1. Training Webinar # 4 David Halpern, MD, MPH January 4, 2012
Patient-Centered Medical Home NCQA’s PCMH 2011 Standards
Training Webinar # 4
David Halpern, MD, MPH
January 4, 2012

2. Legal Disclaimer
© Copyright 2011 North Carolina Community Care Networks, Inc.  All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure NCQA recognition as patient-centered medical homes.  All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with the permission of the respective copyright owners in each case. 2

3. Acknowledgements

4. Let’s Review Standard 6 – Measure & Improve Performance
PCMH6A: Measure Performance
PCMH6B: Measure Patient/Family Experience
PCMH6C: Implement Continuous Quality Improvement – MUST PASS
PCMH6D: Demonstrate Continuous Quality Improvement
PCMH6E: Report Performance
PCMH6F: Report Data Externally 4

5. Today’s Agenda Standard 1 – Enhance Access & Continuity
PCMH1A: Access During Office Hours – MUST PASS (review from Webinar #2)
PCMH1B: After-Hours Access
PCMH1C: Electronic Access
PCMH1D: Continuity
PCMH1E: Medical Home Responsibilities
PCMH1F: Culturally and Linguistically Appropriate Services
PCMH1G: The Practice Team 5

6. PCMH 1A: Access During Office Hours
Practice has written process/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
Document clinical advice

7. PCMH 1A: Access During Office Hours
MUST PASS
4 Points:
4 factors= 100%
3 factors (including factor 1) = 75%
2 factors (including factor 1)= 50% (must-pass threshold)
Factor 1= 25% (not sufficient for passing element)
0 factors or missing factor 1 = 0%
Data Sources:
Documented process for scheduling appointments, providing clinical advice and documenting advice
Report showing same-day access, response times
Screen shots or copies of documented clinical advice

8. PCMH 1A: Example – Factor 1
This is the practice’s
written policy on
same-day scheduling

9. PCMH 1A: Example – Factor 1
(Your Practice Name)
This is the practice’s
written policy on
same-day scheduling

10. PCMH 1A: Example – Factor 1
Brown
Smith
Jones

11. PCMH 1A: Example – Factor 2
Element 1A, Factor 2

12. PCMH 1A: Example – Factor 2
Percent of calls returned on the same day

13. PCMH 1B: After-Hours Access
Practice has written process/standards and monitors performance:
Provide access to routine and urgent-care outside business hours
Provide continuity of medical record information for care and advice when office is closed
Provide timely advice by phone when office is closed – CRITICAL FACTOR
Provide timely advice using interactive electronic system when office is closed
Document after-hours advice

14. PCMH 1B: After-Hours Access
4 Points:
5 factors= 100%
4 factors (including factor 3) = 75%
3 factors (including factor 3)= 50%
1-2 factors= 25%
0 factors = 0%
Data Sources:
Documented process for arranging after hours access, making medical records available after hours, providing timely advice after hours, documenting advice after hours
Report showing after hours availability, response times
Materials communicating practice hours
Screen shots or copies of documented clinical advice

15. PCMH 1B: Example – Factor C
POLICY - The designated lead physician or manager will prepare and maintain a schedule for members of the medical staff to provide on-call services. The schedule will provide for one physician to be on call for Lakeside Family Physicians and one physician for Lakeside Primary Care. Call will transfer to the designated physician at the end of primary care hours on the day listed on the schedule.
PROCEDURE - Physician Procedure: The primary care physician assigned to on-call coverage will be available at all times and capable of responding by telephone within fifteen minutes. The on call physician will document on phone note the following information:
Patient name
Person calling if other than the patient
Physician name
Time and date of call
Reason for call
Advice given
Follow up needed
This is an example of a practice’s policy on after-hours telephone call.

16. PCMH 1C: Electronic Access
Practice provides through a secure electronic system:
Electronic copy of health information within 3 days to more than 50% of patients who request it**
Electronic access to current health information within 4 days to at least 10% of patients**
Clinical summaries provided for more than 50% of office visits within 3 days**
Two-way communication
Request for appointments or prescription refills
Request for referrals or test results
** Meaningful Use Requirement

17. PCMH 1C: Electronic Access
2 Points:
5-6 factors = 100%
3-4 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
Report showing percentage of patients who received electronic copy of health information, access to requested health information, electronic clinical summaries
Screen shots of its secure web site or portal, web page where patients can make requests and communication capability with patients

18. PCMH 1C: Example – Factors 4, 5, 6

19. PCMH 1C: Example – Factors 1, 2
this screenshot demonstrates online lab results

20. PCMH 1C: Example – Factors 5
this screenshot demonstrates online scheduling system

21. PCMH 1C: Example – Factor 5
this screenshot demonstrates online refill requests

22. PCMH 1D: Continuity Practice provides continuity by:
Expecting patients to select a personal clinician
Documenting the choice of clinician
Monitoring percent of patient visits with clinician

23. PCMH 1D: Continuity 2 Points: Data Sources: 3 factors = 100%
Documented process or materials for clinician selection
Screen shot showing patients choice of clinician
Report showing patient encounters with clinician

24. PCMH 1D: Example – Factor 3
“Assigned Visits” = patients who are assigned to that PCP
“Unassigned Visits” = patients who are not assigned to that PCP

25. PCMH 1D: Example – Factor 3

26. PCMH 1E: Medical Home Responsibilities
Practice has process and provides materials about role of medical home:
Practice responsible for coordinating patient care
How to obtain care/advice during/after office hours
Patients provide complete medical history and information on care obtained outside practice
Care team gives patient access to evidence-based care and self-management support

27. PCMH 1E: Medical Home Responsibilities
2 Points:
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
Documented process for providing patient information
Patient materials

28. PCMH 1E: Example – Factor 1

29. PCMH 1E: Example – Factor 1
Patient Center Medical Home FACT SHEET
What is a patient centered medical home? A patient centered medical home is a care team, led by a primary care physician that focuses on each patient’s health goals and needs, and coordinates that patient’s care across all settings. The concept of a medical home was initially introduced by the American Academy of Pediatrics in In March 2007, the AAP, the American College of Physicians , the American Academy of Family Physicians, and the American Osteopathic Association issued the Joint Principles of the Patient Centered Medical Home in response to several large national employers seeking to create a more effective and efficient model of health care delivery. Patient-Centered Medical Home is not an actual building, house or hospital. It’s a team approach to providing comprehensive health care in a high-quality and cost-effective manner.
A Patient-Centered Medical Home is based on a continuous relationship with a personal physician. The physician leads a team of medical professionals who together take responsibility for a person’s care through all stages of life. The patient has one place to call; they have greater access to services; they get personalized care; that care is safe and scientifically valid; and there is a focus on preventive care which keeps costs down and patients healthier.
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.

30. PCMH 1E: Example – Factor 2

31. PCMH 1E: Example – Factor 1 & 4
Examples of information about PCMH model and self-management tools for patients/families

32. PCMH 1E: Example – Factor 4

33. PCMH 1E: Example – Factor 4

34. PCMH 1E: Example – Factor 4
Patient Self management tools are available by clicking on the last tab in Provider Portal or by going to the “Patient Mgmt Tools” tab at the CCNC website:
These tools are all non-branded, evidence based, low literacy appropriate and have been vetted by physicians at CCNC

35. PCMH 1E: Example – Factor 4

36. PCMH 1E: Example – Factor 4

37. PCMH 1E: Example – Factor 4

38. PCMH 1F: Culturally & Linguistically Appropriate Services
Practice meets the cultural and linguistic needs of its patients:
Assesses racial/ethnic diversity of patients
Assesses language needs of patients
Provides interpretation services
Provides printed materials in patient language

39. PCMH 1F: Culturally & Linguistically Appropriate Services
2 Points:
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
Report showing assessment of racial/ethnic/language of patients
Documentation showing use of interpretation service
Materials in other languages or website in other languages

40. PCMH 1F: Example – Factor 2

41. PCMH 1F: Example – Factor 2

42. PCMH 1F: Example – Factor 2

43. PCMH 1F: Example – Factor 3

44. Use the “Meducation” tab to show non-English speakers how to use an inhaler, glucometer, etc.

46. For non-English speakers, you also can print these instructions in 13 languages.

47. CCNC Provider Portal To sign up, visit: https://portal.n3cn.org
Reports are specific to NC Medicaid enrollees, but patient materials can be used/downloaded (for free) for any patients
To sign up, visit:

48. PCMH 1G: Practice Team Practice provides patient care services by:
Defining roles for clinical/nonclinical team members
Holding regular team meetings - CRITICAL FACTOR
Using standing orders
Training and assigning care team to coordinate care
Training on self-management, self-efficacy and behavior change
Training on patient population management
Training on communication skills
Care team involvement in performance evaluation and QI

49. PCMH 1G: Practice Team 4 Points: Data Sources:
7-8 factors (including factor 2) = 100%
5-6 factors (including factor 2) = 75%
4 factors (including factor 2) = 50%
2-3 factors = 25%
0-1 factors = 0%
Data Sources:
Staff position descriptions
Description of staff communication processes
Written standing orders
Description of training process, schedule, materials
Description of how staff is involved in practice improvements

50. PCMH 1G: Example – Factor 1, 3

51. Next Steps (Homework) Review the requirements for Standard 1
What does the practice already do?
What does the practice need to adopt/implement?
Are there elements the practice clearly does not have in place and does not plan to have in place in time for submission?

52. Next Steps (Homework) Organize Your Documents
Create a place on your computer (server or hard-drive) for all of your documentation
You should have a folder for each standard
A checklist can help you determine what you already have created/saved and what you need to prepare from scratch

53. Next Steps (Homework)
Go to NCQA’s website and take advantage of the various (free) training presentations they have available:
2011 Standards
Using the ISS Interactive Survey System
Submitting As a Multi-Site Practice

54. Community Care PCMH Team
David Halpern, MD, MPH
Community Care of North Carolina (CCNC)
R.W. “Chip” Watkins, MD, MPH, FAAFP
Brent Hazelett, MPA
North Carolina Academy of Family Physicians (NCAFP)
Elizabeth Walker Kasper, MSPH
North Carolina Healthcare Quality Alliance (NCHQA)

55. Feel free to contact me:
Questions?
Feel free to contact me:
David Halpern, MD, MPH
(215)