PCMH 6A: Measure Performance Practice measures or receives the following data: 1.Three (3) preventive care measures 2.Three (3) chronic or acute care measures 3.Two (2) utilization measures affecting health care costs 4.Vulnerable population data
This report shows performance measures for hypertension patients at the practice level.
PCMH 6A: Example – Factor 2 This report shows performance measures for diabetes patients at the provider level.
PCMH 6A: Explanation – Factor 4 Vulnerable populations include “those who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability” (AHRQ)
PCMH 6B: Measure Patient/Family Experience Practice obtains feedback on patient experience with the practice and their care: 1.Practice conducts survey measuring experience on at least three (3) of the following: access, communication, coordination, whole-person care 2.Practice uses PCMH CAHPS-CG survey tool 3.Practice obtains feedback from vulnerable populations 4.Practice obtains feedback through qualitative means
PCMH 6B: Example – Factor 2 The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public-private initiative to develop standardized surveys of patients' experiences. The PCMH CAHPS-CG survey was recently released and is available at this website: Guidance/CG/PCMH.aspx
PCMH 6C: Implement Continuous Quality Improvement (CQI) Practice uses ongoing quality improvement process: 1.Set goals and act to improve performance on three (3) measures from Element 6A 2.Set goals and act to improve performance on one (1) measure from Element 6B 3.Set goals and address at least one (1) identified disparity in care for vulnerable populations 4.Involve patients in QI teams or on the practice’s advisory council
PCMH 6C: Implement Continuous Quality Improvement (CQI) Must Pass 4 Points: –3-4 factors = 100% –2 factors = 50% (must-pass threshold) –1 factor = 25% (not sufficient for passing element) –0 factors = 0% Data Sources: –Report or completed PCMH Quality Measurement and Improvement worksheet –Process demonstrating how practice involves patients/families in QI teams or advisory council
PCMH 6C: QI and the “ Model for Improvement” A description of this model and a brief explanation of how to improve your practice using a Plan-Do-Study-Act (PDSA) cycle can be found at this website:
PCMH 6C: QI and the “ Model for Improvement” PLAN What do we want to change? How can we change it? DO Test your initiative Should be a small-scale & quick test STUDY Collect data Did it work? What did you learn? ACT What needs to be changed? Refine your plan & start again
PCMH 6C: Example – NCQA QI Workbook
PCMH 6C: Where Do I Find the NCQA QI Workbook? The Quality Measurement and Improvement Worksheet is located in the PCMH Survey Tool (ISS). Once you have access to the Survey Tool: –log into it and go to Element 6C –click on the red supplemental worksheet button –click on the red link –save the workbook in your own computer to enter data. Label it with a unique name but do not use a “%” sign in the name of the document –enter data in your Worksheet and then save and link the completed Worksheet to the Survey Tool when you are ready to submit
PCMH 6D: Demonstrate Continuous Quality Improvement (CQI) Practice demonstrates ongoing monitoring of the effectiveness of its improvement process: 1.Tracks results over time 2.Assesses effect of its actions 3.Achieves improved performance on one measure 4.Achieves improved performance on a second measure
PCMH 6D: Demonstrate Continuous Quality Improvement (CQI) 3 Points: –4 factors = 100% –3 factors = 75% –2 factors = 50% –1 factor = 25% –0 factors = 0% Data Sources: –Reports showing measures over time, NCQA recognition results or completed Quality Improvement Measurement and Improvement Worksheet
PCMH 6D: Example – Factor 1 & 3 % of hypertension patients on aspirin
PCMH 6D: Example – Factor 1 & 3 % of hypertension patients with BP at goal
PCMH 6D: Example – Factor 1 & 3 % of diabetes patients with BP < 140/90 aspirin HEDIS 90 th percentile (75.5%) our practice
PCMH 6E: Report Performance Practice shares data from Element A & B: 1.Within the practice, individual clinician results 2.Within the practice, practice results 3.With patients or public, individual clinician or practice results
PCMH 6E: Report Performance 3 Points: –3 factors= 100% –2 factors= 75% –1 factors= 50% –0 factors = 0% Data Sources: –Reports (blinded) showing summary data and how it provides results within the practice –Example of patient/public report
PCMH 6E: Example – Factor 1 This report shows performance measures for diabetes patients at the provider level. When you measure this data, you earn credit for PCMH 6A. When you share this data, You earn credit for PCMH 6E.
PCMH 6E: Example – Factor 2 This report shows performance measures for hypertension patients at the practice level. When you measure this data, you earn credit for PCMH 6A. When you share this data, You earn credit for PCMH 6E.
PCMH 6F: Report Data Externally Practice electronically reports: 1.Ambulatory clinical quality measures to CMS** 2.Data to immunization registries or systems** 3.Syndromic surveillance data to public health agencies** **Meaningful Use Requirement
PCMH 6F: Report Data Externally 2 Points: –3 factors= 100% –2 factors= 75% –1 factor= 50% –0 factors = 0% Data Sources: –Reports demonstrating data submission
PCMH 6F: Example – Factor 1
Next Steps (Homework) Review the requirements for Standard 6 –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?
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
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
Community Care PCMH Team David Halpern, MD, MPH Community Care of North Carolina (CCNC) R.W. “Chip” Watkins, MD, MPH, FAAFP Community Care of North Carolina (CCNC) Brent Hazelett, MPA North Carolina Academy of Family Physicians (NCAFP) Elizabeth Walker Kasper, MSPH North Carolina Healthcare Quality Alliance (NCHQA)
NCQA Contact Information Contact NCQA Customer Support to: Order FREE Copy of requirements Order FREE Application Information Purchase ISS Tool Visit NCQA Web Site to: View Frequently Asked Questions View Recognition Programs Training Schedule Send Questions to:
Questions? Feel free to contact me: David Halpern, MD, MPH (215)