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Commit. TRANSFORM. Succeed.

Team Based Care

Knowing and Managing your

Patients

Patient Centered Access and Continuity

Care Management and Support

Performance Management and

Quality Improvement

Care Coordination

and Transitions

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Concept: Team Based CareThe practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

• 3 Competencies• 9 Criteria

• 5 core criteria• 4 elective criteria (5 credits)

• 4 New to 2017

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• Competency A: The practice is committed to transforming the practice into a sustainable medical home. Members of the care team serve specific roles as defined by the practice’s organizational structure and are equipped with the knowledge and training necessary to perform those functions.

Team Based and Practice Organization (TC)

Criteria Core Elective # Credits

TC 01: Designates a clinician lead of the medical home and a staff person to manage the PCMH Transformation and Medical Home Activities

X

TC02: Defines practice organization structure and staff responsibilities/skills to support key PCMH functions

X

TC03: The practice is involved in external PCMH-oriented collaborative activities (e.g., federal/state initiatives, HIE)

X 1

TC04: Patients/families/caregivers are involved in the practice’s governance structure or on stakeholder committees

X 2

TC05: The practice uses an HER system (or modules) that has been certified and issued an ONC Certification ID, conducts a security risk analysis, and implements security updes as necessary correcting identified security deficiencies.

X 2

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TC 01 (Core)

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• Things to consider:• Clinician Lead:

• CMO is not always the best choice• Don’t chose based on availability• Integrated with QI

• PCMH Manager• Can be embedded within a current Job Description• Must provide details on role of manager• Detail communication methods• Detail role on QI• Detail role in communicating with NCQA

TC01:

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TC 02 (Core)

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TC02:

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TC 03 (1 Credit)

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TC03:

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TC 04 (2 Credits)

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TC04:

CHC’s—this is a “give me!”

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TC04:

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TC 05 (2 Credits)

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TC05:

• https://chpl.healthit.gov/#/search

• Everyone: THIS IS A “give me”!

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• Competency B: Communication among staff is organized to ensure that patient care is coordinated, safe and effective.

Team Based and Practice Organization (TC)

Criteria Core Elective # Credits

TC 06: Has regular patient care team meetings or a structured communication process focused on individual patient care

X

TC07: Involves care team staff in the practice’s performance evaluation and quality improvement activities

X

TC08: Has at least one care manager qualified to identify and coordinate behavioral health needs

X 2

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TC 06 (Core)

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TC06: (2014 Equivalent = 2D3)

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TC 07 (Core)

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TC07: (2014 Equivalent = 2D9)

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TC 08 (2 Credits)

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TC08:

• Must have Job description of BH Care Manager – must include expected training of individual• Resume for BH Care Manager (?)

• Organizational chart

• TIP: If you received AIM funding—you will likely have one!

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The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

• Competency C: The practice communicates and engages patients on expectations and their role in the medical home model of care.

Team Based and Practice Organization (TC)

Criteria Core Elective # Credits

TC 09: Has a process for informing patients/families/caregivers about the role of the medical home and provides patients/families/caregivers materials that contain the information

X

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TC 09 (Core)

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TC09: (2014 equivalent = 2B1-8)

• Evidence:• New patient packet• Annual distribution• Must include information on:

• After hours access• Practice scope of services• Evidence based care• Availability of education• Self management support• Practice contacts

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TC: The Transformative Application

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BREAK