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

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Presentation on theme: "PCMH for Your Practice? Here’s a Place to Start R.W. “Chip” Watkins, MD, MPH, FAAFP SCORH Conference Columbia, SC 15 October 2013."— Presentation transcript:

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

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



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

10 Medical Home “Joint Principles” 1)Personal Physician 2)Physician-Directed Practice 3)Whole-Person Orientation 4)Care Coordination/Integration 5)Quality & Safety 6)Enhanced Access 7)Payment 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 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 Source: Fields, et al. 2010

14 This is a No-Brainer! Right?  So Why Aren’t Practices RUNNING to implement PCMH for themselves?!? 1.Time 2.Resources 3.Consultants are expensive 4.Fear a)Gov’t interference b)Loss of control/independence c)Change

15 PCMH 2011 Overview (6 standards/27 elements) 1.Enhance Access and Continuity A.Access During Office Hours B.Access After Hours C.Electronic Access D.Continuity (with provider) E.Medical Home Responsibilities F.Culturally/Linguistically Appropriate Services G.Practice Organization 2.Identify/Manage Patient Populations A.Patient Information B.Clinical Data C.Comprehensive Health Assessment D.Use Data for Population Management 3.Plan/Manage Care A.Implement Evidence-Based Guidelines B.Identify High-Risk Patients C.Manage Care D.Manage Medications E.Electronic Prescribing 4.Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources 5.Track/Coordinate Care A.Test Tracking and Follow-Up B.Referral Tracking and Follow-Up C.Coordinate with Facilities/Care Transitions 6.Measure and Improve Performance A.Measures of Performance B.Patient/Family Feedback C.Implements Continuous Quality Improvement D.Demonstrates Continuous Quality Improvement E.Report Performance F.Report Data Externally Optional Patient Experiences Survey

16 Scoring Total 100 Points LevelPointsRequired Must Pass 1≥ 356 Must Pass 2≥ 606 Must Pass 3≥ 856 Must Pass Recognition requires achieving all 6 must pass elements with a ≥50% score

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  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) CCNC - “How it works” Watkins - 201220

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. Watkins - 201221

22 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 Community Care’s Informatics Center Watkins - 201222

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)

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

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 Resources Available  CCNC  Web-based 2011 PCMH Workbook  Webinars for 2011 PCMH Submissions  Introducing….

33 Resources Available  Use the CCNC PCMH workbook, webinars  resources/ resources/

34 How Do You Get All This Done?

35 Watkins. Journal of Medical Practice Management, Sept/Oct 2012, Vol 28:2, pp. 134-6.


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

38 Creation of Partnership with Appalachian State University PARTNERSHIP:  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.

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

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: 1.Provide same-day appointments – CRITICAL FACTOR 2.Provide timely advice by telephone 3.Provide timely advice by electronic message (may be N/A if the practice does not advise patients via electronic systems) 4.Document clinical advice in the medical record Critical Factors, such as PCMH 1A Factor 1, for Must Pass Elements are Essential to Achieving Recognition

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? 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

62 RED TEAM BLUE TEAM 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.

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 100-200 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 2011 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

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