NCQA’s Patient Centered Medical Home (PCMH) Program

NCQA’s Patient Centered Medical Home (PCMH)

Program

Mina Harkins, MBA, MT(ASCP)Assistant Vice President, Recognition Programs

February 5, 2011

2Achieving NCQA Recognition as a Patient-Centered Medical Home

RI Statewide Learning Collaborative February 5, 2011

A Strategy for Quality Improvement

Address these challenges

1. Eliminating harm

2. Eradicating disparities

3. Reducing disease burden

4. Removing waste

…by acting on these priorities.1. Engage patients and families in

managing health, making decisions

2. Improve the health of the population

3. Improve safety, reliability4. Ensure patients receive

coordinated care within and across organizations, settings and levels of care

5. Guarantee appropriate, compassionate care for patients with life-limiting illnesses

6. Eliminate overuse while ensuring the delivery of appropriate careSource: National Priorities and Goals:

Aligning Our Efforts to Transform America’s Healthcare, 2008



PPC-PCMH Recognition• NCQA has the most widely-adopted evaluation model• States/practices can get on board with a system that

has a strong track record, Federal initiatives are expanding to military and FQHCs

• 1500 sites recognized, over 8,000 clinicians• NCQA provides goals and guidelines for practice

transformation based on evidence – Practices decide how best to reach goals based on

their size, location, area conditions• Gives physicians a roadmap to improve quality with

systematic approach to preventive and chronic care delivery

• Focuses on evidence-based requirements to improve quality and reduced costs



NUMBER OF PPC-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 12/31/10

MS

21-60 Sites

0 Sites

1-20 Sites

201+ Sites1498 PPC-PCMH SITES



0102030405060708090100110120130140150160170180190200210220230240250260270280290300310320330340350360370380390400410420

AK AL AR AZ CA CO CT DC FL GA HI IA ID IL IN KY LAMAMDMEMIMNMOMS NC NE NH NJ NMNV NYOHOKOR PA RI SC TN TX VA VTWAWIWV

Nu

mb

er o

f Pra

ctic

es

State

PPC-PCMH RECOGNIZED PRACTICES BY STATE(As of 12/31/10)

PPC-PCMH Level 3 PPC-PCMH Level 2 PPC-PCMH Level 1



PPC-PCMH Practices*

* As of 12/31/10

1-2 3-7 8-9 10-19

20-50

50+ Total

Level 1

260 217 26 41 9 0 553

Level 2

21 30 4 2 0 0 57

Level 3

295 388 81 89 34 1 888

Total 576 635 111 132 43 1 1498

NUMBER OF PHYSICIANS IN RECOGNIZED PRACTICES



Evaluation of PPC-PCMH Demonstrations: Driving

Quality and Cost Savings• Outcomes for seven medical home

demonstrations – Reduce hospitalization rates (6-19%)– Reduce ER visits (0-29%)– Increase savings per patient ($71-$640)

• Four common features in demonstrations– Dedicated care managers – Expanded access to clinicians– Data-driven analytic tools– Use of incentives

Elements or uses of NCQA’s

PCMH evaluation

Source: Fields, et al. 2010



PCMH 2011: Evolution• Raise expectations through scoring

and new requirements; maintain a pathway for those just beginning to transform

• Streamline requirements/documentation with greater focus on areas with strongest link to desired outcomes

• Move toward performance reporting/benchmarking for clinical and patient experience measures

• Embed and report HIT Meaningful Use



What is different about the PCMH 2011 standards?

• Enhances patient-centeredness• Emphasizes language, culturally sensitive

aspects• Integrates behaviors affecting health,

substance abuse, mental health and risk factor assessment and management

• Enhances applicability to pediatric practices• Aligns with CMS Meaningful Use requirements• Emphasizes relationship with/expectations of

subspecialists• Enhances evaluation of patient experience• Underscores the importance of system cost-

savings• Enhances use of clinical performance measure

results



PCMH 2011 Alignment with Measures of

Meaningful Use• E-prescribing – medication list, allergies• Patient tracking/registry – demographics,

diagnoses, vital signs, smoking, population management, insurance

• Care management – reminders for follow-up care, decision support, Rx reconciliation

• Electronic capability – e-health information to patient, visit summary, e-access to health information, provider information exchange

• Performance reporting/improvement



Comparison of PPC-PCMH and PCMH 2011

PPC-PCMH (9 standards/30 elements)

1. Access and Communication– Processes – Results

2. Patient Tracking and Registry Function

3. Care Management– Continuity Between Settings

4. Self-Management Support5. Electronic Prescribing6. Test Tracking7. Referral Tracking8. Performance Reporting and

Improvement– Measure Performance– Measure Patient/Family

Experience

9. Advance Electronic Communication

PCMH 2011 (6 standards/27 elements)

1. Access/Continuity – Access/Continuity – Medical Home Responsibilities– CLAS– Practice Team

2. Identify/Manage Patient Populations

3. Plan/Manage Care– Care Management (Incl. Behavioral

Health – Identify High Risk Patients– Medication Management/E-

Prescribing

4. Self-Care and Community Referrals

5. Track/Coordinate Care– Test/Referral Tracking and Follow-

Up– Facilities

6. Performance Measurement/Quality Improvement– Measures of Performance– Patient Experience



PCMH 2011 Overview (6 standards/27 elements)

1. Enhance Access and Continuity A. Access During Office HoursB. Access After HoursC. Electronic AccessD. Continuity (with provider)E. Medical Home ResponsibilitiesF. Culturally/Linguistically Appropriate

ServicesG. Practice Organization

2. Identify/Manage Patient PopulationsA. Patient Information B. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population Management

3. Plan/Manage CareA. Implement Evidence-Based Guidelines B. Identify High-Risk PatientsC. Manage CareD. Manage MedicationsE. Electronic Prescribing

4. Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources

5. Track/Coordinate CareA. Test Tracking and Follow-UpB. Referral Tracking and Follow-UpC. Coordinate with Facilities/Care

Transitions

6. Measure and Improve Performance A. Measures of PerformanceB. Patient/Family FeedbackC. Implements Continuous Quality

Improvement D. Demonstrates Continuous Quality

ImprovementE. Report PerformanceF. Report Data Externally

Optional Patient Experiences Survey



ScoringTotal 100 Points

Level Points Required Must Pass

1 ≥ 35 6 Must Pass



Recognition requires achieving all 6 must pass elements with a ≥50% score



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



PCMH 1: Enhance Access and Continuity

Standard• Access

– During/after office hours – Appointments and advice

• Electronic access • Continuity of care with

clinician/care team• Information to patients

about medical home• Culturally and

linguistically appropriate services (CLAS)

• Specific staff roles, responsibilities, training

Meaningful Use CriteriaPatients provided

electronic: • Copy of health

information• Clinical summary of visit• Access to health

information



PCMH 2: Identify and Manage Populations

Standard• Collects demographic and

clinical data• Searchable data:

diagnoses, advance directives, immunizations, screenings, BMI, medications

• Assess/document risks• Create lists; use for point

of care reminders

Meaningful Use Criteria

• Language, gender, race, ethnicity, DOB

• Problem list• Medication list• Medication allergy list• Vital signs• Growth chart (peds.)• Smoking status• Lists of patients with

specific conditions for QI, decrease disparities

• Follow-up reminders for care



PCMH 3: Plan and Manage Care

Standard• Identify patients with

specific conditions including high-risk or complex, behavioral health

• Care management – Pre-visit planning – Progress toward goals – Barriers to treatment

goals• Reconcile medications• E-prescribing

Meaningful Use Criteria• Clinical decision support• Medication reconciliation

with transitions of care• E-prescribing• Drug-drug, drug-allergy

checks• Transmit prescriptions

using EHR• Drug-formulary checks



PCMH 4: Provide Self-Care Support and Community Resources

Standard• Assess self-management

abilities• Document self-care plan;

provide tools and resources

• Counsel on healthy behaviors

• Assess/provide/arrange for mental health/substance abuse treatment

• Provide community resources

Meaningful Use CriteriaPatient-specific education

materials



PCMH 5: Track and Coordinate Care

Standard• Track lab/imaging results;

notify patients• Integrate results into

medical record• Track referrals• Coordinate with facilities

– Hospitalized patients and ER

– Establish information exchange with facilities

– Follow up with discharged patients

Meaningful Use Criteria• Incorporate lab/test

results• Exchange patient

information with other providers (meds/ allergies, tests)

• Provide summary care record for transitions and referrals



PCMH 6: Measure and Improve Performance

Standard• Measure performance

(preventive/chronic/acute care clinical measures)

• Track utilization measures

• Patient experience survey - identifies vulnerable populations

• Continuous quality Improvement

• Report performance– Clinical measures

Meaningful Use CriteriaReport:• Ambulatory clinical

quality measures to CMS/ state

• Immunization data to registries

• Syndromic surveillance data to public health agencies



Emphasize Patient-Centered Care

Increasing patient-centeredness

PCMH 1: Enhance Access and Continuity• Provide continuity of care with the same provider• Provide information to the patient about medical

home• Provide access to care during and after office

hours• Provide patient materials and services meeting

the language needs of patients PCMH 4: Provide Self-Care and Community Support • Provide resources to support patient/family self-

managementPCMH 6: Measure and Improve Performance• Involve patients/families in quality improvement• Obtain performance data for key vulnerable

populations



Focus on Behavioral Health

Incorporating attention to behaviors affecting health, mental health and substance abuse

• PCMH 1: Enhance Access and Continuity– Comprehensive assessment includes depression screening,

behaviors affecting health and patient and family mental health and substance abuse

• PCMH 3: Plan and Manage Care– One of three clinically important conditions identified by the

practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition

– Practice must plan and manage care for the selected condition• PCMH 4: Provide Self-Care and Community Resources

– Self-care support includes educational and community resources and adopting healthy behaviors

• PCMH 5: Track and Coordinate Care– Tracks referrals and coordinates care with mental health and

substance abuse services• PCMH 6: Measure and Improve Performance

– Preventive measures include depression screening



Focus on Pediatrics

• Goal for PCMH 2011 to enhance applicability to pediatric practices

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

– “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 and age appropriate screenings• 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 Support – Population specific referrals include parenting and respite care



Focus on Patient Experience

Increasing the emphasis on patient feedback

PCMH 6: Measure and Improve Performance • Expanded the survey categories (access,

communication, coordination, self-management support, whole person orientation, comprehensiveness, shared decision-making) and the requirements for the practice.

• Use of patient survey results for quality improvement• Involve patients/families in quality improvement• Optional Recognition for reporting results using a

standardized Patient Experiences survey & methodology



The Case for Patient-Centered Medical Home Recognition

• Gives physicians a roadmap to improve quality with systematic approach to preventive and chronic care delivery

• Focuses on evidence-based requirements to improve quality and reduced costs

• Considers capabilities of small and large practices, without sacrificing quality

• Program is built on what is shown to improve care and can be copied or replicated



The Case for Patient-Centered Medical Home Recognition

• Requires electronic information when necessary– electronic systems alone are not

sufficient

• Incentivizes investment in quality infrastructure and processes

• Complements evaluation of clinical effectiveness, patient experiences and efficiency



Patient PerspectivePCMH Practices

Focus Group Findings• PCMH patients emerge as highly satisfied with their

current PCP practices, and deem “continuity of care” as related rationale (with one participant using the term).



Patient PerspectiveNon-PCMH Practices

Focus Group Findings• Conversely, a majority of General Population Patients

emerge overall with less satisfaction. (A few General Population Patients who have long-standing PCP relationships emerge as satisfied and convey practices similar to care coordination practices described by PCMH Patients).



Benefits of PCMH• Clinician Burnout

– 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline

• Total Cost– 29 percent fewer emergency visits and 6 percent

fewer hospitalizations.– Estimated total savings of $10.3 per patient per

month• Patient Experience

– Improved access, coordination, goal-setting• Quality

– Improved HEDIS results

Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs 29:5 (2010): 835-843.



NCQA Contact Information

Contact NCQA Customer Support to:• Order FREE Information/Application Packets• Purchase ISS Tool• 1-888-275-7585

Visit NCQA Web Site to:• View Frequently Asked Questions• View Recognition Programs Training Schedule• www.ncqa.org/medicalhome.aspx

Send Questions to: [email protected]

http://www.ncqa.org/medicalhome.aspx

mailto:[email protected]

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NCQA’s Patient Centered Medical Home (PCMH) Program

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