OUR ROAD TO PCMH RECOGNITIONBaldwin Family Health Care

Russ Kolski RN• Strategic Projects Director• Background in

• Quality Management• Safety and Compliance• Accreditation (Joint Commission / AAAHC)

• Given Medical Home Responsibility in July 2011• PCMH Accreditation• Meaningful Use• Pay for Performance

(Not my only role)

Baldwin Family Health Care• Health Center since 1967• Rural Area• Serve West Central Michigan• 5 Medical Locations• 3 Locations with Retail Pharmacies• 3 School Based Health Centers• 25,000 Annual Medical Visits

• PCMH Status as of 2011• AAAHC Recognized for PCMH• BCBS Recognized for PCMH at 2 of 5 locations

Road to NCQA PCMH

Started 2011

Baldwin Family Health Care

Dedicated Lead Selected

June 2011

HRSA PCMH Demonstration

September 2011

MiPCT / CMSDemonstration

October 2011

Transition toOpen Access

October 2011

Staff Training(Familiarization)

November 2011

Trial Staff Huddles/Pre-plan

November 2011

LEAN EventStaff Work Flow

November 2011

First Site LiveNextGen EHR

December 2011

SubmittedMU Year 1

January 2012

MiPCT CaseManagers Hired

January 2012

ImplementedQuality Dept.

January 2012

Implementedi2i Tracks Registry

January 2012

Pre-Visit Planningfor All Patients

March 2012

EducationMU Stage 2

April 2012

Hired AddedQuality Staff

May 2012

Last Site LiveNextGen EHR

June 2012

Referral TrackingMoved to Registry

July 2012

HRSA QualityFunding

September 2012

Report DevelopmentRegistry Enhancement

Oct. 2012 – Feb. 2013

Annual TrainingPCMH Module

November 2012

Participationin ACO

February 2013

NCQA PCMHSubmission Pt.1

June 2013

NCQA PCMHSubmission Pt. 2

December 2013

PCMHSteering Comm.

October 2011

PCMH Weekly Workgroup

August 2012

“If we keep doing what we are doing, we will keep getting what we got.”

Yogi Berra

Personal PCMH Learning• Limited Understanding at Start• Attended PCMH Seminars

• Local PHO• Michigan State Medical Society

• Obtained Chronic Care Professional Certification• Reading

• LEAN – Toyota Production System• TransforMed• IHI• PATH

Internal Planning• EHR Transition (1st site live 12/2011 – last 6/2012)

• Provider Coordinating Committee• Transition Committee

• Established PCMH Steering Committee• Education at all levels• Visit Workflow Re-design

• Transition from Acute Care to Preventative / Wellness Based Care• Match pre-EHR Provider Productivity• Integrate PCMH Elements into Standard Work

Steering Committee Membership

• CEO (Ex-Officio)• PCMH Lead• Quality Manager• Chief Medical Officer• Physician Lead for EHR• Mid-level Provider• COO / Privacy Officer• Site Facility Manager• Finance Representative• Dental Representative*• Behavioral Health*

“Every system is perfectly designed to get the results it gets.”

Paul B. Batalden MD

Co-founder Institute for Healthcare Improvement

Founding Director Center for Healthcare Improvement and Leadership – The Dartmouth Institute

New Structure• Eliminate Medical Support Specialist Role at 5 sites

• Former Diabetes Registry Coordination (Old PECS System)

• Centralize Registry Function within Quality Department• Added Quality Department Staff

• PCMH Registry Specialist – May 2012• PCMH Report Generator – May 2012

• Care Managers for 2 locations (MiPCT) – January 2012• CMS Muliti-payer Demonstration Project

• Create PCMH Lead at each site – May 2012• Additional responsibility for selected staff member

Planning Tools• Annual Performance Improvement Plan

• Schedule of Activities

• Comparison of Clinical Quality Measures for UDS/MU/PCMH/Pay for Performance Measures

• Crosswalk between NCQA and BCBS PCMH Standards

• Working examples will be shown at end of presentation

Annual PI Plan Activity

Clinical Quality Indicator Reporting

January UDS ED Visits Open Access Framework for Clinical Portion of Annual PI Plan

February Record Audit 7 Day post Hospitalization Visits with PCPMarch MU Generic Rx Rate Patient Self Mgt.April UDS ED Visits Open AccessMay Record Audit 7 Day post Hospitalization Visits with PCPJune MU Generic Rx Rate Patient Self Mgt.July UDS ED Visits Open Access

August Record Audit 7 Day post Hospitalization Visits with PCP

September UDS/MU Generic Rx Rate Patient Self Mgt.October PH Medications ED Visits Open AccessNovember UDS 7 Day post Hospitalization Visits with PCPDecember MU Generic Rx Rate Patient Self Mgt.

Monthly Patient Contact Schedule

  Item 1 Item 2 Item 3 Item 4 Item 5 Item 6January Diabetes Well Child - 7-21 Immunizations 7-12 Chlamydia Cardiovascular Smoking CessationFebruary HTN Well Child - Years / Lead Immunizations - 15 Mo Pap/Mam Osteoporosis / RA BMIMarch Asthma Well Child - 3 to 6 Immunizations 3 - 6 Colonoscopy COPD Chronic KidneyApril Diabetes Well Child - 7-21 Immunizations 7-12 Chlamydia Cardiovascular Smoking CessationMay HTN Well Child - Years / Lead Immunizations - 15 Mo Pap/Mam Osteoporosis / RA BMIJune Asthma Well Child - 3 to 6 Immunizations 3 - 6 Colonoscopy COPD Chronic KidneyJuly Diabetes Well Child - 7-21 Immunizations 7-12 Chlamydia Cardiovascular Smoking CessationAugust HTN Well Child - Years / Lead Immunizations - 15 Mo Pap/Mam Osteoporosis / RA BMISeptember Asthma Well Child - 3 to 6 Immunizations 3 - 6 Colonoscopy COPD Chronic KidneyOctober Diabetes Well Child - 7-21 Immunizations 7-12 Chlamydia Cardiovascular Smoking CessationNovember HTN Well Child - Years / Lead Immunizations - 15 Mo Pap/Mam Osteoporosis / RA BMIDecember Asthma Well Child - 3 to 6 Immunizations 3 - 6 Colonoscopy COPD Chronic Kidney

Activity Schedule

Periodic Assessment - BCBS

What Needs Measured?

Goal Comparisons

Periodic Assessment - NCQA

NCQA Report Priorities

Data Location and Reporting

NCQA Reporting

Evidenced Based Care - MQIC

Protocol Creation / Modification

Staff / Patient Tools• PCMH Brochure• Care Management / Self Management Documentation• Standardized Work Documentation• Staff Education Tools

PCMH Brochure

Care Planning

Create Staff Documentation

Success’• NextGen EHR Implementation• i2i Tracks Registry Implementation• Centralized PCMH Functions

• Mailings for all sites using fold and seal mailers• Report processing and distribution

• One Time download of all immunization in State Immunization Registry (MCIR) to our EHR

• PCMH Module in Annual Competency Training• Planning

• Worked Smarter, not Harder• Made sure Measures met multiple goals

Weak Areas (Failures)• Open Access Scheduling

• Competing Priorities

• Internal CAHPS Surveying• Costly• Time Consuming

• Interfaces• MCIR Upload

• Identification of Managed Care Population• 4 different attempts• Too Large – Wrong Measures – Too Small – Just Right

• Provider Engagement• Competing Priorities (Productivity / EHR / PCMH)

Pearls• Education

• Leadership (Administration and Board)• Provider• Staff (Clinical and Support)

• Change is Difficult• Changing to the Chronic Care Model is More Difficult than meeting

the NCQA PCMH Standards• Staff and Providers do not want to give up the old way• Competing Priorities

• Care Management Population Selection• What is your time frame to meet goal? – Work Backwards• What percent of your proposed patients are seen during that time?• Who will do Care Magement?

Pearls• Registry

• Data Validation• How will you measure various aspects of care?• Will your registry report on those items?• Success is tied to staff proficiency with EHR.

• Standardize• What will be documented where?• Who will perform specific ongoing reporting tasks?

• Adopt the “Everyone works to their highest level of licensure or training” philosophy.

• Live the “Triple Aim” and immerse yourself in PCMH

Pearls• Communication

• Newsletters• Reference Materials for Staff

• Investment• Financial (Registry / Licenses / Education / Staffing)• Staff Time (Education / New Tasks / Learning Curve)

• Flexibility• Modify timeline as needed• Ask for help

Success?• NCQA PCMH Designation at all 5 sites• Meaningful Use Payments for Stage 2 (2014)• Reporting

• Valid Results• Available for all known measures• Trending data available

• Improved Quality Scores• UDS• Pay for Performance Indicators – All Payers

• Gain Sharing with our new ACO Initiative