1. PCMH for Your Practice? Here’s a Place to Start
R.W. “Chip” Watkins, MD, MPH, FAAFP
SCORH Conference
Columbia, SC
15 October 2013

2. Who am I? R.W. “Chip” Watkins, MD, MPH, FAAFP
Senior Physician Consultant on CCNC’s PCMH Efforts
NCQA Physician Review Oversight Committee (ROC)
NCQA Reviewer
NCQA’s Advisory Panel for CEC Exam
Medical Director – High Country Community Health
Past-President and Board Chair – NC Academy of Family Physicians
Can delete this and the next slide if there is going to be an introduction…

3. What is a Patient-Centered Medical Home (PCMH)?

4. Patient-Centered Medical Home
The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery
The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery.
There is no single definition that has been universally accepted, but in general, the PCMH model:
1. Emphasizes the relationship between patients and their primary care physicians
2. Employs a team-based approach
3. Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology

7. The Challenge
Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous
Sir Cyril Chandler
Chairman of the Board
Great Ormond Street Hospital
For Children NHS Trust
Liverpool, England

8. What we have…
What we need!!
Atul Gawande, MD

9. Patient-Centered Medical Home
Emphasizes the relationship between patients and their primary care physicians
Employs a team-based approach to care
Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology to improve population management and preventive care
PCMH is a great model if you are a member of CCNC, simply because the PCMH model includes most, if not all, of the tools, resources, and services that are built into the CCNC model.

10. Medical Home “Joint Principles”
Personal Physician
Physician-Directed Practice
Whole-Person Orientation
Care Coordination/Integration
Quality & Safety
Enhanced Access
Payment
Each patient has an ongoing relationship with a personal physician, who provides comprehensive, continuous primary care.
The physician is responsible for directing a team that takes collective responsibility for patient care.
The physician is responsible for providing comprehensive care at all stages of life and for coordinating care as necessary with appropriate specialists.
Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) in Febraury, 2007

11. Features of PCMH Four common features in demonstrations
Dedicated care managers
Expanded access to clinicians
Data-driven analytic tools
Use of incentives

12. Benefits of the PCMH Model
Quality – Outcomes for seven medical home demonstrations
Fewer ER visits (15%-50%)
Fewer hospital admissions (6-24%)
Lower mortality rates
Better preventive service delivery
Better chronic disease care
Higher patient satisfaction
Groups that have undertaken this redesign process have demonstrated:
ER visits:
Group Health Cooperative – 29% reduction in 2 years
Health Partners – 39% reduction in 5 years
Genesee – 50% reduction in 4 years
Johns Hopkins – 15% reduction in 8 months
SC BCBS – 32.2% reduction
Hospitalization rates:
Group Health – 6% reduction in admissions in 2 years
Health Partners – 24% in admissions in 5 years
Geisinger – 14% reduction in admissions in 2 years
Genesee – 15% reduction in admissions in 4 years
Intermountain – 10% reduction in admissions in 2 years
Johns Hopkins – 24% reduction in inpatient days in 8 months
SC BCBS – 10.7% reduction in admissions, 36.3% reduction in inpatient days
Mortality rates:
Intermountain – 3.5% reduction in 2-year mortality
Preventive Service Delivery:
Geisinger – 74% increase in preventive care in 2 years
Genesee – 137% increase in mammography in 4 years
Colorado Medicaid/SCHIP – 267% increase in well-child visits
Chronic Disease Care:
Health Partners – 129% increase in optimal diabetes care, 48% increase in optimal heart disease care in 5 years
Geisinger – 22% increase in CAD care, 34.5% improvement in diabetes care
Source: Fields, et al. (2010) and Reid RJ, Coleman K, et al. (2010).

13. Benefits of the PCMH Model
Efficiency – Cost
Lower total costs of care - (6.5-22%)
Shorter patient wait times
Less staff burnout/turnover (10% Vs. 30%)
Higher staff satisfaction/productivity
These same groups have demonstrated reductions in total costs of care, patient wait times, and staff burnout.
Total Costs of Care:
Group Health – savings of $10.30 PMPM at month 21
Health Partners – 8% reduction in total costs at 5 years
Geisinger – 9% reduction in total costs at 2 years
Intermountain – savings of $53.33 PMPM at 2 years
Colorado Medicaid/SCHIP – 21.5% reduction in total costs
SC BCBS – 6.5% lower total medical/pharmacy costs
10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline
Source: Fields, et al

14. This is a No-Brainer! Right?
So Why Aren’t Practices RUNNING to implement PCMH for themselves?!?
Time
Resources
Consultants are expensive
Fear
Gov’t interference
Loss of control/independence
Change

15. PCMH 2011 Overview (6 standards/27 elements)
Enhance Access and Continuity
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Manage Medications
Electronic Prescribing
Provide Self-Care and Community Resources
A. Self-Care Process
B. Referrals to Community Resources
Track/Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate with Facilities/Care Transitions
Measure and Improve Performance
Measures of Performance
Patient/Family Feedback
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Report Performance
Report Data Externally
Optional Patient Experiences Survey

16. Scoring Total 100 Points
Recognition requires achieving all 6 must pass elements with a ≥50% score
Level
Points
Required Must Pass 1
≥ 35
6 Must Pass 2
≥ 60 3
≥ 85

17. Alignment with Measures of Meaningful Use
E-prescribing – medication list, allergies
Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance
Care management – reminders for follow-up care, decision support, Rx reconciliation
Electronic capability – e-health information to patient, visit summary, e-access to health information, provider information exchange
Performance reporting/improvement

18. How Much Do You Know About CCNC?

19. CCNC - “How it works”
Primary care medical home available to 1.6 million Medicaid patients in all 100 counties
Provides 5,000 local primary care physicians (94% of all NC PCPs) with resources to better manage Medicaid population
Not-for-profit networks link local community providers (health systems, hospitals, health departments and other community providers) to primary care physicians
Resources include 600 local care managers, 26 pharmacists, 14 psychiatrists and 20 medical directors to improve local health care delivery

20. CCNC - “How it works”
The state identifies priorities and provides financial support through an enhanced PMPM payment to community networks
Networks pilot potential solutions and monitor implementation (physician led)
Networks voluntarily share best practice solutions and best practices are spread to other networks – for ALL payors
The state provides the networks (CCNC) access to data
Cost savings/ effectiveness are evaluated by the state and third-party consultants (Treo Solutions, Milliman)
CC pays the providers a PMPM for managing patient care, but THIS PMPM goes to the networks to support things like network infrastructure, hiring and managing their case managers, IT support, support physician leadership in terms of the medical director and psychiatrist, QI coordination staff, and support staff, and so on.
Watkins

21. System-Wide Results
Community Care is in the top 10 percent in US in HEDIS for diabetes, asthma, heart disease compared to commercial managed care.
Which resulted in over 1.5 Billion dollars in savings to the state in the period of
Watkins

22. Community Care’s Informatics Center
Informatics Center ─ Medicaid claims data
Utilization (ED, Hospitalizations)
Providers (Primary Care, Mental Health, Specialists)
Diagnoses – Medications – Labs
Costs
Individual and Population Level Care Alerts
Real-time data
Hospitalizations, ED visits, provider referrals
Multipayer Datafeeds
Medicare, Medicaid, BCBSNC, and SEHP
A huge part of our success is also attributable to getting physicians and networks access to actionable data.
This includes the Provider Portal, through which treating physicians can access comprehensive patient information, including what other providers are doing for the patient.
The Pharmacy Home is a project we’re working on to merge data from private sector organizations like Surescripts, Lab Corp and make it available to participating providers.
Treo Solutions is helping us determine where we get the biggest “bang for the buck.” they’re helping us identify the most impactable patient, so we put our resources where they do the most good.
CMIS is an electronic record of care management activities used by CCNC care managers since 2001, with over 1,500 active users statewide.  CMIS contains demographic data and claims data on over 2.8 million Medicaid recipients, including the 1 million currently enrolled with a practice in a CCNC network. 
Intelligent data use is also critical to separating statistical “noise” and outliers from fraudulent activities as part of our clinical integrity efforts.
Watkins

23. What is the Multi-Payer Advanced Primary Care Practice Demonstration Project (MAPCP)?

24. What is the Multi-Payer Demo?
The purpose of the Multi-Payer Advanced Primary Care Practice “demonstration project” (MAPCP) is to evaluate the effectiveness of the PCMH model, when supported by both public and private payers
NC is one of 8 states that was awarded an MAPCP demo

25. What is the Multi-Payer Demo?
7 rural counties across NC were chosen to participate in the demo: Ashe, Avery, Bladen, Columbus, Granville, Transylvania, and Watauga

26. What is the Multi-Payer Demo?
To participate, practices in these counties must obtain PCMH recognition from the National Committee for Quality Assurance (NCQA) during their first year of the demo
In return for implementing the PCMH model, practices will earn incentive payments from the largest public and private payers in NC: CMS and BCBS-NC/SHP.

27. Recognition of Added Value
Incentive Payments from Medicare
CMS will pay a per member per month fee for each Medicare patient in practices achieving PCMH recognition through NCQA:
Level 1 = $2.50 PMPM ($30 each year)
Level 2 = $3.00 PMPM ($36 each year)
Level 3 = $3.50 PMPM ($42 each year)
We are beginning to see initiatives from CMS in many other areas as well –CPCI – Comprehensive Primary Care Initative – PMPM

28. Recognition of Added Value
Increased Reimbursement from BCBS
Eligibility for the Blue Quality Physicians Program (BQPP), a recognition program for primary care practices that builds on PCMH recognition from NCQA
Once you qualify for the BQPP, BCBS will increase its fee structure by 10% or more for all of your BCBS/SEHP patients

29. Let’s Talk About Resources for Your NCQA Submission

30. Resources Available NCQA PCMH Standards and Guidelines – “The Rules”
Standards, Elements, Factors
Policies and Procedures
Software Products
Online Application Account
Business and demographic information
Free
Interactive Survey System (ISS)
Responses to the Standards and Guidelines
ISS Survey Tool
$80
Recognition Programs Section of NCQA’s Website
These are free of charge from NCQA

31. Go to NCQA Home
Then Programs
Then Recognition
Then PCMH 2011
Then Before, During,
and After I’m Recognized
for lists of online
resources

32. Comprehensive PCMH Document Library 2011
Resources Available
CCNC
Web-based 2011 PCMH Workbook
Webinars for 2011 PCMH Submissions
Introducing….
Comprehensive
PCMH
Document
Library 2011
These are free of charge from NCQA

33. Resources Available Use the CCNC PCMH workbook, webinars

34. How Do You Get All This Done?

35. Watkins. Journal of
Medical Practice
Management,
Sept/Oct 2012,
Vol 28:2, pp

37. ASU Practicum in Primary Care
ASU College of Health Science,
School of Healthcare Management

38. Creation of Partnership with Appalachian State University
Recruit ASU students from School of Health Care Management
Develop curriculum, syllabus, website, core documents
Create new practicum course with internship opportunity
Teach students about PCMH, Provider Portal, Care management process
Send students out to practices to assist in attaining PCMH certification, BQPP cert and QI initiatives

39. ASU Practicum in Primary Care
Fall of 2011 – 5 students
Spring 2012 – 9 students – BSBSNC Foundation Grant Obtained
Summer 2012 internship – 8 students
Fall 2012 – 14 students
Spring 2013 – 15 students
Fall 2013 – 16 students

40. ASU Practicum in Primary Care
Developed curriculum, core documents, website

41. ASU Practicum in Primary Care
Worked through curriculum and have weekly didactic meetings on ASU campus
BAA for HIPPA compliance
Students prepare PCMH PPT for “their” practice and give to group
Go through the Standards and hit high points
Students share successes/failures with facilitators/faculty
Placed students in field and worked with the practices
Students give PPT
Work with practices – develop “PCMH Team”, schedule time with team, give weekly assignments, follow-up, etc.
Also include care management process, managing change, PDSA cycles, and provider portal training

42. Program Growth
ASU School of Health Care Management has made the “Practicum in Primary Care” a CORE curriculum class
Students willing to spend 2 semesters with us get full credit for their internship (300 hours)
“Keeping the Medical Home Fires Burning” is a new initiative where practices that have been recognized work with students on QI projects

43. Program Growth Remote Learning Initiative
Students work with practices within 3 hours of Boone
MOVI (secure) web-hosting
Face-to-face visits every 3 weeks or so

44. CCNC’s PCMH Efforts Beginning of MP Project
After a sustained effort to promote PCMH by medical practices, CCNC networks and CCNC’s PCMH Team. Network staff spent time in medical practices all over the state.  Web-based materials made available on the CCNC web site were snapped up quickly: approximately 1,700 copies of the 2011 and 2008 Workbooks have been downloaded since last Fall, and about 1,300 individuals downloaded videos or PowerPoint presentations from the PCMH webinar series.
Today, 6 months after the start of the Multi-payer Advanced Primary Care Practices (MAPCP) demo, there are 366 PCMH-recognized practices — nearly ten times as many as in 2010.
North Carolina currently has more PCMH-recognized practices than any other state except for New York and Pennsylvania. When adjusting for PCMH practices per capita, North Carolina is second in the nation, behind only New York.

45. Getting into the Weeds

46. Types of Documents

47. Time Periods

48. Organize the Documents
1. Create a folder on your network drive for documents the practice MAY want to attach
2. Develop a checklist of documents already used in the practice and documents that need to be prepared
3. Refer to published standards and use to identify what the practice has and what needs to be created
4. Save a copy of the Record Review Workbook and/or Quality Measurement and Improvement Worksheet to your document folder
5. Consider putting multiple examples in one document for a single element, e.g. screenshots
6. Identify documents that may be applicable for more than one element
NOTE: NCQA advises a target of three (3) documents or fewer per element (some elements require more, others just one). This will depend on the number of factors in the element and the diversity of document types included.

49. Manage the Documents
1. Use a unique naming convention for each document, that is, don’t use the same name for multiple documents
2. Use a logical organizing principle such as:
 PCMH 1 A—Name of Document.docx
 PCMH 1 B—Name of Document.xls
3. Avoid special characters and punctuation in document name (e.g. quotation marks, question marks, commas, apostrophes, ampersands). NCQA’s system will not accept the documents.
4. Don’t put the same document in two different places in the document library; instead, enter it once and link to multiple elements
5. Use text boxes, arrows or other methods to identify important sections; briefly explain the importance to the element(s).
6. If N/A is marked, explain the reason in Text/Notes section in the Survey Tool.

50. Linking Documents

52. What is the oldest a submitted document can be?

53. Tips in Summary 1. Be efficient – use only what is needed.
a. Read the documentation requirements and provide only what is necessary.
b. Try to limit the documentation to one document per element for multiple factors.
2. Make sure documentation is legible. Legibility impacts NCQA’s review.
3. Clearly explain the documents and the section you want NCQA to see.
a. Label documents with the appropriate title
b. Make use of text boxes to explain, highlight, box in a targeted section or information and use arrows.
c. Do not handwrite notes on documents to explain data, and then scan them into your computer. Handwritten notes are difficult to read.
d. When using textboxes to hide information in non‐PDF documents, save the documents as ―read‐only, or convert to PDF. Otherwise, textboxes can moved and PHI revealed.
e. For screen shots, print screens and scan, or paste print screen as a picture into a Word document or PowerPoint slide.

54. Tips in Summary 4. Combine “like” documents whenever possible.
a. E.g., multiple policies written in MS Word may be combines into one document; refer to page number for individual elements.
5. Block PHI on all documents. Do not submit any protected health information. Keep a master list of patient files submitted in case of an NCQA audit. Physician names/information can remain on the files.
6. Do not use a flash drive (USB device) as the file path for your linked documents.

55. PCMH 1A – During Office Hours
Practice has written process/defined standards, and demonstrates that it monitors performance against the standards to:
Provide same-day appointments – CRITICAL FACTOR
Provide timely advice by telephone
Provide timely advice by electronic message (may be N/A if the practice does not advise patients via electronic systems)
Document clinical advice in the medical record
Critical Factors, such as PCMH 1A Factor 1, for Must Pass Elements are Essential to Achieving Recognition
Applies to routine and urgent care – time reserved for same-day appointments.
NA requires a statement from practice
Can’t use “work-in” process or just fill in no-shows.

56. PCMH 1A: Scoring and Documentation
MUST PASS
4 Points
Scoring
4 factors = 100%
3 factors (including Factor 1) = 75%
2 factors (including Factor 1)= 50%
Factor 1 = 25% (not 1 factor)
0 factors or missing factor 1 = 0%
Documentation:
F1-4: Documented process for scheduling appointments, providing clinical advice and documenting advice and
F1-3: Reports with 5 days of data showing same-day access, response times compared to practice defined standards
F4: Three examples of clinical advice or report with percent documented advice in record in recent one month period
Must get at least 2 factors
or 50% to PASS

57. Notes Section
Ex. 1: This is an example of a practice writing an explanation to NCQA in the “Notes” section of the survey tool. NCQA Reviewer Note: The practice responded "Yes" to factors 1-2, 4 and "No" to factor 3. Reviewer agrees with the practice's self-assessment. ______________________________________________________________ 1A1, 1A2, 1A4. Attached policy demonstrates that: 1) 25% of appointment slots each day are reserved for same day appointments. These appointments are usually booked early in the morning for the same day but may be booked the afternoon prior if needed; 2) documenting phone conversations with patients in the medical record is expected and; 3)a response to patient phone calls is expected to occur within 24 hours. 1A1. A report shows the % of same day appointments. 1A1. Screenshots show that the schedule template is built to accommodate 4 total appointments per hour: 2 established patients, 1 new patient and 1 same day (work- in) patient each hour. This same template is applied to every provider, every day. 1A2. Audit results attached 1A3. marked "no" because, while we have recently enabled the electronic messaging feature through our patient portal, we have not yet received any messages from patients. 1A4. Three examples of clinical advice documented in medical records are attached.

58. PCMH 1A1- Process
HCCH Process: Providing patients access to same-day appointments
As primary care providers, it is essential that we maintain the capacity to see patients when they need to obtain care and services.
As a patient-centered organization, our standard is that patients are able to schedule appointments at times that meet their needs.
Each practice reserves appointment slots for all providers on each scheduled day in order to provide same-day access to patients requesting care or services.
These slots are clearly identified in the provider’s schedule and may only be filled on the same day. (A slot may occasionally be filled after 3 pm on the day prior for a patient requesting an appointment the following morning.)

59. What’s missing from this document
What’s missing from this document? How long should the process have been in place?

60. PCMH 1A - Documentation
Same-Day Appts Marked
by arrow and labeled SD

61. 5 Day Audit for Same Day Appts
You need to report on ALL the providers in the practice

62. 5 Day Audit for Same Day Appts
Report for Red and Blue Teams Same Day availability slots for 5 days (5/14-5/18): Red Team has 37 slots available. Blue Team has 34 slots available.
RED TEAM
You need to report on ALL the providers in the practice
BLUE TEAM

63. Reviewer Comments 1A
Ex. 1: Factor 4 - The practice provided examples that did not demonstrate clinical advice. Messages left for patients to make appointments does not meet the intent of clinical advice.
Ex. 2: To receive credit for factor 4, the practice must submit two items, 1) a documented process for staff to follow for entering phone and electronic message clinical advice in the patient record and 2) at least three examples of clinical advice documented in a patient record or generates a report identifying how often advice is documented in the medical record.
The practice submitted a process; however the three examples provided did not meet the intent of the factor. The three examples were communication between clinician and nurse. The examples should show clinical advice documented in a patient's medical record. Factor 4 was changed to no.
Ex. 3: The practice scored factors 1-4 “yes”. The reviewer changed factors 1- 4 to “no” because the practice did not have a documented process with an implementation date or other evidences that it has been in place for at least 3 months. The reviewer requested additional documentation to support the practice’s “Yes” responses.
The additional documentation was submitted and now the reviewer agrees with the practice’s assessment and has changed factors 1-4 from “No” back to “Yes”.

64. Top 10 Points To Remember About Your NCQA Submission!

65. Top 10 Points To Remember! Number 10 - Eligibility
Recognitions are awarded at the geographic site level
Clinicians Who Are Eligible
MDs, DOs, NPs, PAs with panels of primary care patients
75% of those patients come for “first contact”, comprehensive, and continuous PCP care
Clinicians who see patients routinely at more than one site should be listed on each site’s application
Multi-Sites have:
3 or more sites
The same EMR
The same policies and procedures for staff
The ability to be bound by a single contract

66. Top 10 Points To Remember! Number 9 – Timing of Application Submission
Submit Online Applications and ISS Survey Tools in Pairs
One application for each site first
One ISS Tool for each site
The Online Application Account can be used for multiple submissions over time
A separate Online Application must be submitted 5 days before NCQA can accept any PCMH ISS Survey Tool
Pair

67. Top 10 Points To Remember! Number 8 – Record Review Workbook
Really understand how to use the Record Review Workbook
Read and understand THE INSTRUCTIONS
Watch the CCNC webinars and NCQA videos and webinars
Condition 3A factor 3 must be included
Double check you have the right number of patients in 3A and 3B
Use the methodology outlined in the INSTRUCTIONS
Method 1 and 2 can be mixed and matched

68. No. 8 - Look at the Instructions
Three tabs
Instructions
Patient Conditions
Record Review

69. Top 10 Points To Remember! Number 7 – Give Yourself Enough Time
Online Application must precede the ISS tool by 5 days
NCQA may take 60 days to review single site tools and 30 days for Multi-Site Corporate tools
Thus Multi-site Recognitions may take 90 days
It takes time for NCQA to set up a call to discuss the corporate tool and to copy elements into site tools
Large Multi-sites should stagger site submissions to allow a single reviewer to keep up
When NCQA asks for more documentation it adds TIME

70. Top 10 Points To Remember!
Number 6 – Overestimate Pre-submission Work Time
Takes hours
Develop a PLAN and TIMELINE
Develop a PCMH TEAM in your office with responsibilities for each member
Meet regularly – use Quick Look
Give enough time to collect and upload all your documents – up to 150 documents or more

71. Quick Look Worksheet in CCNC PCMH Workbook

72. Top 10 Points To Remember!
Number 5 – Don’t Let Recognitions Expire Before Renewing
Expired Recognitions are not retroactively extended
Expired practices and providers will fall off the lists NCQA sends to P4P program sponsors monthly
They reappear when practices earn a new Recognition

73. Top 10 Points To Remember!
Number 4 – Pay attention to Documentation Requirements
Interpret the S&G document requirements LITERALLY
All should attend S&G training and CCNC webinars to understand the requirements of each element
Read all related FAQs
If S&G requires X types of documents, be sure you include all of them
NCQA does not pre-approve documentation

74. Top 10 Points To Remember!
Number 3 – Use NCQA’s and CCNC’s PCMH Written and Archived Training Resources
When a system doesn’t work, READ the instructions
If it still doesn’t work, FOLLOW the instructions
Have someone on your team attend a “Facilitating Patient-Centered Medical Home Recognition” conference if possible
Plan on one person in your organization or 2 people in your network attending the Content Expert Certification

75. Top 10 Points To Remember!
Number 2 – Prepare Reviewer-Friendly Documentation
Organize by standards, elements, and factors
Helps to organize in 1 PDF per element
Efficient – limit to only what is necessary for the requirement
Labeled and Highlighted – corresponding fields
Dated or Date Range (where appropriate)
Learn how to do a screenshot – think “Greenshot” or “SnagIT”

76. Processes for
5C 1,2,3,4,5

77. Top 10 Points To Remember!
Number 1 – Focus on the Most Critical Factors First
Have a Plan – Timeline it
PCMH 1A factor 1
Providing same day appointments
PCMH 4A factor 3 (RRWB element)
Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families
PCMH 6C – factors 1 and 2
There is no Recognition without these
Good places to begin early practice transformation
Assure that your documentation meets requirements

78. One More Thing…
We need to motivate and reward patients for taking care of their OWN HEALTH!

79. Next Steps (Homework) Interested in building your own PCMH Team?
Become a part of CCNC
Identify a “PCMH Champion” who will help guide the practice through the quality transformation process
Identify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff
Identify a “Lead Administrator” who will track progress, organize materials, and complete the Survey Tool/PCMH application
Use CCNC’s tools and resources for PCMH!

81. PCMH for Your Practice? Here’s a Place to Start
R.W. “Chip” Watkins, MD, MPH, FAAFP
SCORH Conference
Columbia, SC
15 October 2013