1. Care Management: The Transition to Meeting NCQA Standards for PCMH Clyde H. Satterly, MD, MBA SUNY Upstate Medical University, Dept of Family Medicine

2. PCMH Recognition Getting started Getting started Review the Standards (Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) version Review the Standards (Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) version Found at publications@ncqa.org Found at publications@ncqa.orgpublications@ncqa.org Survey tool is available for $80 Survey tool is available for $80

3. Survey Tool Fee is $80 to register Fee is $80 to register Online Survey Tool Online Survey Tool Can download the standards for review Can download the standards for review Allows self assessment for readiness to apply for recognition Allows self assessment for readiness to apply for recognition Takes about two hours to do rough estimate Takes about two hours to do rough estimate Will result in a quick score Will result in a quick score

4. Survey Tool Tool takes you through the nine Standards Tool takes you through the nine Standards There are 10 must pass elements of 30 There are 10 must pass elements of 30 Must get a 50% score on a given element to pass Must get a 50% score on a given element to pass 5/10 elements,Level I Recognition 5/10 elements,Level I Recognition 10/10 elements 50% or greater, Level II 10/10 elements 50% or greater, Level II 10/10 elements 75% or greater, Level III 10/10 elements 75% or greater, Level III

6. Standard 3 Care Management Possible 20 of the total 100 points Possible 20 of the total 100 points Not too straightforward Not too straightforward Contains one of the 10 must pass elements for recognition Contains one of the 10 must pass elements for recognition

7. Element A Source: PPC-PCMH Version Standards Source: PPC-PCMH Version Standards

8. Clinically Important Conditions Chronic recurrent condition that practice sees Chronic recurrent condition that practice sees Can be the same as the most frequently seen conditions Can be the same as the most frequently seen conditions Must be the ability to treat/change the condition Must be the ability to treat/change the condition Can be condition that the practice has targeted for performance improvement Can be condition that the practice has targeted for performance improvement

9. Clinically Important Conditions There is no hierarchy among them There is no hierarchy among them They will be used in fulfilling Standards 2, 3, 4 and 9 They will be used in fulfilling Standards 2, 3, 4 and 9 Goal is for the practice to adopt evidenced based guidelines for the conditions Goal is for the practice to adopt evidenced based guidelines for the conditions The guidelines must be meaningful to the clinicians in the practice The guidelines must be meaningful to the clinicians in the practice Must be consistent with standards of care they want to follow Must be consistent with standards of care they want to follow

10. SUNY Upstate Family Medicine Medical Service Group SUNY Upstate Family Medicine Medical Service Group Hypertension Hypertension Diabetes Mellitus Diabetes Mellitus Hyperlipidemia Hyperlipidemia Same items we used for PQRI reporting Currently reporting stats for Medicare only but practice has adopted the guidelines for all patients

11. Data Source Organizers or algorithms for developing treatment plans Organizers or algorithms for developing treatment plans Flow sheets or templates for documenting progress Flow sheets or templates for documenting progress Registry (such as PQRI) Registry (such as PQRI) Screenshots for treatment plans and documenting progress Screenshots for treatment plans and documenting progress

14. Element B Source: PPC-PCMH-Version Standards Source: PPC-PCMH-Version Standards

15. Preventive Service Clinician Reminders Age appropriate screening tests Age appropriate screening tests Colonoscopy Hemoccult Mammogram PAP Smear DEXA Cholesterol Diabetes

16. Preventive Service Clinician Reminders Age appropriate immunizations Age appropriate immunizations Pneumovax Seasonal flu H1N1 flu Tetanus booster Childhood immunizations

17. Preventive Service Clinician Reminders Age appropriate risk assessments Age appropriate risk assessments Smoking Diet Depression Fall prevention

18. Preventive Service Clinician Reminders Counseling Counseling Smoking Cessation Diet/Exercise Alcohol/Substance Abuse Seatbelt use Safety helmets

19. Data Source Paper based system-submit templates, flow sheets, algorithms or reminders Paper based system-submit templates, flow sheets, algorithms or reminders EHR-submit reports generated or can use screen shots EHR-submit reports generated or can use screen shots The practice must demonstrate that clinicians have decision support available for interaction with patients (in appointments, by phone, e- mail, etc.) The practice must demonstrate that clinicians have decision support available for interaction with patients (in appointments, by phone, e- mail, etc.)

20. SUNY Upstate Family Medicine Medical Service Group Screen shots from EMR Screen shots from EMR

21. Element C Source: PPC-PCMH Version Standards Source: PPC-PCMH Version Standards

22. Practice Organization The emphasis is on a team approach to managing patient care The emphasis is on a team approach to managing patient care Shared responsibilities maximize each team members level of training and expertise Shared responsibilities maximize each team members level of training and expertise In larger practices this might involve the use of nurse case managers In larger practices this might involve the use of nurse case managers

23. Practice Organization Non physician staff remind patients of appointments and collect information prior to appointments Non physician staff remind patients of appointments and collect information prior to appointments Next follow up noted in both chart note and on encounter form Nurse orders labs prior to visit Nurse assures labs/tests in chart at time of visit Reminder Pro calls patient day before

24. Practice Organization Non physician staff execute standing orders for medication refills Non physician staff execute standing orders for medication refills All routine medications are filled for #30 with 5 refills or #90 with 1 refill IF recent f/up in 6 mos If no recent f/up then #30 with no refill If refill of controlled substance then only if chart indicates okay and refill is not early

26. Practice Organization Non physician staff educate patients/families about managing conditions Non physician staff educate patients/families about managing conditions In process for SUNY Currently setting up group visits Posting our intranet for standard patient education materials the nurse can use Currently some nurses do more than others

27. Practice Organization Non physician staff coordinate care with disease management or case management programs Non physician staff coordinate care with disease management or case management programs In process for SUNY Currently doing this with home health care agencies Some health plans are offering case management programs here

28. Data Source Supporting information required here is basic Supporting information required here is basic Staff job descriptions Staff job descriptions Procedure and protocol manuals Procedure and protocol manuals EMR screen shots EMR screen shots

29. Element D Source: PPC_PCMH Version Standards Source: PPC_PCMH Version Standards

30. Element D - Cont’d Source: PPC-PCMH Version Standards Source: PPC-PCMH Version Standards

31. Care Management of Important Conditions Note the practice must document at least 4 of the 11 items are met to a degree of greater than 10% for all three conditions Note the practice must document at least 4 of the 11 items are met to a degree of greater than 10% for all three conditions This item is scored only once by a chart review This item is scored only once by a chart review Chart review looks at a three month period Chart review looks at a three month period

32. Care Management of Important Conditions Number of patients for whom each item is entered _________________________________ Total number of patients seen at least once in the last three months

33. Care management of Important Conditions Not all patients with important conditions need care management Not all patients with important conditions need care management The patient may already be achieving good outcomes The patient may already be achieving good outcomes In this case a notation in the chart indicating the patient is on target is sufficient In this case a notation in the chart indicating the patient is on target is sufficient

35. Care Management of Important Conditions Item #4 Assessing patient progress toward goals Item #4 Assessing patient progress toward goals

37. Care Management of Important Conditions Item#5 Reviewing medication lists with patients Item#5 Reviewing medication lists with patients

39. Care Management of Important Conditions Items #7-8 The barriers to be addressed may include the patient’s lack of understanding, motivation, financial need, insurance issues or transportation problems Items #7-8 The barriers to be addressed may include the patient’s lack of understanding, motivation, financial need, insurance issues or transportation problems Documentation of barriers and what, if anything, was done to address them Documentation of barriers and what, if anything, was done to address them

40. Care Management of Important Conditions Item#9 Important appointments are those that the practice has requested the patient to make in order to follow standards of care (e.g., follow-up visits for monitoring blood pressure, blood sugar or lipid levels.) Item#9 Important appointments are those that the practice has requested the patient to make in order to follow standards of care (e.g., follow-up visits for monitoring blood pressure, blood sugar or lipid levels.) The practice should follow up if these appointments are not kept The practice should follow up if these appointments are not kept

42. Care Management of Important Conditions Item #10 Examples of longitudinal patient data may include graphs or flow sheets showing blood pressure, weight, Hgb A1c, LDL levels etc over time Item #10 Examples of longitudinal patient data may include graphs or flow sheets showing blood pressure, weight, Hgb A1c, LDL levels etc over time

45. Care Management of Important Conditions Item#11 Examples of after visit follow up may include checking with patients to confirm they filled a prescription or received care with a consultant. Item#11 Examples of after visit follow up may include checking with patients to confirm they filled a prescription or received care with a consultant.

46. Element E Source: PPC-PCMH Version Standards Source: PPC-PCMH Version Standards

47. Element E – Cont’d Source: PPC-PCMH Version Standards Source: PPC-PCMH Version Standards

48. Continuity of Care A facility may be a hospital, emergency room, skilled nursing facility or surgical center A facility may be a hospital, emergency room, skilled nursing facility or surgical center The practice does NOT wait for these patients to make an appointment but contacts them directly The practice does NOT wait for these patients to make an appointment but contacts them directly

49. Continuity of Care Need for nursing home care is anticipated Need for nursing home care is anticipated The patient receives care at another facility The patient receives care at another facility The patient has frequent ER visits or hospitalizations The patient has frequent ER visits or hospitalizations The patient needs care of a specialist The patient needs care of a specialist Practice provides the facility with appropriate information The practice reviews data to identify these patients and contacts them for follow up or reviews care plans of the patients Practice identifies these patients as needing case management and arranges for such (practice can do this internally or can use external organization) The practice makes referral and consults with the specialist and carries out recommendations

50. Data Source The level of documentation is basic The level of documentation is basic Protocols showing practice timeframe for follow-up after a hospital stay or ER visit Protocols showing practice timeframe for follow-up after a hospital stay or ER visit Documentation showing how these patients are identified (hospital or ER printouts etc) Documentation showing how these patients are identified (hospital or ER printouts etc) Documentation of nursing facility care plans that have been reviewed Documentation of nursing facility care plans that have been reviewed Case management notes Case management notes Medical record notes Medical record notes

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