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May 16, 2014 update Medical Home Western Montana Region- PCMH Implementation and the Varying HIT Components & Impacts
May 16, 2014
update Medical Home
Western Montana Region- PCMH Implementation and the Varying HIT Components & Impacts
Agenda
• Current Medical Home Status- Providence WMT
• Application- HIT determinants
• Workflow- o Patient Registry (Population Health Outreach)
o Patient Portal
o Care Coordination
• Advancing your Medical Home/CPI o Reporting
• Access
• Clinical Quality
• QCI
PMG WMT PCMH Vision
To be the Patient-Centered Medical Home of choice across
Montana, with the capabilities necessary to support an
integrated care delivery system.
Our Journey
Pilot Clinics (2011-2013)
Preparation (March – October
2013)
Application (October
2013)
Recognized Status
(December 2013)
CQI Process (January 2014 +)
NCQA PCMH recognition is valid for 3 years.
Our Journey, cont’d.
• 7 practices recognized with NCQA in 2013, with 2 additional
applications (Internal Medicine) submitted in April 2014
• Scores range from 69-88/100
o All Level 2 except 1- Polson
o 2 clinic edits
0-35 points = Level 1
36-85 points = Level 2
86-100 points = Level 3
Primary Care is not PCMH
Another view…
-Group Health Innovates: Medical Home Model of Primary
Care, August 2, 2012, Eric B. Larson
Key Medical Home Functions
• Care Transitions (ED and Hospital Discharge Follow-up)
• Population Health Outreach
• Care Coordination for complex/high needs patients
• Referral & Lab/Imaging tracking and follow up
• Standardized quality reporting and quality improvement
• Care team development
• Development of ancillary medical home services (chronic
disease education, mental/behavioral health)
• Pre-visit preparation
PCMH Stakeholder Council
Recognized PCMH Programs
NCQA 2011 Standards
• NCQA just released the PCMH 2014 reqs…
• Integration of behavioral health – Expectations rise. Practices are expected to collaborate with behavioral health care providers and to communicate behavioral health care capabilities to patients.
• Care management focus on high-need populations – Practices are expected to address socioeconomic drivers of health and poorly controlled or complex conditions. Practices should also focus on the special needs of patients referred from the “medical neighborhood”.
• Enhanced emphasis on team-based care – Revised standards emphasize collaboration with patients as part of the care team and establish team-based care as a “must-pass” criterion for NCQA Recognition.
• Alignment of improvement efforts with the triple aim – Practices must show that they are working to improve across all three domains of the triple aim: patient experience, cost and clinical quality.
• Sustained transformation – In keeping with the goal of continuous improvement, practices show that they comply with NCQA standards over long periods.
NCQA 2014 Standards Anticipated Changes….
Application HIT Determinants for creating a PCMH application – per NCQA 2011
Enhance Access and Continuity • Same day appointments*
• Timely clinical advice by telephone (during and after hours)*
• Timely electronic communication (during and after hours)*
• Monitors visits with selected provider/Continuity
• Assess racial and ethnic diversity of population
• Assess language needs of population
• Electronic Access o Patients can request electronic copy of health information and receive within 3 business days
o Patients have electronic access to health info within four days
o Clinical summaries are provided for more than 50% of office visits within three business days
o Two way communication
o Patient can request appointments or refills via electronic means
o Patient can request referrals or test results via electronic means
Identify & Manage Patient Populations
• Practice uses an electronic system that records primary demographic information for more than 50% of patients.
• System is searchable and structured for >80% of patients: o Up-to-date problem list with current and active dx
o Allergies, including medication allergies and adverse reactions
o Blood pressure, Height and Weight with date of update, for more than 50% of patients 2 years and older
o Calculates and displays BMI, Plots and displays growth charts
o Status of tobacco use
o List of prescription medications
o Age and gender appropriate immunizations
• Population Health Management* o 3 preventive care services; 3 chronic care services
o Patients not recently seen
o Specific medications
Plan and Manage Care
• Care Management for chronic, high-risk or complex patients* o Individual care plan including treatment plan
o Written plan of care & Summary (AVS)
o Assess barriers
o Additional benefit from additional care management support
o Follow-up with those who have not kept appointments
• Medication Management o Reviews and reconciles medications
o Information for new medications
o Assess patient/family understanding
o Assess patient response and barriers to adherence
o Document over the counter medications
• Electronic Prescribing o E-prescribe
o Performs patient specific checks for drug-drug and drug-allergy reactions
o Alerts for generic alternatives
Creation of Smart Phrases
within electronic medical
record, by our PCMH
physician champion.
HINT:
Track and Coordinate Care • Self-Management Process
o Uses HER to identify patient-specific education resources and provide to patient
o Develop and document self-management plans and abilities
o Provides self-management tools
• Test/Referral Tracking* and Follow-Up o Tracks lab and imaging until results are available, flagging, f/u on overdue
o Flags abnormal results
o Electronically communicates with labs/facilities to order and retrieve results
o Electronically incorporate lab results into structured field in med record
• Coordinate and Manage Care Transitions o Identify patients with hospital admission and ER visit
o Sharing information- discharge summaries, follow-up care, transitioning pediatric, etc.
o Provides electronic summary of care record to another facility
Measure & Improve Performance
• Measure Performance o 3 Preventive Care services; 3 Chronic Care services
o 2 Utilization Measures
o Data stratified by vulnerable populations
• Continuous Quality Improvement* o Set goals and act to improve
o Tracking results over time
o Blinding data by provider and clinic
o Assessing effects and achieving performance
o Sharing data by clinic and provider detail
• Report Data Externally o Electronically reports ambulatory clinical quality measures to CMS, states or other external
entities
o Electronically reports data to immunization registries or systems
o Electronically reports syndromic surveillance data to public health agencies
MU - Two Birds, One Stone?
Workflow
Patient Registry
Patient Portal
MyChart is the Epic Patient Portal
• Sign up options o In the room
o Through the After Visit Summary
o E-mail prior to scheduled appointment
• Increase Communication o Patient to provider
o Lab and imaging results
o Pre-visit questionnaires
• Meaningful Use
Care Coordination- Complex
• Care Coordinator
• Referral Management
• Tools in Epic o Care Manager
o Health Maintenance
o Synopsis Options
• 20 different flow sheets that gather metrics related to various disease processes
o Home monitoring flow sheets
o Documentation flow sheets
o Educational material
• Team approach
Transition of Care
• Discharge Report generated daily
within clinic by Clinical staff. See
Tips and Tricks for report
generation.
• Report filtered by clinic specific
hospital inpatient discharges and
PCP
• Clinical staff initiates call to
patient or caregiver within two
business days of discharge.
• Transition of Care telephone
encounter completed with
template of questions, discharge
summary reviewed.
• Encounter routed to PCP with
appointment date for provider
review.
• Patient is scheduled for Transition
of Care visit within 7 days of
discharge
Transition of Care
• Provider determines whether
Transition of Care codes are
appropriate based on criteria.
• Criteria: Patient must be established
within the practice and present with
moderate or high complexity within
7 calendar days of discharge.
• Codes: 99495 Moderate,
99496 High
• Document date patient had contact
post discharge and date of
discharge.
• Only one TCM code can be billed
within 30 day period.
• If patient does not meet criteria,
standard follow up visit coded.
Advancing Your Medical Home
Reporting- PCMH Specific
Reporting: Access
Reporting: Clinical Quality
Reporting: CQI
Reporting: Provider Engagement
Questions?
