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PCMH 3:Plan and Manage Care

Deborah Johnson Ingram

“There is documented body of evidence that in

healthcare there exist a great variability in care

that patients receive often by virtue of where

they live. “

“Healthcare should be equitable and should

not vary in quality because of personal

characteristics such as gender, ethnicity,

geography and socioeconomic status.”

“There is documented body of evidence that in

healthcare there exist a great variability in care

that patients receive often by virtue of where

they live. “

“Healthcare should be equitable and should

not vary in quality because of personal

characteristics such as gender, ethnicity,

geography and socioeconomic status.”

Evidence Based Medicine

1. Sackett et al., “Evidence-based Medicine.”

Evidence based medicine is not “cookbook” medicine. Because

it requires a bottom up approach that integrates the best external

evidence with individual clinical expertise and patients' choice, it

cannot result in slavish, cookbook approaches to individual

patient care.

Evidence based medicine is the conscientious, explicit, and

judicious use of current best evidence in making decisions

about the care of individual patients. The practice of evidence

based medicine means integrating individual clinical expertise

with the best available external clinical evidence from

systematic research (emphasis added).1

Evidence Based Medicine:

What It Is and Isn’t

• Good doctors use both individual clinical expertise and

the best available external evidence, and neither alone

is enough.

• Without clinical expertise, practice risks becoming

tyrannized by evidence, for even excellent external

evidence may be inapplicable to or inappropriate for

an individual patient.

• Without current best evidence, practice risks

becoming rapidly out of date, to the detriment of

patients.

Evidence Based Medicine:

What Else You Should Know

• Practice implements

evidence-based

guidelines

• High-risk patients

identified

• Care team performs

care management

through pre-visit

planning, developing

plan and treatment

goals

Intent of Standard

PCMH Standard 3

PCMH Standard 3 Element A

Critical Factor

Critical Factor


PCMH Standard 3 Element AExamples of Adult Chronic Conditions

� Diabetes

� Hypertension

� Hyperlipidemia

� CAD

� COPD

� HIV

� Asthma

� Obesity

� Chronic Back Pain

� Chronic Kidney Disease (CKD)

Examples of Pediatric Conditions

� GERD (Acid Reflux)

� Obesity

� Otitis Media

� ADD


Examples of Conditions Related to Unhealthy

Behaviors

� Smoking Dependency

� Drug Dependency

� Alcoholism

� Obesity

Examples of Mental Health or Behavioral Health

Conditions

� ADD

� ADHD

� Schizophrenia

� Bi-Polar Disorder

� Depression

Quality Improvement / Clinical Guidelines

In order to evaluate this practices effectiveness of performing quality care for clinically

important conditions relevant to our patient population, this practice shall refer to the

following clinical guidelines when treating patients with said diagnosis:

Diabetes

Hypertension

COPD

Clinical Guidelines

Management of Diabetes Mellitus

Recommendations:

Screening1 Consider fasting plasma glucose (FPG) at least every three years:

for patients with a BMI>25kg/m2

and one or more risk factors

Quality Measures: 2.

HbA1c control : <7%

Blood Pressure Control: = 130/80

LDL control: <100 mg/dl

Annual eye exam

Annual Foot exam

Neuropathy assessment

Smoking status and cessation advice or treatment

Evaluation: 3.

• HbA1c measurement every six monthsBlood Pressure

measurement at each routine diabetes visit

• Fasting lipid profile annually

• Nephropathy screening

Quality Improvement / Clinical Guidelines

In order to evaluate this practices effectiveness of performing quality care for clinically

important conditions relevant to our patient population, this practice shall refer to the

following clinical guidelines when treating patients with said diagnosis:

Diabetes

Hypertension

COPD

Clinical Guidelines

Management of Diabetes Mellitus

Recommendations:

Screening1 Consider fasting plasma glucose (FPG) at least every three years:

for patients with a BMI>25kg/m2

and one or more risk factors

Quality Measures: 2.

HbA1c control : <7%

Blood Pressure Control: = 130/80

LDL control: <100 mg/dl

Annual eye exam

Annual Foot exam

Neuropathy assessment

Smoking status and cessation advice or treatment

Evaluation: 3.

• HbA1c measurement every six monthsBlood Pressure

measurement at each routine diabetes visit

• Fasting lipid profile annually

• Nephropathy screening


Sample of a Practice/ Clinic

Quality Improvement Clinical

Guideline

Example of Evidence-Based COPD Visit Template



Evidence-Based Guidelines ReferencesNHLBI:http://www.nhlbi.nih.gov/guidelines/current.htm

ACP:http://www.acponline.org/clinical_information/guidelines/guidelines/

Veterans Affairs:http://www.healthquality.va.gov/

Guidelines.gov:http://guidelines.gov

Hypertension:http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm

http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

COPD:http://www.annals.org/content/147/9/633.full

Diabetes:http://www.healthquality.va.gov/Diabetes_Mellitus.asp

http://diabetes.org (ADA)

PCMH Standard 3 Element B


Examples of High Risk that can effect whole

person care planning and management

�High level of resource

� Visits

� Multi- meds

� Complex treatment

�Frequent visits for urgent or emergent care

�Frequent Hospitalizations

�Multi-Comorbidities, including mental health

�Non-Compliance w/ Rx Tx

�Terminal Illness

�Advance Aged w./frailty



Factor 1

PCMH 3B Factor 1

Our Town clinic has a community with a high prevalence of

uncontrolled diabetics that are insulin dependent. The vast

majority of these patients develop End Stage Renal Disease.

Our clinic collaborated w/ the local health department to

address this epidemic of DM pts.

__________________________________________________________

PCMH 3B Factor 2 We identified that 37% (210/569) of our DM patients fall into this

high risk DM grouping by assessing their: eGFR’s, Microalbumin, A1c,

etc results from the past 12 months. These patients are assigned to a

high risk care manager provided to us through the health department

and referred to a Nephrologists. Together our goal is to get these

patients more compliant or into a controlled status with intensive

tracking and follow-up.

See monthly tracking report attachedSee monthly tracking report attachedSee monthly tracking report attachedSee monthly tracking report attached


Factor 1 & 2

PCMH 3 factor 2

Our Town Clinic High Risk DM Patients Report

PCMH Standard 3 Element B Factor 2

PCMH Standard 3 Element C

PCMH Standard 3 Element C

PCMH Standard 3 Element C Factor 1

Pre Visit Preparation- are activities that clinical staff

undertake to prepare for a visit before the patient is

seen by the clinician

Some common pre-visit planning/preparations activities

include:

• making sure that all lab results and referral reports are in

the medical record

• calling a patient to come in and receive routine lab work

before the visit with the clinician

• assessing how the patient is doing in terms of meeting

goals for managing their chronic condition

• making notes on goals that need to be addressed before

the visit

• confirming that routine preventive services such as flu

vaccines have been ordered and or performed



PCMH

Standard 3

Element C

Factor 2

Care plans w/

goals that are

reviewed and

updated


� Patient Received Copy

PCMH

Standard 3

Element C

Factor 3

Gives patient

a written plan

of care



4/02/07

PCMH 3C factor 4-Assessing and Addressing barriers when Tx goals are not met


PCMH Standard 3 Element C Factor 5Remember: Relevant visits are determined by the practice and the clinician.

PCMH 3C factor 5:

Provide patients w/ clinical summaries at each relevant visit



Factor 6: Identifies

patients who might

benefit from

additional care

management

support


Collecting Data for PCMH 3C

PCMH 3C: 2 Methods for Collecting DataPCMH 3C: 2 Methods for Collecting Data

Method 1

Query your electronic system for the patients w/ conditions identified PCMH 3A and the high-risk or complex patients identified in PCMH 3B to calculate the percentage directly for each factor

Denominator = Total # of patients

with one of the important

conditions seen at least once by

the practice in a recent 3 month

period

Numerator = # of patients identified

in the den. For whom each item is

entered in the medical record

Method 2

Review a sample of 48 patient records to obtain the information. (Note: Patient records may

be a registry or electronic

records or paper medical

records.)

If you cannot use Method 1, you

must use Method 2 to respond to

these elements and must fill out the

Patient Conditions and Record

Review Worksheets.

You may respond to some elements

with Method 1 and others with

Method 2.

PCMH 3C: Method 2- Selecting Patients

for Record Review

PCMH 3C: Method 2- Selecting Patients

for Record Review

Patients: Select 48 patients who have any one or more of the three chosen

clinically important conditions (3A) and have had a care visit related to the

selected important condition. You will review these same 48 patient files for all

of the elements in this Record Review Workbook. Each of the three important

conditions and the high-risk or complex patients must be equally

represented. There must always be a total of 48 patients.

Conditions: If the practice identified high-risk patients in 3B, these patients should

be included in the Workbook in addition to the 3 important conditions identified in

3A.

If you have 2 important conditions identified in 3A (1 being unhealthy then you will

have 24pts of each condition

If you have 3 conditions identified then you will 16 of each condition

If you have 4 conditions identified in A &B then you will have 12 of each condition

PCMH Record Review WorkbookPCMH Record Review Workbook

PCMH Record Review WorkbookPCMH Record Review Workbook

PCMH Standard 3 Element D

PCMH Standard 3 Element D

PCMH Standard 3 Element D Factor 1






PCMH 3D: 2 Methods for Collecting DataPCMH 3D: 2 Methods for Collecting Data

Method 1

Query your electronic system for the patients w/ conditions identified PCMH 3A and the high-risk or complex patients identified in PCMH 3B to calculate the percentage directly for each factor

Denominator = Total # of patients

with one of the important

conditions seen at least once by

the practice in a recent 3 month

period

Numerator = # of patients identified

in the den. For whom each item is

entered in the medical record

Method 2

Review a sample of 48 patient records to obtain the information. (Note: Patient records may

be a registry or electronic

records or paper medical

records.)

If you cannot use Method 1, you

must use Method 2 to respond to

these elements and must fill out the

Patient Conditions and Record

Review Worksheets.

You may respond to some elements

with Method 1 and others with

Method 2.

PCMH Standard 3 Element E

PCMH Standard 3 Element E

PCMH Standard 3 Element E Factor 1


Our Town

MedicalDr A. Dr B. Dr C. Dr. E



Factor 1- Our Town clinic has a policy to enter a Rx’s in the EMR. Therefor

the total # of Rx’s entered for the reporting period of 2/15/11-5/14/11 were

2,822 or 100% generated electronically



Factor 3: Our Town

Clinic electronically

ordered 70% or

6101/8650 for

patients w/ at

least 1 med in their

med list


Factor 4: Our town clinic uses an EMR that provides patient specific Drug to

Drug interactions. In this example the medication ordered was Dilantin. The

EMR then alerted the provider of appropriate alerts because the patient is Dx

w/ Alcohol dependency



Factor 5




Factor 6

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