Applying NCQA PPC-PCMH Standards to Primary Care and Behavioral Health Maria Ludwick, MPH Harold Pincus, MD

Agenda PCASG Quality Improvement Program NCQA Patient Centered Medical Home Basics Adaptation to PC - BH Gaps in Implementation Strategies to Fill the Gap Note: This is a participatory session

Goals for the Primary Care Access and Stabilization Grant Increase access to care on a population basis Develop sustainable business entities Provide evidenced based, quality health care Develop an organized system of care 2

PCASG Quality Improvement Program Interprets NoA requirement for a quality improvement program at the grantee level Approved by CMS in June 2008 Outlines a uniform set of quality standards Minimum quality requirements Optional incentive payment program Encourages maximum participation Based on National Committee for Quality Assurance (NCQA) Physician Practice Connections – Patient Centered Medical Home

Why NCQA PPC-PCMH? Widely recognized for health care quality standards Received input from a variety of stakeholders e.g. professional organizations, insurers, and patient advocacy groups Standards emphasize use of systematic, patient-centered, coordinated care management processes Reinforces partnerships between individual patients, and their personal physicians, and when appropriate, the family Uses of registries, care coordination, information technology, and other means to assure patients have the right care when they need it Standardized survey tool & methodology enables equitable distribution of PCASG funds Encourages grantees to seek NCQA recognition

Optional Quality Incentive Payment (QIP) 5% of PCASG grant funds available for QIP ($3.85M) 3 opportunities (March, June and Dec 09) ~$1.283M each payment Round One Awards Ranged from $67k-$135k Three Payment Tiers Based on NCQA levels but less stringent Graduated tiers/Graduated payments Half of an organization’s eligible service delivery sites must pass to obtain a specific tier

PPC-Patient Centered Medical Home Basics Measures evaluate: Use of systems Effectiveness in prevention Management of chronic illness and patient safety Measures are “actionable” at practice level Measures are validated by relating them to performance Score is based on: Responses in Web-based Survey Tool Supporting documentation attached to Survey Tool Each element specifies type of documentation: Reports; Documented processes; Records or files

Data Sources & Guidance Data sources and documentation are required Each element indicate type of HIT required to perform functions Basic – (HIT) Basic Paper-based or administrative electronic system Intermediate – (HIT) Intermediate Electronic system for clinical functions Advanced – (HIT) Advanced Electronic system for connectivity or interoperability Practices can achieve a passing score on All Must Pass Elements with Basic Health Information Technology

PPC-PCMH Content and Scoring Standard 1: Access and Communication Has written standards for patient access and patient communication** Uses data to show it meets its standards for patient access and communication** Pts 4 5 9 Standard 2: Patient Tracking and Registry Functions Uses data system for basic patient information (mostly non-clinical data) Has clinical data system with clinical data in searchable data fields Uses the clinical data system Uses paper or electronic-based charting tools to organize clinical information** Uses data to identify important diagnoses and conditions in practice** Generates lists of patients and reminds patients and clinicians of services needed (population management) 2 3 6 21 Standard 3: Care Management Adopts and implements evidence-based guidelines for three conditions ** Generates reminders about preventive services for clinicians Uses non-physician staff to manage patient care Conducts care management, including care plans, assessing progress, addressing barriers Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities 20 Standard 4: Patient Self-Management Support Assesses language preference and other communication barriers Actively supports patient self-management** Standard 5: Electronic Prescribing Uses electronic system to write prescriptions Has electronic prescription writer with safety checks Has electronic prescription writer with cost checks Pts 3 2 8 Standard 6: Test Tracking Tracks tests and identifies abnormal results systematically** Uses electronic systems to order and retrieve tests and flag duplicate tests 7 6 13 Standard 7: Referral Tracking Tracks referrals using paper-based or electronic system** PT 4 Standard 8: Performance Reporting and Improvement Measures clinical and/or service performance by physician or across the practice** Survey of patients’ care experience Reports performance across the practice or by physician ** Sets goals and takes action to improve performance Produces reports using standardized measures Transmits reports with standardized measures electronically to external entities 1 15 Standard 9: Advanced Electronic Communications Availability of Interactive Website Electronic Patient Identification Electronic Care Management Support **Must Pass Elements

NCQA PPC – PCMH Requirements: Must pass criteria 1A – Written standards for patient access 1B – Data to show it meets access standards 2D – Use charting tools to organize clinical info 2E – Data to identify 3 important conditions 3A – EBG for 3 conditions – 2 to pass 4B – Supports patient self management 6A – Test tracking 7A – Referral tracking 8A – Measure performance 8C – Report performance

Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective Community Health System Resources and Policies Health Care Organization Self- Management Support Clinical Information Systems Delivery System Design Decision Support Productive Interactions Patient-Centered Coordinated Timely and Evidence- Efficient Based and Safe Informed, Empowered Patient and Family Prepared, Proactive Practice Team Improved Outcomes

Chronic Disease Clinical Models Hypertension Congestive heart failure (CHF)/Coronary artery disease (CAD) Stroke COPD (Chronic Obstructive Pulmonary Disease) DM (Disease Management) Asthma Multiple comorbidities Transitional care management

Depression Clinical Models Chronic (planned) care model – Wagner Collaborative care – Katon Partners in Care (AHRQ) – Wells PROSPECT – Alexopoulous, Katz, Reynolds Telephone care management – Simon, Hunkeler IMPACT (Hartford) – Unutzer RESPECT (MacArthur) – Dietrich Quality Improvement for Depression (NIMH) – Rost, Ford, Rubenstein Child models – Campo, Asarnow, GLAD-PC Other models for anxiety/PTSD

Clinical Model: Major Components Leadership Accountability Vision Resources Practice design Patient registry Protocols Care manager Clinical information systems Red flags Feedback to provider on clinical progress Support care manager Decision support Guidelines Provider training Expert/specialist consultation Referral pathways Self management support Patient preferences, cultural competency Information on depression, medications, skills Community resources Information on and for consumer groups and other services Access to non-provider sources of care

Leadership Leadership Component Key Principles Description Leadership There must be a leadership team composed of organizational partners with overall program accountability for implementation across partnering organizations A team of primary care, mental health, and senior administrative personnel that: Garners resources (personnel, space, financial) Incorporates and coordinates stakeholder interests Promotes adherence to treatment guidelines and protocols Sets target goals for key process measures and outcomes Encourages efforts at continuous quality improvement A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Delivery System Design Component Key Principles Description Delivery System Design The delivery system is available to implement all aspects of decision support. It consists of: Access to guidelines and protocols A depression patient registry A care manager responsible for implementing coordinated care in conjunction with primary care providers and, when necessary, mental health specialists A systematized approach to obtaining access to mental health specialists for referral, consultation, and feedback Care manager, either on or off site, implements protocols for: Systematically identification of patients at elevated risk for depression Screening of patients at elevated risk for major depression using a structured assessment tool Stratification of treatment intensity by episode severity and patient preference Monitoring and promotion of adherence to guideline-based treatment(s) for depression Routing follow-up at intervals specific to a patient’s phase of depression treatment (acute, continuation, or maintenance) Structure is in place to ensure facilitated access to mental health specialists A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Clinical Information System Component Key Principles Description Clinical Information System The clinical information system consists of tools to facilitate the roles of the primary care providers and care managers Note: The clinical information system does not necessarily need to be interactive with other computer systems Enables the primary care physician and care manager to establish a registry to identify, manage, and track depressed patients Tracks key process and program measures (e.g. percent of patients who received a structured assessment for depression, percent of patients continuing pharmacotherapy after 3 months, percent of patients who achieved a 50% decrease in depression scores) A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Decision Support Decision Support Component Key Principles Description Decision Support Evidence-based depression treatment guidelines and care protocols are available to improve recognition and treatment of depression There are evidence-based treatment guidelines and care protocols for: Systematically identifying patients at elevated risk for depression Case identification using a structured assessment tool Stratification of treatment intensity by severity Treatment by provider and care manager Mental health specialist referral Staff are trained in using decision support tools Materials receive periodic review and updating Mental health specialists are readily available for decision support and patient referral A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Self-Management Support Component Key Principles Description Self-Management Support Materials, tools, and processes are available to promote patient activation and self-care for depression Self-management support consists of: Shared decision making between patient and provider(s), taking into account patient preferences for treatment and family involvement Culturally appropriate patient information available in a variety of formats (e.g. print, audio, and videotape) Self-study materials including such self-care techniques as goal setting and problem solving, as well as promotion of adherence to pharmacotherapy CM follow-up on a patient’s progress with advice and acquisition of skills described in self-study materials A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Community Resources Community Resources Component Key Principles Description Community Resources Patient information and education about depression are available from organizations that are independent of providers and health plan Patients and families are informed of nonprogram information and other resources designed to assist in their understanding of depression and the various treatments available from such entities as: Local/national organizations Clergy, employee assistance programs, and support groups

Functions of Care Managers Patient-Focused Support Develop and maintain rapport Help access psychosocial treatment (e.g. interpersonal therapy or problem-solving therapy) Education/Self Management Educate about illness, treatments, side effects Communicate, customize, and maintain self-action plan for patient A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Functions of Care Managers Follow-up Encourage adherence to medications and education on their side effects Facilitate and remind patient about telephone or personal visits Facilitate communication and linkages with mental health specialist and primary care provider Intervene in crisis Clinical Systematically monitor depressive symptoms, comorbidities, adherence May provide psychosocial therapy or counseling (e.g. interpersonal therapy or problem-solving therapy) A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Phases of Depression Treatment Recovery Remission Relapse Recurrence No Depression Response Symptoms Syndrome Treatment Phases Acute Continuation Maintenance Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.

General Health/Mental Health Relationships Top Ten Issues General Health/Mental Health Relationships Partnerships Formalize Accountability Referral Consultation/Evaluation Information Flow Money Quid Pro Quo Maintenance Generalize

Gaps (1) Participant comments NCQA Reports

RESULTS FROM Round One NCQA Surveyed Sites 36 Sites Total 34 Primary Care 2 Behavioral Health

Where QIP Participants Did Well PPC1A: Access & Communication Processes e.g. Written Standards* MUST PASS 4 POINTS PPC2A: Patient Data e.g. Practice Management System or Registry* Not MUST PASS 2 POINTS PPC2E: Identify Important Conditions* PPC3A: Implement EBG* 3 POINTS PPC3B: Guideline-based Reminders When Seeing Patient PPC8A: Measures clinical and service performance* TOTAL 20 POINTS PPC1A: Access and Communication>> Processes: WRITTEN STANDARDS FOR: Response to urgent calls within specified time; Telephone triage; Same day appts; 24/7 policy; language services available PPC2E: Most frequently seen (single time or chronic); most important risk factors; clinically important conditions (recurring or chronic) PPC3A: For 3 clinically import conditions; workflow organizes; templates (paper or electronic) PPC3B: Paper or electronic guideline based alerts or reminders to conduct assessments or write orders PPC8A: Clinical outcomes; service data * PCASG Quality Minimum Requirement

Where QIP Participants Didn’t Do Well PPC2F: System for Population Management Generates lists of patients needing appts or follow-up, reminders for follow, on particular meds, chronic condition Not MUST PASS 3 POINTS PPC3E: Continuity of Care Identifies patients receiving care in facilities; routinely sends info to facilities; contacts patients after discharge 5 POINTS PPC4B: Actively Supports Self-Management: Readiness for change, language appropriate educational resources, self-monitoring tools, support programs, written care plan MUST PASS 4 POINTS

Where They Didn’t Do Well (cont) PPC6A: Test Tracking and Follow-up: Track lab and imaging tests until results return; flags overdue and abnormal results; notify patients of abnormal results; paper based or electronic MUST PASS 7 POINTS PPC7A: Referral Tracking and Follow-up For referral to specialist or consultant: origination: referring clinician; reason for referral; status; insurance/preapproval 4 POINTS

Where Results Were Variable PPC1B: Report on Access & Communication Visits with assigned physician; Response times; Same day appointment access; Language services available MUST PASS 5 POINTS PPC2B & C: Has and Uses Clinical Data System (SEARCHABLE) Age appropriate preventive services (immunizations, screening, counseling); Allergies; Vitals (BP, weight, BMI); Labs, imaging and path results Not MUST PASS 3 POINTS each PPC2D: Charting Tools Problem lists, medications, structured templates 6 POINTS PPC3C: Care Team Non-clinician provides reminders, standing orders, education, coordination PPC3D: Care Management Care plans, treatment goals, assess progress 1B >> 15 entities No or limited: 0 at 100% 2B&C: Are they in a data system and how often are they consistently collected 2D: Organizing Clinical Data: 11 had no capacity to chart 3C: Practice organization: has non-physician staff

Behavioral Health Organizations Challenges & Successes Reporting on Access & Communication Charting Tools Care Management Challenges Clinical Data System for Population Management Self Management Support Test Tracking

Primary Care Organizations Challenges & Successes Processes for Access & Communications Charting Tools Challenges Reporting on Access & Communication Clinical Data Systems System for Population Management Care Management Continuity of Care Self Management Support Test Tracking

Gaps (2) Organizing care management Incorporating self management Tasks/Roles/People Incorporating self management Disease registries Referral tracking Communication/HIPAA Test tracking Guideline-based reminders Using data for QI Continuity of care Anticipation of needs

Care Management Functions Patient engagement/rapport Screening/Assessment Education/Planning Self management support Clinical monitoring/Tracking Reminders (patient/provider) Accessing resources/referrals Coordination/Continuity Problem solving/counseling/therapy

General Health/Mental Health Relationships Top Ten Issues General Health/Mental Health Relationships Partnerships Formalize Accountability Referral Consultation/Evaluation Information Flow Money Quid Pro Quo Maintenance Generalize