PCMH: Part 4 – Learn How to Start or Improve Your Quality Improvement Program

PCMH: PART 4 CARE COORDINATION AND PERFORMANCE

IMPROVEMENT AND QUALITY IMPROVEMENT PROGRAMS JUNE 24, 2016

Confidential © 2015 Galen Healthcare Solutions

SOLVING FOR TODAY. PREPARING FOR TOMORROW.

You have been automatically muted. Please use the Q&A panel to submit questions during the presentation

Presenter

Christy Erickson, MSN, PMP, PCMH CCE

Director, Clinical TransformationOver 10 years of Healthcare IT & Clinical Informatics experienceOver 25 years of Nursing & Nurse Practitioner experience

Agenda• PCMH Overview

• Standard 5- Care Coordination and Care Transitions

• Standard 6- Performance Measurement and Quality Improvement

• Brief review of changes between 2011 and 2014 standards

• MU Alignment of Standards

This just in……….MACRA• MACRA- The Medicare Access and CHIP Reauthorization Act of

2015- WEDNESDAY, 4/27/16 ruling released– Changes payment for Medicare beneficiaries FFS program replacing

sustainable growth rate (SGR) formula

• 2 Paths– MIPS

• Quality (PQRS) (50%)• Advancing Care Information (MU) (25%)• Clinical Practice Improvement Activities (15%)• Resource Use Measures (VM) (10%)

– APM’S• CPC Plus• ACO’s (MSSP, Next Generation ACO Model)• Comprehensive End Stage Renal Disease Care Model• Oncology Care Program

What is PCMH?• Patient Centered Medical Home

• Primary Care Program

• Emphasizes care coordination/management and team based care

• Triple aim

NCQA Roadmap – Download Standards

Scoring Levels Level 1= 35-59 points Level 2= 60-84 points Level 3= 85-100 points

* MUST PASS Elements

PCMH 5: Care Coordination and Care Transitions

• Element A: Test Tracking and Follow-Up

• Element B: Referral Tracking and Follow-Up

• Element C: Coordinate Care Transitions

18 POINT

S

Element 5A: Test Tracking and Follow-Up

1. Tracks lab tests until results are available, flagging and following up on overdue results.

2. Tracks imaging tests until results are available, flagging and following up on overdue results.

3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot

screening7. More than 30 percent of laboratory orders are electronically recorded in the patient

record. +8. More than 30 percent of radiology orders are electronically recorded in the patient

record. +9. Electronically incorporates more than 55 percent of all clinical lab test results into

structured fields in medical record. +10. More than 10 percent of scans and tests that result in an image are accessible

electronically +

+ Stage 2 Core Meaningful Use RequirementCritical Factor

Meaningful Use Alignment 5A-Test Tracking and Follow-Up

NCQA Requirements Modified Stage 2 Ruling NCQA ResponseElectronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record.

Removed as MU Measure NCQA maintaining requirement but will accept an example of capability in lieu of a report

More than 10 percent of scans and tests that result in an image are accessible electronically

Removed as MU Measure NCQA maintaining requirement but will accept an example of capability in lieu of a report

Element 5A: Scoring6.0 points

• 8-10 factors (including factors 1 and 2) = 100%• 6-7 factors (including factors 1 and 2) = 75%• 4-5 factors (including factors 1 and 2) = 50%• 3 factors (including factors 1 and 2) = 25%• 0-2 factors (doesn’t meet factors 1 and 2) = 0%

Element 5A Factor 1-10: Documentation

PCMH 5A1-6• Process/Policy

• Date• Practice Name• Define process

• tracking labs and imaging studies• overdue labs and imaging studies• abnormal labs and imaging studies• patient notification• newborn hearing and screening tests

• Define timeline and frequency of lab/imaging results monitoring

• Report or Log or Examples• For each factor• Across patients

Element 5A Factor 1-10: Documentation

PCMH 5A7-10• Report

• 3 months of recent data• Numerator• Denominator

PCMH 5A1-2, 3-5

Element 5A2: Overdue Order Tracking

Element 5A3: Abnormal Results Tracking

Element 5A5: Sample Lab Notification to Patient

Element 5A7-8: CPOE Labs/Imaging

Element 5B: Referral Tracking and Follow-Up

1. Considers available performance information on consultants/specialists when making referral recommendations.

2. Maintains formal and informal agreements with a subset of specialists based on established criteria.

3. Maintains agreements with behavioral healthcare providers. 4. Integrates behavioral healthcare providers within the practice site. 5. Gives the consultant or specialist the clinical question, the required

timing and the type of referral. 6. Gives the consultant or specialist pertinent demographic and clinical

data, including test results and the current care plan. 7. Has the capacity for electronic exchange of key clinical information+ and

provides an electronic summary of care record to another provider for more than 50 percent of referrals. +

8. Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports.

9. Documents co-management arrangements in the patient’s medical record.

10.Asks patients/families about self-referrals and requesting reports from clinicians. + Stage 2 Core MU Requirement

Critical Factor

MUST PASS

Meaningful Use Alignment 5B-Referral Tracking and Follow-

UpNCQA Requirements Modified Stage 2

RulingNCQA Response

Has the capacity for electronic exchange of key clinical information+ and provides an electronic summary of care record to another provider for more than 50 percent of referrals

Health Information Exchange with a lower threshold of “more than 10%” (includes an exclusion)

NCQA will accept a report demonstrating a more than 10 percent threshold

Element 5B: Scoring6.0 points

• 9-10 factors (including factor 8) = 100%• 7-8 factors (including factor 8) = 75%• 4-6 factors (including factor 8) =

50%• 2-3 factors (including factor 8) = 25%• 0-1 factors (doesn’t meet factor 8) = 0%

Must meet at least 4 factors (including Factor 8) to pass this Must-Pass Element

Element 5B: Documentation• PCMH 5B1-3

• Examples• PCMH 5B4

• Examples/Materials• PCMH 5-6, 8, 10

Process/Policy• Date• Practice Name• Define process

• Clinical question • Supporting documentation• Tracking of referrals, timeframe, roles/responsibilities• Intake process- query of referrals since last visitReport or Log or Examples

• For each factor (report 5 days)

Element 5B: Documentation

• PCMH 7Screen Shot andReport • 3 months of recent data• Numerator• Denominator

• PCMH 9• 3 Examples

PCMH 5B1

PCMH 5B2: Sample Agreement

PCMH 5B4: Behavioral Healthhttp://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html#PracticeModel2

Coordinated Co-Located IntegratedMinimal collaboration-separate facilities and systems, communicate sporadically

Basic collaboration- mental health services on site, different systems

Close collaboration- fully integrated, part of same team, same facility/systems

Basic collaboration-separate facilities and systems, periodic communication

Close collaboration-partially integrated, some systems in common (EHR, Scheduling), close proximity for face-to-face

Close collaboration-mental health services are integrated to some degree with primary care services

http://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html#PracticeModel2

http://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html#PracticeModel2

PCMH 5B5-6: Examples following process

PCMH 5B8: Referral Tracking

Element 5C: Coordinate Care Transitions1. Proactively identifies patients with unplanned hospital admissions

and emergency department visits. 2. Shares clinical information with admitting hospitals and emergency

departments. 3. Consistently obtains patient discharge summaries from the hospital

and other facilities. 4. Proactively contacts patients/families for appropriate follow-up care

within an appropriate period following a hospital admission or emergency department visit.

5. Exchanges patient information with the hospital during a patient’s hospitalization.

6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.

7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care. +

+ Stage 2 Core MU Requirement

Meaningful Use Alignment 5C-Coordinate Care Transitions

NCQA Requirements Modified Stage 2 Ruling

NCQA Response

Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.

PCMH 5C aligns with Objective 5: Health Information with a lower threshold of “more than 10%” (includes an exclusion)

NCQA will accept a report demonstrating a more than 10 percent threshold.

Element 5C: Scoring6.0 points

• 7 factors = 100%• 5-6 factors = 75%• 3-4 factors = 50%• 1-2 factors = 25%• 0 factors = 0%

Element 5C: Documentation• PCMH 5C1

Process• Date• Practice Name• Define process for identifying patients who’ve been in the

ER/hospitalized.• Reporting/Log of patients who’ve been hospitalized

• PCMH 5C2Process

• Date• Practice Name• Define process for providing hospitals and ER’s clinical

information• 3 de-identified data examples of patient information sent to

hospital/ER


Process• Date• Practice Name• Define process for obtaining hospital discharge summaries• 3 examples of discharge summaries

• PCMH 5C4Process

• Date• Practice Name• Define process for providing patient care follow up post

admission and ER visit.• 3 de-identified examples of patient follow up post

discharge


Process• Date• Practice Name• Define process for two way communication with hospitals• Example of two-way communication

• PCMH 5C6Process

• Date• Practice Name• Define process for obtaining proper consent for release of

information• PCMH 5C7

Report-3 months• Numerator/Denominator • Or Example showing capability

PCMH 5C1-4: Sample Process

PCMH 5C3: Sample De-Identified Discharge Data

PCMH 6: Performance Measurement and Quality Improvement

• Element A: Measure Clinical Quality Performance

• Element B: Measure Resource Use and Care Coordination

• Element C: Measure Patient/Family Experience

• Element D: Implement Continuous Quality Improvement

• Element E: Demonstrate Continuous Quality Improvement

• Element F: Report Performance• Element G: Use Certified EHR Technology

20 POINT

S

Element 6A: Measure Clinical Quality Performance

At least annually

1. At least two immunization measures.

2. At least two other preventive care measures.

3. At least three chronic or acute care clinical measures.

4. Performance data stratified for vulnerable populations (to assess disparities in care).


Element 6A: Scoring3.0 points

• 4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factors = 25%• 0 factors = 0%

Element 6A1-4: Documentation• For each measure

• Period of measurement• Number of patients represented by

data• Rate (percentage) based on

numerator/denominator

PCMH6A: Report Sample

Element 6B: Measure Resource Use and Care Coordination

1. At least two measures related to care coordination.

2. At least two utilization measures affecting health care costs.

Element 6B: Scoring3.0 points

• 2 factors = 100%

• 1 factors = 50%

• 0 factors = 0%

Element 6B1-2: Documentation

Report• Showing practice performance results

• Initial submission: Data <1 year old

PCMH 6B1 Documentation

Element 6C: Measure Patient/Family Experience

1. The practice conducts a survey (using any instrument) to evaluate patient/family experiences on at least three of the following categories:

– Access. – Communication. – Coordination. – Whole person care/self-management support.

2. The practice uses the PCMH version of the CAHPS Clinician & Group Survey Tool. 3. The practice obtains feedback on experiences of vulnerable patient groups. 4. The practice obtains feedback from patients/families through qualitative means.

Element 6C: Scoring4.0 points

• 4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factor = 25%• 0 factors = 0%

Element 6C: DocumentationPCMH 6C1-4

• Report with summarized results of patient feedback

• If going for NCQA Distinction must provide a report

Element 6C: Sample Patient Survey Data

Element 6D: Implement Continuous Quality Improvement

MUST PASS1. Set goals and analyze at least three clinical quality

measures from Element A. 2. Act to improve at least three clinical quality measures

from Element A. 3. Set goals and analyze at least one measure from

Element B. 4. Act to improve at least one measure from Element B. 5. Set goals and analyze at least one patient experience

measure from Element C. 6. Act to improve at least one patient experience measure

from Element C. 7. Set goals and address at least one identified disparity in

care/service for identified vulnerable populations.

Element 6D: Scoring4.0 points

• 7 factors = 100%• 6 factors = 75%• 5 factors = 50%• 1-4 factors = 25%• 0 factors = 0%

Must meet at 5 factors to pass this Must-Pass Element

Element 6D: Documentation

• PCMH 6D1-7 Report • Showing how each measure met

OR

• PCMH Quality Measurement and Improvement Worksheet

Element 6D: Quality Measurement and Improvement Worksheet

Element 6D: Quality Measurement

Element 6E: Demonstrate Continuous Quality Improvement

1. Measuring the effectiveness of the actions it takes to improve the measures selected in Element D.

2. Achieving improved performance on at least two clinical quality measures.

3. Achieving improved performance on one utilization or care coordination measure.

4. Achieving improved performance on at least one patient experience measure.

Element 6E: Scoring3.0 points

•4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factors = 25%• 0 factors = 0%

Element 6E: Documentation

• PCMH 6E1-4 Report • Showing how each measure met

OR

• PCMH Quality Measurement and Improvement Worksheet

Element 6E: Tracking Improvement Over Time

Element 6F: Report Performance

1. Individual clinician performance results with the practice.

2. Practice-level performance results with the practice.

3. Individual clinician or practice-level performance results publicly.

4. Individual clinician or practice-level performance results with patients.

Element 6F: Scoring3.0 points

• 3-4 factors = 100%• 2 factors = 75%• 1 factors = 50%• No scoring option= 25%• 0 factors = 0%

Element 6F: Documentation• PCMH 6F1 Report of clinician results

• Provided to clinicians and practice staff and explain how results shared with group

• PCMH 6F2 Report of practice results

• Explain how results shared with group

• PCMH 6F3-4- Report• Example of how report is shared with

patients and public

Element 6F: Reports

Element 6F: Reports

Element 6G: Use of Certified EHR Technology

1. The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID.

2. The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies. +

3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.

4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.

5. The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically.

6. The practice reports clinical quality measures to Medicare or Medicaid agency, as required for Meaningful Use.

7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically.

8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10. The practice generates lists of patients, and based on their preferred method of

communication, proactively reminds more than 10 percent of patients/families/caregivers about needed preventive/follow-up care.+


Element 6G: Scoring0 points

No Scoring option

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2011-pcmh-2014-crosswalk

Standard 55A6: Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening 5B1: Considers available performance information on consultants/specialists when making referral recommendations 5B2: Maintains formal and informal agreements with a subset of specialists based on established criteria 5B3: Maintains agreements with behavioral healthcare providers 5B4: Integrates behavioral healthcare providers within the practice site 5B8: Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports 5B9: Documents co-management5C4: Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit 5C5: Exchanges patient information with the hospital during a patient’s hospitalization 5C6: Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners

Cross Walk 2011-2014




Standard 66A1: At least two immunization measures 6A2: At least two other preventive care measures 6A3: At least three chronic or acute care clinical measures6B1: At least two measures related to care coordination 6B2: At least two measures affecting health care costs 6E1: Measuring the effectiveness of the actions it takes to improve the measures selected in Element D 6E2: Achieving improved performance on at least two clinical quality measures 6E3: Achieving improved performance on one utilization or care coordination measure 6E4: Achieving improved performance on at least one patient experience measure

Cross Walk 2011-2014





• Gap Analysis/Audit

• Identify areas requiring work• Process/Policy• Organizational change• Reports, Samples

• Focus on areas that are quick wins first

Next Steps- Tips/Tricks

Gap Analysis Sample

Gap Analysis Sample



Referenceshttp://store.ncqa.org/index.php/recognition/patient-centered-medical-home-pcmh.html

http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8.%20PCMH%20Recognition%202014_Appendix%206_Summary%20of%20Updates%20to%20PCMH%202014%2003.28.2016%20FINAL.pdf?ver=2016-04-01-142019-047












THANK YOU



Thank you for joining us today.To access the slides from today’s presentation, please visit:

http://wiki.galenhealthcare.com/Category:Webcasts

For additional assistance or to request information about our many services and products, please contact us through our

website:

www.galenhealthcare.com

http://wiki.galenhealthcare.com/Category:Webcasts

http://www.galenhealthcare.com/

Date post:	07-Feb-2017
Category:	Healthcare
Upload:	julie-champagne
View:	253 times
Download:	2 times