| primary care information project dco-on0056-20090404-njpp1 printed 0 title primary care...

|Primary Care Information Project

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TITLE

Primary Care Information ProjectNYC Department of Health & Mental Hygiene

Quality Improvement Team

Primary Care Information Project

Quality Improvement ProgramPatient-Centered Medical Home

2010


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What is a Patient Centered Medical Home and Who is NCQA?

“There is a clear consensus that primary care needs to be at the center of a reformed US health care system. The Patient-centered Medical Home (PCMH) has emerged as the key strategy for the redesign of primary care. The PCMH model builds upon the core concepts of primary care that include accessible, accountable, coordinated, comprehensive, and continuous care in a healing physician-patient relationship over time. Added to these basic primary care concepts are features that improve quality of care, improve patient centeredness, organize care across teams, and reform the payment system to support this enhanced model of primary care.”

PCP/ Patient

Specialist

Hospital

VNS

Pharmacy

Patient Centered Home

COORDINATION OF CARE

Annals of Family Medicine 8:88-89 (2010) © 2010 Annals of Family Medicine, Inc.doi: 10.1370/afm.1087


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NCQA PCMH Nine Focus Areas

PPC1: Access and Communication

PPC2: Patient Tracking and Registry Functions

PPC3: Care Management

PPC4: Patient Self-Management Support

PPC5: Electronic Prescribing

PPC6: Test Tracking

PPC7: Referral Tracking

PPC8: Performance Reporting and Improvement

PPC9: Advanced Electronic Communication


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THERE ARE 10 MUST-PASS ELEMENTS IN PCMH SCORING

Elements Points

1: Access & Communication (9 pts)1A: Access & communication processes1B: Access & communication results

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Source:NCQA Overview Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH)

2: Patient Tracking & Registry Functions (21 pts)2A: Basic system for managing patient data2B: Electronic system for clinical data2C: Use of electronic clinical data2D: Organizing clinical data2E: Identifying important conditions2F: Use of system for population management

2336 4 3

3: Care Management (20 pts)3A: Guidelines for important conditions3B: Preventive service clinician

reminders3C: Practice organization3D: Care management of important

conditions3E: Continuity of care

34355

4: Patient Self-Management Support (6 pts)4A: Documentation of communication needs4B: Self-management support

24

= Must pass elements

5: Electronic prescribing (8 pts)5A: Electronic prescription writing5B: Prescribing decision support-safety5C: Prescribing decision support-efficiency

332

6: Test tracking (13 pts)6A: Test-tracking and follow-up6B: Electronic system for managing tests

76

7: Referral tracking (4 pts)7A: Referral tracking

4

8: Performance Reporting & Improvement (15 pts)8A: Measures of performance8B: Patient experience data8C: Reporting to physicians8D: Setting goals and taking action8E: Reporting standardized measures8F: Electronic reporting- external entities

3 33321

9: Advanced Electronic Communications (4 pts)9A: Availability of interactive website9B: Electronic patient identification9C: Electronic care management support

121

Elements Points

TOTAL POINTS 100


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PPC-PCMH STRUCTURE DETAIL Description

Level 1

•25-49 points; Must-pass elements = 5 of 10, with performance of at least 50%

Level 2

•50-74 points; Must-pass elements = 10 of 10, with performance of at least 50%

Level 3

•75 points or more; Must-pass elements = 10 of 10, with performance of at least 50%

Achievement levels

IT requirements

Steps for evaluation

Basic: Requires electronic practice management

Intermediate: Requires EHR or e-prescribing

Advanced: Requires interoperable IT capabilities

•Practice conducts self-scoring assessment

•Practice completes on-line Survey Tool

•NCQA evaluates all data and documents & provides score

•At least 5% of practices receive additional, onsite audit by NCQA

•NCQA provides final information to the practice

•NCQA reports information on the practice, the providers and level of performance to NCQA & data users (health plans & physician directories) for practices that pass a level

Pricing charged by NCQA

•Initial fee Survey Tool license -$80

•Initial Application fee

-$450-$2700 for 1-6 non-sponsored provider

-$360-$2700 for 1-6 sponsored providers

•Add-on Survey Application fee to advance to next level

-Ranges from $225-$1350 for 1-6 providers

PCIP RATE- HALF OF THE RATE NOTED ABOVE- $225/PHYSICIAN – benefit of participating with PCIP


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PCIP QUALITY IMPROVEMENT ACTIVITIES – WHAT DO WE DO?

–Provide technical assistance to physicians to help them improve the health outcomes of patients,

–Focus on 4 priority TCNY areas (ABCS)–Help providers get to meaningful use–Provide CME/CNE credits for participating with QI

–Provide support for office redesign (e.g., workflows, documentation, standard processes) to improve office efficiency

–if desired, prepare for NCQA Patient Centered Medical Home (PCMH)

–Provide additional coaching on preventive-health features & how to use them for QI

–Provide a forum for discussing performance feedback and sharing best practices for QI efforts

–Provide feedback to the teams at PCIP on what we observe during site visits (development, IS, Billing, EMR)


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Standard 1- Access and Communication

▪ Scheduling▪ Methods to contact MD▪ Identifying health insurance▪ Patient feedback

Concepts Addressed

INTENT OF THE STANDARD Practice removes barriers to care by providing improved access for appointments

and on-going patient communication Patients have a personal physician, coordinating care and diagnostics during one

visit Obtain patient feedback about potential access and communication issues to

reduce barriers to care

▪ Written telephone triage process

▪ Written policy – helping patients identify insurance options

▪ Job descriptions for each staff member

Supporting Evidence


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PPC 1 – Access and Communication

Practical Examples:

Incorporate feedback from patients and staff into office process

Develop policies, procedures, and job descriptions to ensure that staff understand responsibilities.

Consider holding monthly staff meetings to discuss staff ideas and provide training

Conduct a patient survey and incorporate feedback into the practice

Post information in your office or website about how to obtain insurance for those patients who do not have coverage


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Standard 2- Patient Tracking and Registry Function

▪ Registry▪ Capturing patient data▪ Charting tools/documentation

Concepts Addressed

INTENT OF THE STANDARD Capturing and using data for population management and data driven decision

making to improve outcomes for chronic conditions• Proactively outreach to patients --identify needed treatment outside of the

normal office visit Capture important information for continuity of care if patient sees another

provider Promote consistency of patient care

▪ Conduct a 36 chart review, MRR spreadsheet

▪ Chose three disease focus areas, prove they are clinically important for the practice

▪ Written description- how often the registry is used, examples of preventive outreach efforts

Supporting Evidence


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PPC 2 Patient Tracking and Registry Functions

Practical Examples:

Identify three chronic clinical conditions to focus on at your practice

Run a billing report of top 10 billed ICD 9 codes Identify health conditions prevalent in your zip code through

DOH report Run registry query to determine percentage of patients with

condition at your practice

Select chart sample (36 patients) for medical record review

Use the registry to identify potential gaps in care for patients, i.e., overdue Hgb A1C, HTN patients without an office visit in 12 months

Use letters function, telephone encounters, and emails to document outreach efforts


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Standard 3 – Care Management

▪ Care management▪ Clinical focus areas▪ Team approach-non-

physician staff

Concepts Addressed

INTENT OF THE STANDARDPatients receive coordinated care at the practice according to evidence - based

guidelinesProvide a physician directed, team based approach to managing and coordinating

the patient care – non-physician staff are an important part of the care teamAvoid patient safety errors or duplicative, unnecessary care through coordination

with patient, family and external organizations (hospital, health plan, nursing home)

▪ PCIP Multi-site▪ Job Descriptions▪ Policy and Procedures▪ Create Standing Orders▪ MRR to assess use of care

plans, review of medication list, self-monitoring etc

Supporting Evidence


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PPC 3 – Care Management

Practical Examples: Maximize the features of system and delegate to non-physician team

members

• Clear CDSS alerts • Have each staff member practice to the fullest capacity of their license and

use standing orders

Create a program for patient self management

• Order FREE educational material from the DOH and distribute to patients• Refer patients to local classes or programs (i.e.: Weight Watchers, HTN,

Diabetes)

Document all of the coordination work

• Create a policy and workflow on how to communicate with external agencies (documenting phone calls using t-encounters in the patient chart)

• Document referral follow-up • Customize Preventive medicine section. The doctor can then easily document

(1) Individualized treatment goals; (2) assess patient treatment goals; and (3) Assess barriers when patient have not met their goals

• Use flowsheets and incorporate self-monitoring results into flowsheet.


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Standard 4 – Patient Self-Management

▪ Smart forms▪ Patient home monitoring▪ Documentation of patient

education▪ Patient goal setting

Concepts Addressed

INTENT OF THE STANDARD Engaged patients will participate in their care and take responsibility improving

outcomes through self monitoring, community programs, and group classes Patients become part of the care team and collaborate with the practice by setting

their own goals and being accountable Physicians consider hearing and vision barriers to learning and self management

▪ 4A – PCIP multi-site 1 point▪ NYCDOH free educational

materials▪ Hite site website link▪ Document referral to

community resources

Supporting Evidence


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PPC 4 – Patient Self-Management

Practical Examples:

Encourage patients to manage their chronic conditions• Provide educational materials• Provide patients with a printed visit summary

Assess readiness to change• Use smart forms to screen

Assess barriers to achieving clinical and personal goals

• Create and use alerts at the front desk for assessing hearing and vision barriers

• Customize Preventive medicine section. This allows for easier documentation of goal assessments


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Standard 5- Electronic Prescribing

▪ Prescribing workflows▪ Potential incentives and

rewards for eRx▪ Meaningful use

Concepts Addressed

INTENT OF THE STANDARDElectronic prescribing reduces errors through using drug safety checks and

eliminating transcription errorsRecording medications in the EHR helps coordinate care among providers and in

the event of an emergency

▪ Screen shots of the practice’s schedule (last 5 days)

▪ Screen shots of eRx’s (printing, faxing or automating success)

▪ Indicate what % of eRx’s the practice does on a daily or weekly basis

Supporting Evidence


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PPC 5 – Electronic Prescribing

Practical Examples:

Encourage coordination of pharmacy care and e-prescribing

Routinely document patient’s preferred pharmacy and document in EHR

Compare 5 days of practice schedule with reports of eRx to determine percentage of patients using service


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Standard 6- Test Tracking

▪ Developing Strong Workflows

▪ Using Lab interfaces

▪ Closing the loop and coordinating care

Concepts Addressed

INTENT OF THE STANDARD Timely follow up/tracking of lab tests will assist providers in medical decision

making Patients and families can engage in care by understanding the test results and

adhering to treatment plans that improve outcomes

▪ Written process for lab workflow

▪ Screenshots of letters or telephone encounters that notify patients of lab results

Supporting Evidence


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PPC 6- Test Tracking

Practical Examples:

Use a lab interface

Develop a strong workflow

Create written policy for test tracking and follow-up

Track all tests and document all actions in the telephone

encounter section

Notify patients of lab results by either sending letters or calling

the patient

**Remember to document all telephone calls!


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Screen shots of completed referral and tracking process

Standard 7-Referral Tracking

▪ Referral workflows▪ Delegating follow-up items to

staff

Concepts Addressed

INTENT OF THE STANDARDCoordination of complex care requires the systematic tracking of referrals

and treatment plan from other providers

Supporting Evidence


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PPC 7- Referral Tracking

Practical Examples:

Develop a strong workflow

Create policies for tracking outgoing referral

Use eCW to document all outgoing referrals

Continuously track referrals until consult notes are received


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Standard 8- Performance Reporting and Improvement

▪ Using the practice’s data to change health outcomes

Concepts Addressed

INTENT OF THE STANDARD Practice uses all available data to improve all aspects of care and includes patient

feedback into the process Data is shared within the practice to target improvement and with external

agencies (I.e., health plans, PQRI, DOH) Practices utilize data-driven decision making

▪ Patient surveys and score sheet

▪ Written process for survey distribution

▪ Written plan for performance assessment and improvement

Supporting Evidence


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PPC 8-Performance Reporting and Improvement

Practical Examples:

Develop a strong workflow and delegate items to non physician staff

Determine which reports will be run, by whom, and how often

Hold monthly staff meetings to discuss results, set goals, and take action

Review quality measures monthly and identify areas that need

improvement

Periodically assess the practice’s performance by distributing patient

surveys

Use data from registry and patient feedback to drive discussions

Report to CMS through PQRI Measures to satisfy external reporting

requirements


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Standard 9-Advanced Electronic Communication

▪ Using website education as a tool

▪ Must be interactive

▪ Email communication management

Concepts Addressed

INTENT OF THE STANDARD Patients can communicate with providers in a variety of ways that is convenient

and maximizes coordination of care- Website, email, patient portal- Communicate with disease/case mgmt- Patient web-based education

▪ Written processes of electronic communication

▪ Screenshots of direct communication between patients and physicians

▪ must be secure communication- not regular email

Supporting Evidence


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PPC9- Advanced Electronic Communication

Practical Examples:

Create policies for electronic communication

Implement the patient portal

Educate patients about how/when to use the portal to

communicate

Develop an interactive website


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PPC9- Advanced Electronic Communication


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GETTING STARTED AT YOUR PRACTICE – WHAT DO WE DO FIRST?

–Visit www.NCQA.org and download the standards –Read the requirements and determine where you would like to make

changes at your practice to optimize workflows and patient care

–Arrange a visit from QI / EMR / Billing teams to optimize workflows and documentation

–Organize a plan and timeline for making changes–Delegate tasks to your staff

–Involve your entire team in the process–Get feedback from staff and patients

1) Start by defining policies, procedures and job descriptions –Use PCIP templates to create these documents

2) Administer a patient satisfaction survey3) Hold your first staff meeting


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PCMH Project Plan – PDCA CYCLE

PLAN: A QI Specialist performs an onsite assessment with the physician and other key staff members at the practice. Following the visit, the practice receives a project plan and timeline along with recommendations for workflow redesign and toolkit items to help achieve goals.

• DO: QI project plan begins; practice purchases NCQA online tool, defines policies and procedures, job descriptions, distributes /scores patient surveys, improves EHR documentation, identifies 3 clinically important conditions to focus PCMH efforts, practice considers advanced communication techniques ie: portal/website options

• CHECK: QI assesses workflow changes at practice and suggests additional changes as needed, practice analyzes data (including patient survey data and chart audit results)

• ACT: QI Specialist reviews all documentation and provides feedback---Practice submits application to NCQA

| primary care information project dco-on0056-20090404-njpp1 printed 0 title primary care...

Documents

quality of care

redesign of primary

continuity of care

continuous care

patient data

care management ppc4

basic primary care concepts

core concepts of primary