Presentation on theme: "PCMH for Your Practice? Here’s a Place to Start"— Presentation transcript:
1PCMH for Your Practice? Here’s a Place to Start R.W. “Chip” Watkins, MD, MPH, FAAFPSCORH ConferenceColumbia, SC15 October 2013
2Who am I? R.W. “Chip” Watkins, MD, MPH, FAAFP Senior Physician Consultant on CCNC’s PCMH EffortsNCQA Physician Review Oversight Committee (ROC)NCQA ReviewerNCQA’s Advisory Panel for CEC ExamMedical Director – High Country Community HealthPast-President and Board Chair – NC Academy of Family PhysiciansCan delete this and the next slide if there is going to be an introduction…
4Patient-Centered Medical Home The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care deliveryThe 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 physicians2. Employs a team-based approach3. Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology
7The ChallengeMedicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerousSir Cyril ChandlerChairman of the BoardGreat Ormond Street HospitalFor Children NHS TrustLiverpool, England
9Patient-Centered Medical Home Emphasizes the relationship between patients and their primary care physiciansEmploys a team-based approach to careIntegrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology to improve population management and preventive carePCMH 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.
10Medical Home “Joint Principles” Personal PhysicianPhysician-Directed PracticeWhole-Person OrientationCare Coordination/IntegrationQuality & SafetyEnhanced AccessPaymentEach 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
11Features of PCMH Four common features in demonstrations Dedicated care managersExpanded access to cliniciansData-driven analytic toolsUse of incentives
12Benefits of the PCMH Model Quality – Outcomes for seven medical home demonstrationsFewer ER visits (15%-50%)Fewer hospital admissions (6-24%)Lower mortality ratesBetter preventive service deliveryBetter chronic disease careHigher patient satisfactionGroups that have undertaken this redesign process have demonstrated:ER visits:Group Health Cooperative – 29% reduction in 2 yearsHealth Partners – 39% reduction in 5 yearsGenesee – 50% reduction in 4 yearsJohns Hopkins – 15% reduction in 8 monthsSC BCBS – 32.2% reductionHospitalization rates:Group Health – 6% reduction in admissions in 2 yearsHealth Partners – 24% in admissions in 5 yearsGeisinger – 14% reduction in admissions in 2 yearsGenesee – 15% reduction in admissions in 4 yearsIntermountain – 10% reduction in admissions in 2 yearsJohns Hopkins – 24% reduction in inpatient days in 8 monthsSC BCBS – 10.7% reduction in admissions, 36.3% reduction in inpatient daysMortality rates:Intermountain – 3.5% reduction in 2-year mortalityPreventive Service Delivery:Geisinger – 74% increase in preventive care in 2 yearsGenesee – 137% increase in mammography in 4 yearsColorado Medicaid/SCHIP – 267% increase in well-child visitsChronic Disease Care:Health Partners – 129% increase in optimal diabetes care, 48% increase in optimal heart disease care in 5 yearsGeisinger – 22% increase in CAD care, 34.5% improvement in diabetes careSource: Fields, et al. (2010) and Reid RJ, Coleman K, et al. (2010).
13Benefits of the PCMH Model Efficiency – CostLower total costs of care - (6.5-22%)Shorter patient wait timesLess staff burnout/turnover (10% Vs. 30%)Higher staff satisfaction/productivityThese 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 21Health Partners – 8% reduction in total costs at 5 yearsGeisinger – 9% reduction in total costs at 2 yearsIntermountain – savings of $53.33 PMPM at 2 yearsColorado Medicaid/SCHIP – 21.5% reduction in total costsSC BCBS – 6.5% lower total medical/pharmacy costs10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baselineSource: Fields, et al
14This is a No-Brainer! Right? So Why Aren’t Practices RUNNING to implement PCMH for themselves?!?TimeResourcesConsultants are expensiveFearGov’t interferenceLoss of control/independenceChange
15PCMH 2011 Overview (6 standards/27 elements) Enhance Access and ContinuityAccess During Office HoursAccess After HoursElectronic AccessContinuity (with provider)Medical Home ResponsibilitiesCulturally/Linguistically Appropriate ServicesPractice OrganizationIdentify/Manage Patient PopulationsPatient InformationClinical DataComprehensive Health AssessmentUse Data for Population ManagementPlan/Manage CareImplement Evidence-Based GuidelinesIdentify High-Risk PatientsManage CareManage MedicationsElectronic PrescribingProvide Self-Care and Community ResourcesA. Self-Care ProcessB. Referrals to Community ResourcesTrack/Coordinate CareTest Tracking and Follow-UpReferral Tracking and Follow-UpCoordinate with Facilities/Care TransitionsMeasure and Improve PerformanceMeasures of PerformancePatient/Family FeedbackImplements Continuous Quality ImprovementDemonstrates Continuous Quality ImprovementReport PerformanceReport Data ExternallyOptional Patient Experiences Survey
16Scoring Total 100 PointsRecognition requires achieving all 6 must pass elements with a ≥50% scoreLevelPointsRequired Must Pass1≥ 356 Must Pass2≥ 603≥ 85
17Alignment with Measures of Meaningful Use E-prescribing – medication list, allergiesPatient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insuranceCare management – reminders for follow-up care, decision support, Rx reconciliationElectronic capability – e-health information to patient, visit summary, e-access to health information, provider information exchangePerformance reporting/improvement
19CCNC - “How it works”Primary care medical home available to 1.6 million Medicaid patients in all 100 countiesProvides 5,000 local primary care physicians (94% of all NC PCPs) with resources to better manage Medicaid populationNot-for-profit networks link local community providers (health systems, hospitals, health departments and other community providers) to primary care physiciansResources include 600 local care managers, 26 pharmacists, 14 psychiatrists and 20 medical directors to improve local health care delivery
20CCNC - “How it works”The state identifies priorities and provides financial support through an enhanced PMPM payment to community networksNetworks pilot potential solutions and monitor implementation (physician led)Networks voluntarily share best practice solutions and best practices are spread to other networks – for ALL payorsThe state provides the networks (CCNC) access to dataCost 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
21System-Wide ResultsCommunity 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 ofWatkins
22Community Care’s Informatics Center Informatics Center ─ Medicaid claims dataUtilization (ED, Hospitalizations)Providers (Primary Care, Mental Health, Specialists)Diagnoses – Medications – LabsCostsIndividual and Population Level Care AlertsReal-time dataHospitalizations, ED visits, provider referralsMultipayer DatafeedsMedicare, Medicaid, BCBSNC, and SEHPA 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
23What is the Multi-Payer Advanced Primary Care Practice Demonstration Project (MAPCP)?
24What 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 payersNC is one of 8 states that was awarded an MAPCP demo
25What 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
26What 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 demoIn 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.
27Recognition of Added Value Incentive Payments from MedicareCMS 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
28Recognition of Added Value Increased Reimbursement from BCBSEligibility for the Blue Quality Physicians Program (BQPP), a recognition program for primary care practices that builds on PCMH recognition from NCQAOnce you qualify for the BQPP, BCBS will increase its fee structure by 10% or more for all of your BCBS/SEHP patients
29Let’s Talk About Resources for Your NCQA Submission
30Resources Available NCQA PCMH Standards and Guidelines – “The Rules” Standards, Elements, FactorsPolicies and ProceduresSoftware ProductsOnline Application AccountBusiness and demographic informationFreeInteractive Survey System (ISS)Responses to the Standards and GuidelinesISS Survey Tool$80Recognition Programs Section of NCQA’s WebsiteThese are free of charge from NCQA
31Go to NCQA HomeThen ProgramsThen RecognitionThen PCMH 2011Then Before, During,and After I’m Recognizedfor lists of onlineresources
32Comprehensive PCMH Document Library 2011 Resources AvailableCCNCWeb-based 2011 PCMH WorkbookWebinars for 2011 PCMH SubmissionsIntroducing….ComprehensivePCMHDocumentLibrary 2011These are free of charge from NCQA
33Resources Available Use the CCNC PCMH workbook, webinars
37ASU Practicum in Primary Care ASU College of Health Science,School of Healthcare Management
38Creation of Partnership with Appalachian State University Recruit ASU students from School of Health Care ManagementDevelop curriculum, syllabus, website, core documentsCreate new practicum course with internship opportunityTeach students about PCMH, Provider Portal, Care management processSend students out to practices to assist in attaining PCMH certification, BQPP cert and QI initiatives
39ASU Practicum in Primary Care Fall of 2011 – 5 studentsSpring 2012 – 9 students – BSBSNC Foundation Grant ObtainedSummer 2012 internship – 8 studentsFall 2012 – 14 studentsSpring 2013 – 15 studentsFall 2013 – 16 students
40ASU Practicum in Primary Care Developed curriculum, core documents, website https://sites.google.com/site/pcmhprac/
41ASU Practicum in Primary Care Worked through curriculum and have weekly didactic meetings on ASU campusBAA for HIPPA complianceStudents prepare PCMH PPT for “their” practice and give to groupGo through the Standards and hit high pointsStudents share successes/failures with facilitators/facultyPlaced students in field and worked with the practicesStudents give PPTWork 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
42Program GrowthASU School of Health Care Management has made the “Practicum in Primary Care” a CORE curriculum classStudents 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
43Program Growth Remote Learning Initiative Students work with practices within 3 hours of BooneMOVI (secure) web-hostingFace-to-face visits every 3 weeks or so
44CCNC’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.
48Organize the Documents 1. Create a folder on your network drive for documents the practice MAY want to attach2. Develop a checklist of documents already used in the practice and documents that need to be prepared3. Refer to published standards and use to identify what the practice has and what needs to be created4. Save a copy of the Record Review Workbook and/or Quality Measurement and Improvement Worksheet to your document folder5. Consider putting multiple examples in one document for a single element, e.g. screenshots6. Identify documents that may be applicable for more than one elementNOTE: 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.
49Manage the Documents1. Use a unique naming convention for each document, that is, don’t use the same name for multiple documents2. Use a logical organizing principle such as: PCMH 1 A—Name of Document.docx PCMH 1 B—Name of Document.xls3. 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 elements5. 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.
53Tips 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 titleb. 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.
54Tips 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.
55PCMH 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 FACTORProvide timely advice by telephoneProvide 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 recordCritical Factors, such as PCMH 1A Factor 1, for Must Pass Elements are Essential to Achieving RecognitionApplies to routine and urgent care – time reserved for same-day appointments.NA requires a statement from practiceCan’t use “work-in” process or just fill in no-shows.
56PCMH 1A: Scoring and Documentation MUST PASS4 PointsScoring4 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 andF1-3: Reports with 5 days of data showing same-day access, response times compared to practice defined standardsF4: Three examples of clinical advice or report with percent documented advice in record in recent one month periodMust get at least 2 factorsor 50% to PASS
57Notes SectionEx. 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.
58PCMH 1A1- ProcessHCCH Process: Providing patients access to same-day appointmentsAs 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.)
59What’s missing from this document What’s missing from this document? How long should the process have been in place?
60PCMH 1A - DocumentationSame-Day Appts Markedby arrow and labeled SD
615 Day Audit for Same Day Appts You need to report on ALL the providers in the practice
625 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 TEAMYou need to report on ALL the providers in the practiceBLUE TEAM
63Reviewer Comments1AEx. 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”.
64Top 10 Points To Remember About Your NCQA Submission!
65Top 10 Points To Remember! Number 10 - Eligibility Recognitions are awarded at the geographic site levelClinicians Who Are EligibleMDs, DOs, NPs, PAs with panels of primary care patients75% of those patients come for “first contact”, comprehensive, and continuous PCP careClinicians who see patients routinely at more than one site should be listed on each site’s applicationMulti-Sites have:3 or more sitesThe same EMRThe same policies and procedures for staffThe ability to be bound by a single contract
66Top 10 Points To Remember! Number 9 – Timing of Application Submission Submit Online Applications and ISS Survey Tools in PairsOne application for each site firstOne ISS Tool for each siteThe Online Application Account can be used for multiple submissions over timeA separate Online Application must be submitted 5 days before NCQA can accept any PCMH ISS Survey ToolPair
67Top 10 Points To Remember! Number 8 – Record Review Workbook Really understand how to use the Record Review WorkbookRead and understand THE INSTRUCTIONSWatch the CCNC webinars and NCQA videos and webinarsCondition 3A factor 3 must be includedDouble check you have the right number of patients in 3A and 3BUse the methodology outlined in the INSTRUCTIONSMethod 1 and 2 can be mixed and matched
68No. 8 - Look at the Instructions Three tabsInstructionsPatient ConditionsRecord Review
69Top 10 Points To Remember! Number 7 – Give Yourself Enough Time Online Application must precede the ISS tool by 5 daysNCQA may take 60 days to review single site tools and 30 days for Multi-Site Corporate toolsThus Multi-site Recognitions may take 90 daysIt takes time for NCQA to set up a call to discuss the corporate tool and to copy elements into site toolsLarge Multi-sites should stagger site submissions to allow a single reviewer to keep upWhen NCQA asks for more documentation it adds TIME
70Top 10 Points To Remember!Number 6 – Overestimate Pre-submission Work TimeTakes hoursDevelop a PLAN and TIMELINEDevelop a PCMH TEAM in your office with responsibilities for each memberMeet regularly – use Quick LookGive enough time to collect and upload all your documents – up to 150 documents or more
72Top 10 Points To Remember!Number 5 – Don’t Let Recognitions Expire Before RenewingExpired Recognitions are not retroactively extendedExpired practices and providers will fall off the lists NCQA sends to P4P program sponsors monthlyThey reappear when practices earn a new Recognition
73Top 10 Points To Remember!Number 4 – Pay attention to Documentation RequirementsInterpret the S&G document requirements LITERALLYAll should attend S&G training and CCNC webinars to understand the requirements of each elementRead all related FAQsIf S&G requires X types of documents, be sure you include all of themNCQA does not pre-approve documentation
74Top 10 Points To Remember!Number 3 – Use NCQA’s and CCNC’s PCMH Written and Archived Training ResourcesWhen a system doesn’t work, READ the instructionsIf it still doesn’t work, FOLLOW the instructionsHave someone on your team attend a “Facilitating Patient-Centered Medical Home Recognition” conference if possiblePlan on one person in your organization or 2 people in your network attending the Content Expert Certification
75Top 10 Points To Remember!Number 2 – Prepare Reviewer-Friendly DocumentationOrganize by standards, elements, and factorsHelps to organize in 1 PDF per elementEfficient – limit to only what is necessary for the requirementLabeled and Highlighted – corresponding fieldsDated or Date Range (where appropriate)Learn how to do a screenshot – think “Greenshot” or “SnagIT”
77Top 10 Points To Remember!Number 1 – Focus on the Most Critical Factors FirstHave a Plan – Timeline itPCMH 1A factor 1Providing same day appointmentsPCMH 4A factor 3 (RRWB element)Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/familiesPCMH 6C – factors 1 and 2There is no Recognition without theseGood places to begin early practice transformationAssure that your documentation meets requirements
78One More Thing…We need to motivate and reward patients for taking care of their OWN HEALTH!
79Next Steps (Homework) Interested in building your own PCMH Team? Become a part of CCNCIdentify a “PCMH Champion” who will help guide the practice through the quality transformation processIdentify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staffIdentify a “Lead Administrator” who will track progress, organize materials, and complete the Survey Tool/PCMH applicationUse CCNC’s tools and resources for PCMH!