Training Webinar # 6

David Halpern, MD, MPHFebruary 15, 2012

Patient-Centered Medical Home

NCQA’s PCMH 2011 Standards

Legal Disclaimer

© Copyright 2011 North Carolina Community Care Networks, Inc.  All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure NCQA recognition as patient-centered medical homes.  All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with the permission of the respective copyright owners in each case.

Acknowledgements

Let’s Review

• Standard 2 – Identify & Manage Populations– PCMH 2A: Patient Information– PCMH 2B: Clinical Data– PCMH 2C: Comprehensive Health Assessment– PCMH 2D: Use Data for Population Management -

MUST PASS

• Standard 5 – Track & Coordinate Care– PCMH 5A: Test Tracking & Follow-Up– PCMH 5B: Referral Tracking & Follow-Up MUST PASS– PCMH 5C: Coordinate With Facilities & Care Transitions

Let’s Track Our Progress

• Standard 1 – Enhance Access/Continuity• Standard 2 – Identify/Manage Populations• Standard 3 – Plan/Manage Care• Standard 4 – Self-Care Support/Resources• Standard 5 – Track/Coordinate Care• Standard 6 – Measure/Improve

Performance

Today’s Agenda

• What Is The Record Review Workbook?

• Standard 4 – Self-Care Support & Community Resources– PCMH4A: Support Self-Care Process –

MUST PASS– PCMH4B: Provide Referrals to Community

Resources

Record Review Workbook(RRWB)

What Is the “Record Review Workbook”?

• Elements 3C, 3D, 4A– Require medical record abstraction of data– Need % of patients meeting the element

(based on a numerator and a denominator)

• Two methods to collect and submit patient data– Method #1 - report from the electronic system– Method #2 - Record Review Workbook

• Excel workbook in the Survey Tool• Tool to identify a sample of patients and abstract data

needed for Elements 3C, 3D, 4A

Using The Workbook

1. Find Workbook in Survey Tool2. Download and save file to computer3. Review instructions and data needed from

patient records4. Select patient records to review5. Review patient records for data6. Enter data in Workbook7. Enter numerical result in Survey Tool8. Link Workbook to Survey Tool

Selecting Patients for Workbook

~ Use same 48 patients for EACH Workbook Element ~

STEP #1. START DATE = Today’s date February 15th

STEP #2. Go back 30 days = January 15th

STEP #3. • Use appointment or billing system to identify patients with visit on June 5th• Choose every patient with any of 3 clinically important conditions who had a visit on this date that was related to the important condition

STEP #4. Continue choosing patients going back on consecutive dates until you have selected 48 patients

RRWB = Supplemental Worksheet

Click here

RRWB Tabs

Three tabs Instructions Patient Conditions Record Review

RRWB – Enter Important Conditions

Enter three important conditions here including an unhealthy behavior/mental health or substance abuse AND

high-risk or complex patients, IF you are including them.

RRWB – Enter Conditions

Enter conditions from drop downmenu, for example: Diabetes Hypertension Depression High Risk/Complex

RRWB – Enter Data

Entering NOT USED in row 1“grays” out the column

Response Options Yes No Not Used Not applicable

RRWB – automatically calculates the % of Patients that met factor

Patients that Met Factor Number (33/48) Percent (69%) Result for ISS

Enter RRWB Responses in Survey Tool

Enter responses From RRWB Yes or No AND Percent

Elements• PCMH4A: Provide Self-Care Support –

MUST PASS• PCMH4B: Provide Referrals to Community

Resources

PCMH 4: Self-Care Support & Community Resources

• Practice conducts activities to support patients in self-management: (MUST PASS)

1. Provides education resources or refers at least 50% of patients to educational resources

2. Uses EHR to identify education resources and provide them to 10% of patients**

3. Collaborates with at least 50% of patients to develop and document self-management plans and goals-CRITICAL FACTOR

4. Documents self-management abilities for at least 50% of patients

5. Provides self-management result recording tools to at least 50% of patients

6. Counsels at least 50% of patients on adopting health lifestyles

** Meaningful Use Requirement

PCMH 4A: Provide Self-Care Support

• MUST PASS• 6 Points• Scoring

– 5-6 factors (including factor 3) = 100% – 4 factors (including factor 3) = 75%– 3 factors (including factor 3) = 50% (must-pass) – 1-2 factors = 25% (not sufficient for passing element)– 0 factors = 0%

• Data Sources:– Report from electronic system or submission of

Record Review Workbook

PCMH 4A: Provide Self-Care Support

• Patient Self management tools are available by clicking on the last tab in Provider Portal or by going to the “Patient Mgmt Tools” tab at the CCNC website: www.communitycarenc.org

• These tools are all non-branded, evidence based, low literacy appropriate and have been vetted by physicians at CCNC

PCMH 4A: Remember…

PCMH 4A: Remember…

Provider Portal allows you to search AND download

disease-specific self-management tools, handouts, and video

demos, which patients can access from home

PCMH 4A: Example – Factor 1

Examples of self-management tools for patients/families

PCMH 4A: Example – Factor 1

PCMH 4A: Example – Factor 1

PCMH 4A: Example – Factor 3

Your Goal HbA1c:Green Zone: Great Control

HbA1c is under 7 Average blood sugars typically under 150 Most fasting blood sugars under 150

Green Zone Means: Your blood sugars are under control Continue taking your medications as

ordered Continue routine blood glucose

monitoring Follow healthy eating habits Keep all physician appointments

Yellow Zone: Caution HbA1c between 7 and 9 Average blood sugar between 150-210 Most fasting blood glucose under 200

Work closely with your health care team if you are going into the YELLOW zone

Yellow Zone Means: Your blood sugar may indicate that

you need an adjustment of your medications

Improve your eating habits Increase your activity level Call your physician, nurse, or diabetes educator if changes in your activity level or eating habits don’t decrease your fasting blood sugar levels.Name:___________________________Number:__________________________

Red Zone: Stop and Think HbA1c greater than 9 Average blood sugars are over 210 Most fasting blood sugars are well over 200

Call your physician if you are going into the RED zone

Red Zone Means:You need to be evaluated by a physician.If you have a blood glucose over ____, follow these instructions _____________ __________________________________ Call your physician Physician:_________________________Number:__________________________

PCMH 4A: Example – Factor 3

Demonstrates patient progress and self-monitoring results

Demonstrates barriers to patient’s ability to

meet goals

PCMH 4A: Example – Factor 4

The practice provides patient with self-management tool

(flowsheet) and then includes completed self-

management tool in patient’s chart,

demonstrating patient’s self-management ability.

PCMH 4A: Example – Factor 4 & 5

PCMH 4A: Example – Factor 5

Example of a diabetes log book

PCMH 4A: Example – Factor 5

Example of a hypertension

log book

PCMH 4A: Example – Factor 5

Example of a CHF log book

PCMH 4A: Example – Factor 6

Example of counseling

documentation in the EMR

PCMH 4A: Example – Factor 6

Example of counseling

documentation in the EMR

PCMH 4A: Example Using the Record Review Workbook

• Practice supports patients who need access to community resources:

1. Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support)

2. Tracks referrals provided to patients

3. Arranges for or provides treatment for mental health/substance abuse disorders

4. Offers opportunities for health education and peer support

PCMH 4B: Provide Referrals to Community Resources

• 3 Points• Scoring

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

• Data Sources:– List of community services or agencies – Referral log or report covering at least one month– Processes to provide/arrange for mental health/substance

abuse treatment and health education support

PCMH 4B: Provide Referrals to Community Resources

PCMH 4B: Example – Factor 2

Next Steps (Homework)

• Download the Record Review Workbook and start familiarizing yourself with it.

Next Steps (Homework)

• Organize Your Documents– Create a place on your computer (server or

hard-drive) for all of your documentation– You should have a folder for each standard– A checklist can help you determine what you

already have created/saved and what you need to prepare from scratch

Next Steps (Homework)

– Decide which 3 “Important Conditions” (e.g. diabetes, asthma, congestive heart failure, depression, etc) you want to track over time. One must be related to unhealthy behaviors, mental health, or substance abuse.

– Does your practice already follow evidence-based guidelines when caring for patients with these conditions?

– Are these guidelines documented anywhere?

Community Care PCMH Team

• David Halpern, MD, MPHCommunity Care of North Carolina (CCNC)

• R.W. “Chip” Watkins, MD, MPH, FAAFPCommunity Care of North Carolina (CCNC)

• Brent Hazelett, MPANorth Carolina Academy of Family Physicians (NCAFP)

• Elizabeth Walker Kasper, MSPHNorth Carolina Healthcare Quality Alliance (NCHQA)

Questions?

Feel free to contact me:

David Halpern, MD, MPH

(215) 498-4648

dhalpern@n3cn.org