Primary Care Medical Home certification publicly available on Quality Check at http://www.qualitycheck.org/

Primary Care Medical Home Distinguishing Features

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Joint Commission Accreditation Plus

Primary Care Medical Home Option

Ambulatory Care Accreditation(~ 900 applicable standards pertaining to medical settings, including 123 applicable to PCMH)

PCMH Certification Option (52 additional requirements)

Increasing Patient-Centeredness, Comprehensiveness,Access, Coordination

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The Joint Commission’sPCMH Requirements*

5 Operational Characteristics

1. Patient-Centeredness

2. Comprehensive Care

3. Coordinated Care

4. Superb Access to Care

5. System-Based Approach to Quality and Safety

*from the Agency for Health Care Research and Quality

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Accreditation + PCMH On-Site Survey Process

• On-site survey: No change to ambulatory survey sessions

• Trace patient experience (patient tracers)

– Observe care provided

• Conduct patient interviews re:

– Selection of primary care clinician

– Information offered on how to access the center

– Consideration of language, cultural needs and preferences

• Discussions with organization leaders and staff re:

– Scope of services available—acute, chronic, behavioral health

– Determining the composition of interdisciplinary teams

• Observe use of infrastructure elements

– Clinical decision support tools, HIT, e-prescribing, referral tracking

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Accreditation + PCMH On-Site Survey Process

• Clinical Record review – Patient self-management goals

– Follow-up on care recommendations, test results

• Building Tours

• HR file review– Primary care clinician qualified for the role, working within scope of

practice, and in accordance with laws and regulation

• Review of performance improvement data– Patient perception of access and care coordination

• Daily Briefings and Exit Conference – Written report with both accreditation and PCMH requirements for

improvement

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Accreditation + PCMH: Post-Survey Process

• Follow-up to findings (“Requirements for Improvement”):

Evidence of Standards Compliance for both PCMH and other ambulatory care standards

• Acceptance of Evidence of Standards Compliance:– Special Certification Letter

– Posting on Quality Check

• 3 year Accreditation and Certification period

• Periodical Performance Review– Annual self-assessment of PCMH and ambulatory care standards

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Joint Commission PCMHDecision & Scoring Impacts

Failure to comply with all PCMH “Requirement for Improvements” will not jeopardize accreditation status

Scoring for PCMH requirements during a resurvey is similar to expectations for an initial survey, minimally:– Implement in at least one location, for at least one

population

– Have supporting written policies/procedures

– Plan to implement organization-wide prior to next triennial survey (18-36 months)

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“Readiness” Steps for PCMH Certification Option

If already accredited:• Complete self-assessment relative to additional PCMH

Requirements

– Mock Tracers

– Technical assistance

• Determine best timetable for survey:

– Include as part of next triennial unannounced survey

– Special extension survey

– Communicate to Joint Commission (part of new application)

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“Readiness” Steps for PCMH Certification Option

If not yet accredited:• Complete self-assessment of ambulatory care accreditation

standards and additional PCMH Requirements

• Use resources available:– Mock Tracers – Educational programs

– Technical assistance – Publications

• Determine best timetable for survey– Include as part of scheduled survey

– Communicate to Joint Commission (part of new application)

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PCMH Certification Option Preparation Time

• Estimated time if:

– Joint Commission accredited with existing Medical Home recognition: 1 – 6 months

– Joint Commission accredited without existing Medical Home recognition: 6 – 9 months

– Not yet Joint Commission accredited but have Medical Home recognition: 6 – 12 months

– Not yet Joint Commission accredited and no Medical Home recognition: 6 – 15 months

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Accreditation + PCMH: Application Process

• Application Process – Part of web-based ‘extranet’ platform “e-application”

– First time survey: YOU designate ready date

– Already accredited options:

o Request as part of unannounced triennial survey

o Extension survey: 4-6 months after notification

o Earlier triennial survey

• To Access the Application– If you are currently accredited, contact:

Rex Zordan, 630.792.5509, rzordan@jointcommission.org

– If you are NOT accredited, contactIsa Rodriguez, 630.792.5286, irodriguez@jointcommission.org

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Joint Commission PCMH Resources

• Joint Commission Primary Care Medical Home Website http://www.jointcommission.org/PCMH– PCMH requirements

– Self-Assessment Tool

– Register for trial version of E-dition(Free 60-day access to electronic version of Ambulatory Care Standards)

– Request application

– News, articles and links to other resources!

– Comparisons to other evaluative models.

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Joint Commission Accreditation + PCMH Resources

• Accreditation Support Resources

– Joint Commission ConnectTM (Extranet)

o Perspectives* – Joint Commission’s official monthly e-periodical

o Survey Activity Guide

– Joint Commission Resources (JCR)

o Ambulatory Care standards available in print and electronic formats

o Ambulatory Care conferences and webinars on accreditation and Primary Care Medical Home certification

*Perspectives is available online at http://www.jointcommission.org/new_primary_care_medical_home_option_/

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Distinguishing Features of Joint Commission Accreditation

• Staff & Service– Dedicated Account Executive and Project Director

– Certified and salaried surveyors: ongoing training and evaluation

– Standards Interpretation Staff

– Electronic Manual (“E-dition”)

– Short report turn-around time

• Education & Training Resources– Publications — Webinars and Teleconferences

– Mock surveys — Training Conferences

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• Name Recognition– All settings (Lab/Behavioral

Health)

– Accreditation for 3 year period

• State of the Art Standards– National Patient Safety

Goals

– Levels of Criticality

• Accreditation Process– On-site survey tracers,

consultative, leading practices & written report

– First survey scheduled then re-surveys unannounced

– Periodical Performance Review

– Certifies and accredits your entire organization for a 3 year period, and

– Provides assistance to attain/maintain accreditation and PCMH throughout the process

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Distinguishing Features of Joint Commission Accreditation

Request The Joint Commission for your Quality Initiative

• If you want:

Both Primary Care Medical Home certification and accreditation that’s integrated into one on-site survey…

…by surveyors who are familiar with Health Centers and who provide suggestions for how to meet any non-compliant requirements…

…using an tracer-based evaluative approach that doesn’t require any additional application time or resources…

- Certifies and accredits your entire organization for a 3 year period, and…

- Provides assistance to attain/maintain accreditation and PCMH throughout the process.

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FOR MORE INFORMATION

• Michael Kulczycki

– Executive Director Ambulatory Health Care Accreditation

– 630-792-5290

– mkulczycki@jointcommission.org

• Lon Berkeley

– Co-Project Lead, PCMH Initiative

– Project Director, Community Health Center Accreditation

– 630-792-5787

– lberkeley@jointcommission.org

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NCQA’sPatient-Centered Medical Home (PCMH)

Program

William Tulloch

Director, Government Recognition Initiatives

NCQA

Private, independent non-profit health care quality oversight organization founded in 1990

________________________________________________MISSION

To improve the quality of health care.

VISIONTo transform health care through

quality measurement, transparency, and accountability.______________________________________________

ILLUSTRATIVE PROGRAMSHEDIS® – Healthcare Effectiveness Data and Information Set

* Health Plan Accreditation * Clinician Recognition

* Disease Management Accreditation * Wellness & Health Promotion Accreditation

• * Quality Compass™

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NCQA Recognition Program

• > 30,910 Clinician Recognitions nationally across all Recognition programs (as of 12/31/11)

• Clinical programs– Diabetes Recognition Program (DRP)

– Heart/Stroke Recognition Program (HSRP)

– Back Pain Recognition Program (BPRP)

• Practice process and structural measures– Physician Practice Connections (PPC) – includes specialty

practices

– Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) 2008

– NCQA Patient-Centered Medical Home (PCMH) 201149

PCMH1: 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

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PCMH2: Identify and Manage Patient Populations

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

Management**

Pts

3445

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PCMH3: Plan and Manage Care

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

Pts

43433

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PCMH4: Provide Self-Care Support and Community Resources

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

Resources

Pts

63

9

PCMH5: Track and Coordinate Care

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

Transitions

Pts

666

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PCMH6: 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 Externally

Pts

444

3

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2051

PCMH 2011 Standards and Scoring

**Must Pass Elements

The NCQA PCMH Recognition Process

Practice:

1. Obtains PCMH 2011 Standards and Guidelines

‒ Available free from NCQA Publications

2. Participates in NCQA trainings

3. Obtains Survey Tool and online application account

4. Self-assesses current performance on survey

5. Submits online application to submit final survey

6. Receives email confirmation that practice can submit Survey Tool and documentation

7. Submits Survey Tool and application when ready52

SurveyProcess

NCQA• Reviews submitted Survey Tool

• Checks licensure of all clinicians

• Evaluates Survey Tool responses, documentation, and explanations

• Conducts an audit by email, teleconference, or on-site visit of 5% of final surveys

• Executive reviewer conducts a secondary review

• Peer review by trained Recognition Program Oversight Committee (RP-ROC) member

• Issues final decision and status to the practice within 30 – 60 days

• Reports results Recognition posted on NCQA Web site Not passed – not reported

• Mails PCMH certificate and Recognition packet

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PCMH Scoring & Outcomes

6 standards = 100 points

6 Must Pass elements

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

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

Recognized.

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Level of Qualifying

PointsMust Pass Elementsat 50% Performance

Level

Level 3 85 - 100 6 of 6

Level 2 60 - 84 6 of 6

Level 1 35 - 59 6 of 6

Not Recognized 0 - 34 < 6

NCQA Personnel

• Government Recognition Initiatives Team

– Dedicated team government-related PCMH projects

o Patient-Centered Medical/Health Home Initiative

o CMS Advanced Primary Care Practice Demonstration Project

• Surveyors

– NCQA-trained contract surveyors and staff members

• Executive Reviewers

– NCQA staff w/ extensive training in PCMH Program

• Review Oversight Committee

– Physicians from health plans and medical groups with PCMH experience and NCQA training

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PCMHHI and NCQA

• Interested health centers must file Notice of Intent with HRSA

– Indicates Center is within 12 months of Recognition

• Centers can attend monthly trainings – conference calls and Webinars

– Standards and Survey Process/Interactive Survey System

• Mock Surveys also available

– Opportunity for feedback from trained surveyors

– Highlights areas on which center should focus

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PCMHHI and NCQA cont.

• Survey Preparation

– Time to prepare depends on practice’s current ability to function as a medical home

– Minimum 3 months experience with policies, procedures, protocols and electronic systems

– Most sites take 12 – 18 months to prepare

• Survey Completion

– Survey Tool takes approximately 80 hours of staff time to complete

– Most sites spend 3 – 4 months processing and finalizing Survey Tool

• Recognition period of 36 months57

NCQA Contact Information

Contact NCQA Customer Support to:• Acquire standards documents, application account, 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 questions to PCMH-GRIP@ncqa.org Please use this e-mail box to:• Ask about interpretation of standards or elements• Request registration for Interactive Survey System Survey Tool

demonstration (Web-ex)58

Summary

• Many paths to PCMH

• Check for state and payer initiatives

• Important timelines

– 12 months to complete a survey in HRSA’s initiatives

o Must achieve at least a Level 1 recognition

– PCMH Supplemental Requirements

o Must submit an NOI to any (Federal, State, Private Payer) PCMH initiative by 9/18/2012

– CMS APCP Demonstration

o Must achieve Level III through NCQA by 10/31/2014

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CMSDemo

NOIs HRSA Accrediting or

Recognizing Organization

SurveysCompleted

RECOGNIZED

HRSA AccreditationHRSA PCMHHIState/Payer

NCQARECOGNIZED

Level III

12 Months

36 Months

HRSA PCMHHIRecognition Process

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Summary

• Keep your Project Officer up to date on your progress, successes, and barriers.

• PCMH transformation is a process that takes time.

• Technical assistance is available through a number of organizations.

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Resources

• Accreditation/Recognition Comparison Chart

– http://bphc.hrsa.gov/policiesregulations/policies/pcmhrecognition.pdf

• Quality Improvement Initiatives Fact Sheet

– http://bphc.hrsa.gov/policiesregulations/policies/qioverview.pdf

• TA Resources

– http://www.pcdc.org/resources/patient-centered-medical-home/pcdc-pcmh/ncqa-2011-medical-home.html

– http://www.transformed.com/userLogin.cfm

– http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483

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Questions?