1. The Long and Winding Road to PCMH

2. Presenters Laurel Domanski Diaz, MNO, Director of Business Operations
Dan Gauntner, CNP, Director of Clinical Operations
Marianella Napolitano, RN, MBA, Clinical Quality Coordinator
Marianella

3. Objectives Identify all of the workflows needed to implement PCMH
Deep dive into NFP PCMH application
Identify the challenge areas within the application
Describe how to overcome the challenges presented due to limited ability to produce needed data

4. NFP Background
A Federally Qualified Community Health Center founded in 1980
Last year served 13,400 patients on the near west side of Cleveland
NCQA recognized as PCMH Level 3 under 2011 standards
17 Providers on staff--7 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives
Focus on the medically underserved
Serve a large Hispanic population
Laurel

5. What is a Care Team?
A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.
Erick

6. Our Care Team Composition
Three Providers—combination of Family MDs, Family CNPs, one team’s providers consists of 3 Certified Nurse Midwives
One to two RNs
One to two Patient Advocates
Medical Assistant for each Provider
Front Office representative at each team meeting
Erick

7. Care Team Implementation Activities
Developing new procedures around scheduling, registering patients & directing phone calls to teams.
Conducting activities around team formation, structure and ongoing activities.
Organizing providers and support staff into integrated care teams
Redesigning of Nursing staff structure to provide individual nurses to care teams.
Adding a Patient Advocate to each team, vital role in the PCMH model
Extended Team Support includes:
On-site Clinical Pharmacist
CareSource RN
Wellness Coordinator
Refugee Health Services
Medication Assistance Program
Diabetes Education
Erick

8. The PCMH Team & Application Plan
Identify the PCMH Application Team
Identify Key Application Facilitators
Delegation of different areas of application to relevant person
Need to have a variety of people on team, clinical and non-clinical
Organization of application and documents
Tackle each section, utilizing organization’s resources as needed
Weekly working sessions, day long sessions as submission time approached

9. Survey & Intake – What we needed to create
Inventory of Policies and Procedures, update the manual with EMR implementation, focused on PCMH relevant documents
Inventory of reports that existed, what needed to be created, etc.
Surveyed current workflows and determined how they needed to change to meet the requirements:
Patient Advocate role and new responsibilities to meet requirements
Front Office no-show work
Clinical Teams work flow around self management goals and patient education
Referral follow up process

10. Deep Dive Into the PCMH Application

11. Element 1: Enhanced Access & Continuity
A—Access During Office Hours:
Phone reporting system was used to demonstrate volume of incoming calls that RNs used to triage patient calls
B—After Hours Access:
Reports from our Answering Service that shows when the patients called NFP and at what time NFP providers returned the call.

12. After Hours Documentation
Insert Screenshot on call documentation after hours (within 24 hrs)

13. Element 1: Enhanced Access & Continuity
E—Medical Home Responsibilities
CareEverywhere capabilities allowed us to demonstrate care coordination/communication across different settings.
G—The Practice Team
Standing Orders Protocol Development
Pre-Orders Workflow Implementation (insert workflow)
Cle has EPIC mainly so we use CareEverywhere to demonstrate

14. Pre-Orders Workflow Prior to the Visit Day of the Visit
PA identifies patients with Chronic Conditions
PA scrubs the chart and enters routine labs/immunizations per protocol
PA calls all DM, HTN patients to remind them of visit and to bring blood sugar readings and medications
Documentation of pre-visit / pre-order preparation
Day of the Visit
Team Huddles
From documentation in EPIC, team is aware of pre-orders
MA releases pre-orders during the patient’s visit

15. Pre-Order Protocol

16. Element 2- Identify and Manage Populations
A—Patient Information
Primary Caregiver is defined as the name of the Emergency contact for patients under 18
NFP did not identify a legal guardian/health care proxy
D—Use Data for Population Management
Solutions (Chronic Care, Well Child Care, Coumadin report)
Managed Care Plans registries
Patient Schedule for pre-natal care outreach & chronic disease management
No Show report within EPIC
Televox report for daily reminders

17. 3A—Implement Evidence-Based Guidelines
Element 3 – Plan and Managed Care and Element 4 – Provides Self-Care Support and Community Resources
3A—Implement Evidence-Based Guidelines
Defined guidelines used and inserted screenshots of patient charts where they were used
Health maintenance and best practice alerts
3B–-Identify High Risk Patients
High Risk Definition (Solutions)
Rosters – Ability to analyze data using excel
3C, 3D, 4A
NFP Patient Examples
NCQA Manual Chart Audit option

18. Element 5 – Track and Coordinate Care
5B—Referral Tracking and Follow-up
Access to portals for other Epic providers in the region to obtain reports
Item 7 - Providing an electronic summary of the care record to another provider for more than 50 percent of referrals
NFP provides electronic access to outside providers through Care Everywhere – which is used by majority of healthcare providers in region.

19. Element 6 – Measure and Improve Performance
Leadership commitment to Quality
FQHCs: used your Quality Management Plan from your HRSA grant
UDS reports and trends
Solutions reports
Utilization measures (preventative care measures)
Reinforcement of workflows/training
Immunization Registries
Make mention of any Quality Collaborative that you are currently participating
Insert Dashboard

20. Questions?