ncqa standards workshop physician practice connections - patient-centered medical home (ppc ®...

NCQA Standards WorkshopPhysician Practice Connections - Patient-Centered Medical

Home (PPC®-PCMH™)

2Physician Practice Connections─Patient-Centered Medical Home

Standards Workshop 2009

Agenda

• Patient-Centered Medical Home Overview

• Content of PPC-PCMH– Standards– Documentation examples*

• Recognition Process * Examples in the presentation only illustrate the

element intent. They are NOT definitive nor the only methods of documenting how the elements may be met

The Patient-Centered Medical Home DefinedACP, AAFP, AAP, AOA Joint Principles – April 2007

• Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

• Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

• Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

• Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

PPC-PCMH Content and ScoringStandard 1: Access and Communication

A. Access and communication processes**B. Access and communication results**

Standard 2: Patient Tracking and Registry Functions

A. Basic system for managing patient data B. Electronic system for clinical dataC. Use of electronic clinical dataD. Organizing clinical data**E. Identifying important conditions**F. Use of system for population management

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Standard 3: Care Management

A. Guidelines for important conditions **B. Preventive service clinician remindersC. Practice organizationD. Care management for important conditions E. Continuity of care

Standard 4: Patient Self-Management Support

A. Documenting communication needsB. Self-management support**

Standard 5: Electronic Prescribing

A. Electronic prescription writing B. Prescribing decision support - safetyC. Prescribing decision support - efficiency

Standard 6: Test Tracking

A. Test tracking and follow up** B. Electronic system for managing tests

Standard 7: Referral Tracking

A. Referral tracking**

Standard 8: Performance Reporting and Improvement

A. Measures of performance ** B. Patient experience dataC. Reporting to physicians **D. Setting goals and taking action E. Reporting standardized measures F. Electronic reporting to external entities

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Standard 9: Advanced Electronic Communications

A. Availability of interactive website B. Electronic patient identification C. Electronic care management support

**Must Pass Elements

PPC-PCMH Scoring

Level of Qualifying

PointsMust Pass Elementsat 50% Performance

Level 3 75 - 100 10 of 10

Level 2 50 – 74 10 of 10

Level 1 25 – 49 5 of 10

Not Recognized

0 – 24 < 5

Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1.

Practices with a numeric score of 0 to 24 points or less than 5 Must Pass Elements are not Recognized.

PCMH Must Pass Elements1. PPC1A: Written standards for patient access and patient

communication

2. PPC1B: Use of data to show meeting this standard

3. PPC2D: Use of paper or electronic-based charting tools to organize clinical information

4. PPC2E: Use of data to identify important diagnoses and conditions in practice

5. PPC3A: Adoption and implementation of evidence-based guidelines for three conditions

6. PPC4B: Active support of patient self-management

7. PPC6A: Tracking system for tests and to identify abnormal results

8. PPC7A: Tracking referrals with paper-based or electronic system

9. PPC8A: Measurement of clinical and/or service performance

10. PPC8C: Performance reporting by physician or across the practice

Data Sources & Health Information Technology (HIT) Guidance

• Elements may have multiple suggestions for data sources and documentation– select what your practice would use to demonstrate that function and describe how it is used

• Each element indicates the type of health information technology needed to perform the functions – Basic – (HIT) Basic

• Paper-based or basic (mostly administrative) electronic system

– Intermediate – (HIT) Intermediate• Electronic system for clinical functions

– Advanced – (HIT) Advanced• Electronic system with connectivity or interoperability with

other systems

PCMH Elements by Type of Information Technology (IT)

Basic Intermediate

Advanced

PPC 1 A - B PPC 2 B, C, F PPC 6 B

PPC 2 A, D, E PPC 5 A - C PPC 8 F

PPC 3 A - E PPC 8 E

PPC 4 A - B PPC 9 A - C

PPC 6 A

PPC 7 A

PPC 8 A - D

TOTAL = 18 TOTAL = 10 TOTAL = 2Practice can achieve a passing score on Must Pass Elements with Basic Information Technology

PPC1 - Access and Communication

Patient access to care and communication

• PPC1A: Access and communication processes

• PPC1B: Access and communication results

PPC 1 Element A: Access and communication processes

Practice has written process for*:– Scheduling patients with

same clinician– Coordinating visits with

multiple clinicians during one trip

– Determining how soon a patient needs to be seen

– Responding to urgent calls within specified time

– Providing telephone advice

– Providing language services

*Shows 6 of 12 items in Element A

Must Pass - 4 points• Scoring: based on 12

items– 9-12 items = 100%– 7-8 items = 75%– 4-6 items = 50%– 2-3 items = 25%– 0-1 item = 0%

• Documentation:– Written process– Policies and

procedures– Instructions – Appointment system

PPC1A: Scheduling Policy

PPC 1 Element B: Access and communication results

• Practice shows how it meets patient access and communication standards– Visits with assigned

physician– Appointments

scheduled to accommodate patient condition and need

– Timely response to phone, e-mail and Internet requests

– Language services if the practice’s population requires it

Must Pass - 5 points• Scoring: Based on

number of items met of 5– 5 items = 100%– 4 items = 75%– 3 items = 50%– 2 items = 25%– 0-1 item = 0%

• Data source: – Reports– Logs or screen shots

showing records of appts. scheduled and time for returning calls

Access Standards with Specific Targets and Result Measurements

Standards

Results Measurements

PPC2 - Patient Tracking and Registry Functions

Systematic use of patient information for population management to support patient care

• PPC2A: Basic System for Managing Patient Care

• PPC2B: Electronic System for Clinical Data• PPC2C: Use of Electronic Clinical Data• PPC2D: Organizing Clinical Data• PPC2E: Identifying Important Conditions• PPC2F: Use of System for Population

Management

PPC2A: Basic System for Managing Patient Data

Practice uses electronic data system for searchable patient information 1-9. Name, DOB, gender,

marital status, language preference, race/ethnicity, address, phone, email

10-11. Internal and external IDs

12. Emergency contact info.13. Current and past

diagnoses14. Dates of prior visits15. Billing code16. Legal guardian17. Health insurance coverage18. Preferred method of

communication

2 points • Scoring: Number of

items met of 18– 12-18 items = 100% – 8-11 items = 75% – 6-7 items = 50% – 4-5 items = 25%– 0-3 items = 0%

• Data source: – Reports from

electronic system showing data items entered for 75-100% of patients

Element A- Report Showing Basic Patient Information Field Use

PPC2B: Electronic System for Clinical Data

Practice uses clinical data systems to manage care of patients has searchable data fields for clinical patient information: 1. Preventive services2. Allergies/adverse

reactions3. Blood pressure4-5. Height and Weight6. BMI7-9. Lab test, imaging and

pathology results10.Advance directives11.Head circumference (for

patients ≤ 2 years

3 points• Scoring: Number of

items met of 10– 9-10 items = 100% – 7-8 items = 75% – 5-6 items = 50% – 3-4 items = 25%– 0-2 items = 0%

• Data source: – Reports or screen

shots showing data fields in patient records

Example PPC2B: Screen Shot of Data Fields for Clinical Data

PPC2C: Use of Electronic Clinical Data Practice uses the fields listed in 2B consistently in patient records 1. Preventive services2. Allergies3. Blood pressure4-5. Height and Weight6. BMI7-9. Lab test, imaging

and pathology results

10. Advance directives

3 points• Scoring: Practice enters

a percentage of patients seen in past 3 months with 7 fields completed:– 75-100% of patients =

100% – 50-74% of patients = 75%– 25 -49% of patients = 50%– 10-24% of patients = 25%– <10% of patients = 0%

• Data source: – Reports from electronic

system OR– Record Review Workbook

Element C: Report of percent of patients with clinical data items entered in system

What is the Record Review Workbook?

• Elements PPC 2C, 2D, 3D, 4B • Require medical record abstraction of data• Need % of patients based on numerator and

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 sample of patients and abstract data

needed for Elements 2C, 2D, 3D, 4B

Example PPC 2C, 2D, 3D, 4B Option NCQA Medical Record Review Worksheet

Selecting Patients for Record Review Workbook

~Use same 36 patients for EACH Workbook Element~

STEP #1. START DATE = Today’s date June 1

STEP #2. Go back 30 days = May 1

STEP #3. • Use appointment or billing system to identify patients with visit on April 30• Choose patients with any of three clinically important conditions who had a visit on this date related to the conditions

STEP #4. Continue choosing patients going back on consecutive dates until all 36 patients are selected

PPC2D: Organizing Clinical Data• Practice uses paper or

electronic charting tools used to organize and document clinical information1. Problem lists2. Medication lists (OTC)3. Medication lists (RX)4. Template for risk

factors5. Templates for

progress notes6. Screening for

developmental testing7. Growth charts & BMI

• Based on number of items documented in records of patients seen in last 3 months

Must Pass – 6 points• Scoring - % of patients with

3 tools documented: – 75-100% = 100%– 50-74% = 75%– 25-49% = 50%– 10-24% = 25%– <10% = 0%

• Data source– Record Review Workbook or– Electronic system report

with percent of patients seen in past 3 months

PPC 2D - what to look for in the medical record:

Documented Risk Factors And Medication Lists In Paper Flow Sheet

PPC2D: Pediatric Weight Chart

PPC2E: Identifying Important Conditions

• Practice identifies1. Most frequently seen

diagnoses = most often seen, single episode or chronic; identify by number of patients, visits, total fees billed

2. Most important risk factors = for the demographic population

3. Three clinically important conditions (chronic or recurring) = practice identifies

Must Pass – 4 points• Scoring

– 3 items = 100%– 2 items = 75%– 1 item = 50%– 0 items = 0%

• Data source– Reports from EHR,

practice management system, billing or scheduling system for frequent Dx

– Identify risk factors in reports

– Identify conditions and why selected in the Support Text/Notes section

PPC2E: Example Text Notes in Survey Tool

“Attached are 3 reports:

1. Frequent diagnoses: Dates of service and the diagnosis codes, sorted by codes for frequency.

2. Risk factors: Source of Community Statistics for Risk Factors - www.CDC.gov and http://apps.nccd.cdc.gov/brfss/display_PF.asp

3. Clinically important conditions: As part of a National PCMH Demonstration Project, the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia which represent the best likelihood of being amenable to care management and providing value on costs to the health care system based on regional experience.”

PPC2F: Use of System for Population Management

Practice uses electronic information to generate lists of patients and remind patients and clinicians proactively of services needed:1. Pre-visit planning2. Clinician action3. Specific medications4. Preventive care5. Specific tests6. Follow-up visits7. Care management

services

3 points• Scoring: Practice takes

action on – 5-7 items = 100% – 3-4 items = 75%– 1-2 items = 50%– 0 items = 0%– Practice gets partial credit If

system can generate lists but practice does not use it

• Two Data sources: 1. Lists generated -- reports

from EHR, registry and 2. Example of use of the

lists -- screen shots, written description of process

Population Management ExamplesEHR Query-Patients Needing

Pneunomax vaccine Report – Patients on a Specific Medication

PPC3: Care Management

Practice maintains continuous relationship with patients by using evidence-based guidelines and applying them to needs of individual patients over time.

• PPC3A: Guidelines for Important Conditions • PPC3B: Preventive Service Clinician Reminders• PPC3C: Practice Organization• PPC3D: Care Management for Important

Conditions • PPC3E: Continuity of Care

PPC3A: Guidelines for Important Conditions

• Practice adopts and implements evidence-based diagnosis and treatment guidelines for three clinically important conditions

• Use same conditions in PPC2D, 2E, 3A, 3D, 4B, 9C

– 3 conditions = 100%– 2 conditions = 50%– 1 condition = 25%– 0 conditions = 0%

• Data source: workflow organizers that show guidelines adopted and implemented– Provide source of guidelines– Paper flow sheets,

templates for documenting progress

– Screen shots showing templates for treatment plans and documenting progress

Example PPC3A – Adoption of Evidence –Based Diagnosis and Treatment

Guidelines

Example – Evidence-Based Diabetic Workflow

Organizer (shows what to document at each visit)

Example PPC3A - EHR Prompting Lipid Management Evidence-Based Guidelines

PPC3B: Preventive Service Clinician Reminders

• Practice generates reminders about preventive services for clinicians

• Practice uses paper or electronic guideline-based alerts and reminders to write orders and conduct assessments 1. Screening tests2. Immunizations3. Risk assessments4. Counseling

4 points• Scoring

– Reminders for 4 items = 100%

– Reminders for 1item = 25%– Reminders for no items =

0%• Data source: reports,

screen shots, templates or paper flow sheets showing decision- support for clinicians during visits, calls and email.

Example PPC3B - Preventive Service

Reminders for Clinicians Paper Reminder for Risk

Assessments, Immunizations, Screening Tests

EHR with Risk Assessment Reminders

PPC3C: Practice Organization• Care team manages

patient care:1. Non-physician staff remind

patients of appointments and collect information before appointments

2. Non-physician staff execute standing orders (e.g. med. refills, order tests)

3. Non-physician staff educate patients to manage conditions

4. Non-physician staff coordinate care with external disease management or case management organizations

3 points• Scoring

– 4 items = 100%– 3 items = 75% – 2 items = 50% – 0-1 item = 0%

• Data source– Job descriptions– Protocols– Written standing

orders

Example PPC3C: Practice Organization Standing Orders

Note: If patient needs OV or labs, refill up to one month (one time only). If more requested, check with physician

PPC3D: Care Management for Important Conditions

To manage care of patients with three clinically important conditions, practice uses:

1. Pre-visit planning

2. Individualized written care plans

3. Individualized treatment goals

4. Assess progress toward goal

5. Review of medications with patients

6. Review self-monitoring results and include in medical record

7. Assess barriers when patient not met treatment goals

8. Assess barriers when patient not filled prescriptions or took meds.

9. Follow-up when patient not kept important appointments

10. Review patient clinical data over time

11. After-visit follow-up

5 points• Scoring – patients seen

in past 3 months have 4 items documented:– ≥75% of patients =

100%– 50-74% of patients =

75%– 25-49% of patients =

50%– 11-24% of patients =

25%– ≤10% of patients = 0%

• Data source – Report from electronic

system showing percent of patients seen with documentation of items OR

– Record Review Workbook

PPC3D: Written Care Plan in Medical Record

Patient Progress, Treatment Goals and Medication Review

Patient Progress and Treatment Goals

Treatment plan and goals

Patient progress

PPC 3D - what to look for in the medical record: Documented Patient Progress and Treatment Goals

Medication Review

Assessment & Plan

PPC3E: Continuity of CarePractice provides continuity of care for patients who receive care in inpatient or outpatient facilities1. Identifies patients 2. Sends information to facilities and

patients3. Reviews information from facilities

to identify patients needing proactive contact or are at risk for adverse outcomes

4. Contacts patients post-discharge5. Provides or coordinates follow-up

care to discharged patients6. Coordinates care with external

disease or care management organizations

7. Communicates with patients getting disease or high risk case management

8. Communicates with case managers for patients getting disease or high risk case management

9. Develops written transition plan with patient for transition to other care

10.Coordinates with new physicians

5 points• Scoring

– 5-10 items = 100%– 3-4 items = 75%– 2 items = 50%– 0-1 item = 0%

• Data source: from practice or external organization– Protocols re: timeline

for patient follow-up– Protocols for care plans– Log of patients

receiving care from other facilities

– Registry, EHR, hospital or ER reports

– Health needs assessments

– Blinded case management or medical record notes

Example – ER Visit Follow-Up Log

Example – Follow-Up Care after Hospital Admission

PPC4 - Patient Self-Management Support

Improve patient ability for self-management by:

• PPC 4A - Documenting communication needs

• PPC 4B - Providing self-management support

PPC4A: Documenting Communication Needs

Practice assesses patient-specific barriers to communication using systematic process to:1. Identify and display

in record patient language preference

2. Assess both hearing and vision barriers

2 Points

• Scoring:– 2 items = 100%

– 1 item = 50%

– 0 items = 0%

• Data source - How practice– Records language

preference: screen shots, patient assessment forms

– Determines % of patients preferring another language: reports from EHR, patient record review

PPC4A: Example Documenting Communication Needs

PPC4B: Self-Management Support • Practice documents

patient self-management support for 3 clinically important conditions1. Assess patient

preferences, readiness and ability for self-management

2. Provides educational resources in patient language

3. Provides self-monitoring tools for patients

4-6. Provides or connects patient with support programs, classes, resources

7. Provides patient with written care plan

Must Pass – 4 points• Scoring – % of patients

seen in past 3 months have 3 items documented:– 75-100% patients = 100%– 50-74% = 75%– 25-49% = 50%– 11-24% = 25%– ≤10% = 0%

• Data source – Record Review Workbook

or– Report from electronic

system

PPC 4B - what to look for in the medical record: Documented Use of Self-Monitoring Tools &

Program Referrals

PPC5: Electronic PrescribingPractices uses electronic systems to order

prescriptions, to check for safety and to promote efficiency when prescribing.

• PPC5A: Electronic Prescription Writing • PPC5B: Prescribing Decision Support –

Safety• PPC5C: Prescribing Decision Support –

Efficiency

PPC5A: Electronic Prescription Writing

Practice uses an electronic system to write prescriptions1. Stand-alone system

(i.e., hand-held e-prescribing device, PDA)

2. System that links data to specific patients (i.e., EHR)

3 points• Scoring

– 75-100% of prescriptions for patients seen in past 3 months written with item 2 = 100%

– 75-100% of prescriptions for patients seen in past 3 months written with item 1 = 75%

– System capable of either item 1 or 2 but practice does not use or cannot report %= 25%

– No system capability or <75% of item 1 or 2 = 0%

• Data source: – Reports showing practice

used system for writing prescriptions for 75-100% of patients within past 3 months

PPC5A: Example Prescribing Method

EXPLANATION

January to March 2009 prescribing method is documented in the table. Certain prescriptions (Schedule II) must be printed on special paper prescription pads in our state. 96% of prescriptions were generated from our electronic medical record.

Example PPC 5A - % of Use for Electronic Prescriptions

Evaluation:Our Physicians and nurses put all prescriptions in our EMR which is

linked to patient -specific demographic and clinical data. Note the screen shot that denotes the number of scripts for our

physicians in the last three months, 2046 and the report which notes the number of patients seen during that same time period, 2482.

We propose that this represents a percentage between 75% and 100%, understanding that one prescription does not mean one patient.

2046 prescriptions provides the numerator to determine the percentage. The practice provided another report showing the summary of the 2482 patients seen during the same period to provide the denominator

PPC5B: Prescribing Decision Support – Safety

Electronic prescription reference information at the point of care including alerts and information: 1-2. drug-drug interactions -

general and patient-specific 3-4. drug-disease interactions –

general and patient-specific5-6. Drug-allergy alerts -

general and patient-specific7. Drug-patient history alerts8-9. Appropriate dosing –

general and patient specific10. Drug-lab alerts – general 11-12. Duplication of drugs –

general and patient-specific13-14. Drugs to be avoided in

elderly15. Patient-appropriate

medication information

3 points• Scoring

– Practice uses ≥8 alerts and information = 100%

– Practice uses 4-7 alerts and information = 75%

– Practice uses 2-3 alerts = 50%

– System has >6 alerts but not used = 25%

– No system capability or <6 alerts or practice uses <2 alerts

• Data source: – Reports from system,

showing example of each item

Example PPC5B - EHR Prescription Allergy Pop Up Box (safety check)

PPC5C: Prescribing Decision Support – Efficiency

Cost-efficient electronic prescription writer with: 1. Automatic alerts

for drug choices, including generics

2. Payer-specific formulary that alerts clinician to alternative drugs, including generics

2 points• Scoring

– Practice uses 2 tools = 100%

– Practice uses 1 tool = 75%

– System has both tools but practice doesn’t use it = 25%

– System lacks capability or practice does not use either tool = 0%

• Data source– Reports – Screen shots– Practice protocols

PPC5C: Prescribing Decision Support – Efficiency

PPC6 - Test Tracking

Practice systematically tracks tests ordered and test results, and systematically follows up with patients.

• PPC 6A - Test tracking and follow-up• Basic – if paper system• Intermediate – if electronic communication

within the practice office• Advanced – if electronic communication

between practice and lab and imaging facilities

• PPC 6B - Electronic system for managing tests

PPC6A: Test Tracking and Follow-up

Practice uses paper or electronic system to track tests and follow up 1. Tracks lab tests until

results return to practice and flag overdue results

2. Tracks imaging tests until results return to practice and flag overdue results

3. Flag abnormal test results

4. Notify patients of abnormal results

5. Follows up with inpatient facility on hearing and metabolic screening

6. Notifies patients of normal results

– 4-6 items = 100%– 3 items = 50%– System can do 4 types of

tracking but isn’t in use = 25%

– System can’t track or practice uses <3 types of tracking and follow-up = 0%

• Data source: – Evidence that practice

reviews and uses tracking log before or at beginning of patient visits

– Reports or tracking logs or e-mail inbox flagging results

• Filing results in the medical record until patient comes in does not meet tracking and follow-up standard

Example PPC6A - Lab Tracking Manual Log Spreadsheet

PPC6A: Example Notifies Patient of Abnormal Results

PPC6B: Electronic System for Managing Tests

• Electronic system to1-2. Order lab and imaging

tests 3. Retrieve results from

source 4-5.Retrieve imaging text

and images from source 6. Route and manage

current and historical test results to appropriate personnel for review

7. Flag duplicate tests8. Generate alerts for

appropriateness• Assumes electronic

communication between practice and lab and imaging facilities

6 points• Scoring

– 5-8 functions = 100%– 3-4 functions = 75%– 1- 2 functions = 50%– Doesn’t use system = 0%

• Data source– Reports or screen shots

showing examples of required functions

– Filing results in the medical record until patient comes in does not suffice for tracking and follow-up

Example PPC6B - EHR Order ScreensLaboratory Test Order Screen Radiology Test Order Screen

PPC7 - Referral Tracking

PPC 7A - Document and track referrals

and referral results

Example PPC7A - Manual Consultant Tracking Logs

PPC7A: Example Referral Results

REFERRAL RESULTS Caregiver Patient Dates Status (Reviewed) Type (Referrals) Patient/Procedure Date Ordered

PPC8: Performance Reporting and Improvement

Practice regularly measures its performance and takes actions to continuously improve

• PPC8A: Measures of Performance• PPC8B: Patient Experience Data• PPC8C: Reporting to Physicians • PPC8D: Setting Goals and Taking Action• PPC8E: Reporting Standardized Measures • PPC8F: Electronic Reporting ─ External

Entities

PPC8A: Measures of Performance• Practice measures

or receives clinical and/or service performance data 1. Clinical process2. Clinical outcomes3. Service data4. Patient safety issues

• Reports may be generated by the practice, an affiliated medical group or health plan

• Credit given for NCQA Recognition for items 1 and 2

Must Pass – 3 points

• Scoring – performance measurement:– 2 types = 100%– 1 type = 50%– No measures = 0%

• Data source - Reports from – Manual review of sample

of patient records– Patient surveys– Practice management

system– Registry– Data from health plan or

larger medical group– Electronic database

NCQA Clinical Program RecognitionWhere Can it Be Used to Meet Element?

• NCQA Clinical Recognition Programs– Diabetes Recognition Program (DRP)– Heart/Stroke Recognition Program (HSRP)– Back Pain Recognition Program (BPRP)

• Credit for Clinical Program Recognition may be used for meeting requirements in 7 elements if majority of physicians are Recognized: – PPC 3A, 3D (for selected conditions used for

survey)– PPC 8A, 8C, 8D, 8E, 8F

Example PPC8A – Plan and Network Level Reports

CAHP’s Patient Satisfaction Report Clinical Performance Report

PPC8B: Patient Experience Data

Practice collects data on patient experience with are: 1. Patient access to care 2. Quality of physician

communication3. Patient confidence in

self-care 4. Patient satisfaction

with care

3 points• Scoring – practice

collects data on – 3-4 areas = 100%– 1-2 areas = 50%– 0 areas = 0%

• Data source: – Reports of paper,

telephone, or electronic survey

– Practice must provide summarized data, not a blank survey

PPC8B: Patient Experience Data

PPC8C: Reporting to Physicians

Practice reports performance on measures in PPC8A 1. Across the practice

2. By individual physician

Must Pass – 3 points

• Scoring - practice reports:– Across practice and by

physician = 100%

– Either across practice or by physician = 50%

– No reporting = 0%

• Data source: – Blinded reports with

performance data

– Blinded letters to physicians with performance data

Example of B – Reporting Across the Practice and Across Multiple Practice Sites

PPC8D: Setting Goals and Taking Action

Practice uses performance data to1. Set goals based

on performance data in PPC8A and 8B

2. Takes action to improve performance of individual physicians or practice

3 points• Scoring

– 2 items = 100%– 1 items = 50%– 0 items = 0%

• Data source: – Practice-specific

reports or

– Completion of NCQA’s Quality Improvement Workbook

Example PPC8D – NCQA’s QI Worksheet Documenting Setting Goals And Taking Action

PPC8E: Reporting Standardized Measures

Practice produces reports on performance using nationally approved clinical performance measures– National Quality Forum

endorsed physician level measures

2 points• Scoring based on

number of measures the practice reports– ≥10 items = 100%– 5-9 items = 75%– 3-4 items = 50%– 0-2 items = 0%

• Data source: – Reports showing

performance measures calculated by practice

Example PPC8E - National Quality Forum Endorsed Physician Level Measures

PP8F: Electronic ReportingExternal Entities

• Practice electronically reports results on nationally approved measures to external entities

• Practice gets partial credit if its system has the capability to report data but does not use it

1 point• Scoring based on

number of measures practice reports– ≥10 measure = 100%– 5-9 measures = 75%– 3-4 measures = 50%– 1-2 measures = 25%– 0 measures = 0%

• Data source: – Report to public sector,

health plans or others

PP8F: Example Electronic ReportingExternal Entities

PPC9: Advanced Electronic Communication

Practice uses electronic communication to improve timeliness, effectiveness, efficiency and coordination of care.

• PPC9A: Availability of Interactive Web Site

• PPC9B: Electronic Patient Identification

• PPC9C: Electronic Care Management Support

PPC9A: Availability of Interactive Web Site

Patient has access to Interactive Web site to: 1. Request

appointments2. Request referrals 3. Request test results4. Prescription refills5. See medical record6. Import medical data

to personal records

1 point• Scoring – practice

provides– 5-6 items = 100%– 3-4 items = 75%– 1-2 items = 50%– 0 items = 0%

• Data Source: screen shots showing Web functionality

PPC9A: Example Interactive Website Factor 2, Requesting Appointment

PPC9B: Electronic Patient Identification

Electronic information and clinical decision-support to contact patients by email needing:1. Clinical review or action2. On a particular

medication3. Preventive care4. Special tests5. Follow-up visits6. Disease/case

management support

2 points• Scoring

– 5-6 items = 100%– 3-4 items = 75%– 1-2 items = 50%– 0-1 items = 0%

• Data source– Screen shots showing

identification of patients and example of e-mail

PPC9B: Example Electronically Contacting Patient to Review Test

Results

PPC9C: Electronic Care Management Support

Electronic care management support for three clinically important conditions to1. Communicate with

disease/care managers about patient needs

2. Provide Web-based educational modules for patient self-management

1 point• Scoring

– 4 items = 100%– 3 items = 50%– 2 items = 25%– 0-1 items = 0%

• Data source– Screen shots showing

electronic communication about care management

– Screen shots or links to educational modules

PPC 9C: Example Electronic Care Management Support

Example PPC 9C: Diabetes Education Web-sites for Patient Self-Management

What is the PPC-PCMH application and survey process?

Recognition Process• Practices may use the Survey Tool to self-

assess before submitting to NCQA

• Recognition is based on:– Responses in Web-based Survey Tool– Supporting documentation attached to Survey Tool

• Element specifies type of documentation – Reports

• Reports from EHR, registry, practice management & billing systems

– Documentation of processes • Policies and procedures, protocols

– Records or files • NCQA’s Medical Record Review Workbook• Screen shots from EHR

Who is Recognized?

• NCQA Recognizes practices that meet the criteria described by the endorsed principles of the Patient-Centered Medical Home

• NCQA defines a practice as a physician or physicians practicing together at a single geographic location

• Recognition is at the practice-site level

NCQA’s Interactive Survey System

• ISS is a Web-based application program

• The practice uses ISS (Survey Tool) for:– Entering responses to each

factor for each element – Attaching documents and

providing text to support the responses

Steps for the Physician/Practice1. Review program information

2. Participate in a standards workshop (See www.ncqa.org/rptraining.aspx)

3. Obtain a Survey Tool

4. Participate in a WebEx ISS demonstration of the Survey Tool

5. Use Survey Tool to self-assess current performance

6. Submit completed application, agreements, fee, and results to NCQA when ready

7. Receive final Recognition decision and Level in 30 – 60 days

PPC-PCMH Survey Process1. NCQA receives Survey Tool

2. NCQA evaluates Survey Tool• Responses, documentation, and explanations• Practice may be contacted for clarifications

3. On-site audit - 5% of practices

4. Final decision and status determined

5. Report results with Level 1, 2, or 3 • Recognition posted on NCQA Web site• Not passed - not reported

6. PPC-PCMH certificate and recognition packet

7. Practice achieving Level 1 or 2 can do add-on survey within the 3 year recognition time period

Results: Impact of Program

• Better chronic-care management programs

• Greater attention to patient compliance• Improved patient outreach

– Patient reminders, increased screenings – Educational materials

• Increased data collection and reporting• Significant adoption and use of patient

registriesMeasurement + Rewards = Improvement!

NCQA Contact Information

Contact NCQA Customer Support to:• Acquire standards documents, application materials,

and survey tools• Questions about your user ID, password, access• 1-888-275-7585

Visit NCQA Web Site to:• View Frequently Asked Questions• View Recognition Programs Training Schedule

Submit to questions to ppc-pcmh@ncqa.org Please use this e-mail box to:• Ask about interpretation of standards or elements• Submit application materials (physician workbook and

application)• Request registration for ISS Survey Tool demonstration (Web-ex)

PPC-PCMH Program Sponsors

ncqa standards workshop physician practice connections - patient-centered medical home (ppc ®...

care management

subspecialty care

comprehensive care

indicated care

patient tracking

continuity of care pts

patient data b

ongoing care of patients

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