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RI Care Transformation Collaborative (CTC)
Patient Centered Medical Home
NCQA PCMH 2017
Introduction and BizMed Tools
November 28, 2017
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Overview
Patient Centered Medical Home
What it is
Why you should consider it
How we can help
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The Patient Centered Medical Home
1967 - American Academy of Pediatrics (AAP)
A central location for archiving a child’s medical record 2002 - American Academy of Pediatrics (AAP)
Care that is: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective 2007 – Joint Principles (AAFP, AAP, ACP, AOA)
1. Personal physician 2. Physician directed medical practice 3. Whole person orientation 4. Care is coordinated and/or integrated 5. Quality and safety 6. Enhanced access 7. Payment that recognizes the value added
2008 – National Committee for Quality Assurance
PCMH Recognition program for primary care practices
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A National PCMH Framework
There is hardly anything that occurs (or should occur) in a high-performing
primary care practice that is not addressed by the NCQA PCMH Standards
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Benefits of the Medical Home
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NCQA PCMH Recognition
• What it is – A journey, not an event
– A guided process for change
– A learning experience
– Non prescriptive, personalized framework
– Essential for ACO shared savings
• Advantages of formal recognition – Nationally accepted “gold standard”
– Increasingly used in “preferred” or “tiered” directories
– Increasingly used for value-based incentives • Public payers
• Commercial payers
• Employers
• Enables complex care management billable services
• Helps with MACRA/MIPS scores
– Marketing advantage
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PCMH: The Foundation of Accountable Care
• Patient-Centered Medical Homes – Charged to provide individualized
team-based care while providing population health management to reduce costs, improve outcomes and patient experience
• Accountable Care Organizations – Provider-based organizations
charged to provide the governance and resources necessary to reduce costs, improve outcomes and patient experience for the patients attributed to their population
The PCMH model of care guides policies and processes, and provides the tools,
to initiate and sustain changes in practice operations to enable improved
performance on ACO measures, and accurate evaluation thereof.
PCMH recognition meets the MIPS requirements for Improvement Activities in full
Also:
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NCQA PCMH 2017 Concepts
Team-Based Care and
Practice Organization
(TC)
Organization, care teams,
training, communications…
5 Core 7 Elective Credits
Knowing and Managing
Your Patients (KM)
Population management,
community services,
outreach...
10 Core 22 Elective Credits
Patient-Centered Access
and Continuity (AC)
Appointments, same day,
after hours, phone email
advice…
7 Core 8 Elective Credits
Care Management and
Support (CM)
Risk stratification, care
planning, self-care
support…
4 Core 6 Elective Credits
Care Coordination and
Care Transitions (CC)
Orders, referrals,
transitions of care track
and follow-up…
5 Core 24 Elective Credits
Performance
Measurement and Quality
Improvement (QI)
Implement, track, report on
Quality Improvements…
9 Core 16 Elective Credits
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NCQA 2017 PCMH Standards
Structure
PCMH has 6 Concepts
Concept is made of several competencies
Competencies consist of criteria (questions)
Criteria can be Core or Elective
There are 40 Core criteria and 60 Elective criteria worth 83 credits
To achieve PCMH recognition, practices must:
1) meet all core criteria in the program and
2) earn 25 credits in elective criteria across 5 of 6 concepts.
Concepts Core Criteria Elective Credits
(Criteria)
Team-Based Care and Practice Organization (TC) 5 7
Knowing and Managing Your Patients (KM) 10 22
Patient-Centered Access and Continuity (AC) 7 8
Care Management and Support (CM) 4 6
Care Coordination and Care Transitions (CC) 5 24
Performance Measurement and Quality Improvement (QI)
9 16
Total Available: 40 83(60)
Needed for Recognition: 40 25
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NCQA 2017 Core PCMH Criteria
Team-Based Care and Practice Organization (TC)
1. PCMH transformation leadership
2. Formal organizational structure
3. Regular meetings (huddles, practice staff)
4. Training
5. Involve staff in quality improvements
6. Educate patients about PCMH
Care Management and Support (CM)
1. Risk-stratification for extra care-management
2. Monitoring of high-risk registry
3. Personalized care plans
4. Care plan provided to patient/caregiver
Knowing and Managing Your Patients (KM)
1. Clinical documentation and health assessment
2. Depression screening
3. Assessing diversity and addressing disparities
4. Outreach for recommended clinical services
5. Medications management
6. Community resources utilization
Care Coordination and Care Transitions (CC)
1. Lab and Imaging Test Management:
2. Referral Management
3. Identifying Unplanned Hospital and ED Visits
4. Sharing Clinical Information with hospitals
5. Post-Hospital/ED visit Follow-Up
Patient-Centered Access and Continuity (AC)
1. Evaluate patients needs for access
2. Same-day appointment access
3. After-hours appointment access
4. Clinical advice by phone w/ access to EHR
5. Personal clinician assignment and monitoring
Performance Measurement and Quality
Improvement (QI)
1. Measure clinical quality and resource use
2. Measure access to appointments
3. Measure patient experience
4. Set goals and take action to improve the above
5. Reporting Performance within the Practice
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Concept Example: Care management
Care Management and Support (CM) Core 4 Credits 6
Competency A: The practice systematically identifies patients who may benefit from care management.
CM 01 (Core): Considers the following when establishing a systematic process and criteria for identifying patients who may benefit from care management (practice must include at least three in its criteria): A. Behavioral health conditions. B. High cost/high utilization. C. Poorly controlled or complex conditions. D. Social determinants of health. E. Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/ family/caregiver. CM 02 (Core): Monitors the percentage of the total patient population identified through its process and criteria.
CM 03 (2 Credits): Applies a comprehensive risk- stratification process for the entire patient panel in order to identify and direct resources appropriately.
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.
CM 04 (Core): Establishes a person-centered care plan for patients identified for care management.
CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management.
CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans.
CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans.
CM 08 (1 Credit): Includes a self-management plan in individual care plans.
CM 09 (1 Credit): Care plan is integrated and accessible across settings of care.
Risk
stratification
Care Planning
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New 2017 PCMH Recognition Process
Sign Up for NCQA Q-PASS
Administrative Setup and
Upfront Payment
Transformation 12 months &
up to 3 check-in points
Final NCQA Review
Recognition Decision
Annual Reporting
New Process Highlights
• Streamlined administration
• Streamlined multi-site process
• Must pay for the review upfront
• Only 1 recognition level instead of 3
• Limited to 12 months work period (or additional fees applied)
• 3 intermediary check-in reviews (more available for additional fees)
• Added flexibility for evidence of implementation (virtual demonstration)
• Annual reporting reviews after recognition (instead of 3 years)
• PCMH 2014 Level 3 recognized practices go directly to annual reporting
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PCMH 2017 Annual Reporting
Concepts Criteria Patient-Centered Access (AR-PA) Pick 1 of 3
AR-PA1 Patient Experience Feedback – Access AR-PA2 Third Next Available Appointment AR-PA3 Monitoring Access – Other Method
Team-Based Care (AR-TC) Pick 1 of 2
AC-TC1 Pre-Visit Planning Activities AC-TC2 Employee Experience Feedback
Population Health Management (AR-PH) AR-PH1 Proactive Reminders (Attestation)
Care Management (AR-CM) AR-CM1 Identifying and Monitoring Patients for Care Management Care Coordination and Care Transitions (AR-CC) First one plus 1 of last 4
AR-CC1 Care Coordination Processes (Attestation)
AR-CC2 Patient Experience Feedback – Care Coordination AR-CC3 Lab and Imaging Test Tracking AR-CC4 Referral Tracking AR-CC5 Care Transitions
Performance Measurement and Quality Improvement (AR-QI) AR-QI1 Clinical Quality Measures AR-QI2 Resource Stewardship Measures
AR-QI3 Patient Experience Feedback Behavioral Health (AR-BH) Informational only
AR-BH1 Behavioral Health eCQMs AR-BH2 Behavioral Health Staffing AR-BH3 Behavioral Health Referral Monitoring
AR-BH4 Depression Screening AR-BH5 Anxiety Screening AR-BH6 Behavioral Health Clinical Decision Support
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The BizMed Toolbox
www.bizmedtoolbox.com
Free software for you
Try PCMH out BEFORE you commit to paying NCQA
Simple and easy to use from anywhere
Collaborate with facilitators
Lots of tools and templates ready to use
24x7 technical support
Submits your work to NCQA when ready
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Example: PCMH 2017 Dashboard
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Example: Competency & Criteria
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Get a Head Start
BizMed resources in the PCMH workflow
Policies & process descriptions – detailed, annotated, MS Word, ready to use
Toolkits to track and analyze operations
Patient surveys
Patient materials
Examples
Links to curated external resources
Whitepapers, webinars
More added every day…
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Example: Tools to Analyze Phone Calls
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Example: Tools to Analyze Schedules
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Example: Tools to Analyze Schedules (cont.)
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Example: Policies & Procedures
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Example: Forms, Checklists, etc.
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Finally, make it about Patient Care
• You can take the PCMH elements in order and pick ad-hoc measures as you go
• You can select lists and reports based on what your EHR can produce
• You can select reports and results based on your current quality initiatives
• You can select measures based on performance bonuses from insurers
-- OR --
• You can combine everything into an overall strategic plan for your practice
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Example: Clinical Quality Improvement
Select Conditions
Select Guidelines
Train Team
Members
Outreach for
Services Manage Care
Select Quality
Measures
Act and Improve
Quality
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Focused Quality Example: Diabetes Care
Select Conditions
1. Depression
2. LT/ST DM Complications Admit
3. Low SES
4. Uncontrolled DM
5. Plan referrals (care gaps)
Quality Measures
1. Pneumovax & flu shots
2. DM & Obesity screening
3. DM composite (5 services*)
4. Ophthalmology referrals
5. LT/ST complications admit
6. Stratify by SES
Guidelines
1. Depression
2. Diabetes
3. UTI
4. Obesity
5. Annual visits
6. Generics - DM & Depression
Manage Care
Outreach
1. Diabetes & Obesity screening
2. Pneumovax & flu shots
3. DM composite (5 services)
4. A1c > 8 & not recently seen
5. Insulin for low SES
Train Team Members
1. Diabetes standing orders
2. DM population management
3. DM self-care education
4. Diet & exercise education
5. DM QI activities
Act and Improve Quality
1
2
4
3
5
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* Comprehensive Diabetes Care Composite – 5 services:
(HbA1c testing, LDL C screening, BP measure, neuropathy attention: urine or ACE/ARB or referral, eye exam )
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Summary – PCMH is just a framework
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Try BizMed here:
www.bizmedtoolbox.com
For more information and assistance:
Email: [email protected]
Phone: 1-866-861-0160
Margalit Gur-Arie
314-651-9137