Presentation on theme: "Patient Centered Medical Home"— Presentation transcript:
1 Patient Centered Medical Home Data and Recognition ReviewforSaint Luke’s Medical GroupbyJennifer Woods, RN, BSNDirector of Physician Practice Management
2 Goals of PresentationProvide better understanding of the Patient Centered Medical Home as a care model.Provide understanding of the credentialing process for Patient Centered Medical Home.Explore areas where this model provided a guidance for improvement in care.Review transformation in becoming a Patient Centered Medical Home.
3 What is a Patient-Centered Medical Home? A patient-centered medical home (PMCH) is a model of primary care where each patient has a relationship with their primary care physician who leads their care team, and the care of the patient is coordinated to support their healthcare needs.Enhanced care is achieved through open scheduling, expanded hours, and communication between patients, physicians and staff.
4 PMCH: Not a New Concept! Historical Review 1967: American Academy of Pediatrics (AAP) first introduced the term “medical home” which described primary care that was accessible, family-centered, coordinated, comprehensive, continuous, compassionate and culturally effective.
5 PMCH: Not a New Concept! Historical Review 2002: Seven national family medicine organizations created “The Future of Family Medicine” project. Recommendations from this report included “taking steps to ensure that every American has a personal medical home, developing reimbursement models to sustain family medicine and primary care.
6 PMCH: Not a New Concept! Historical Review 2005: Dr. Barbara Starfield published “Contribution of Primary Care to Health Systems and Health”, which acknowledged several primary care processes to benefit health:Greater accessBetter quality of careGreater focus on preventionEarly management of health problemsReducing unnecessary specialty or inpatient services
7 PMCH: Not a New Concept! Historical Review 2006: The Patient-Centered Primary Care Collaborative (PCPCC) is founded by numerous employers, primary care physician associations (American Academy of Family Physicians (AAFP). This new organization was charged with developing a national movement to endorse widespread adoption of the patient-centered medical home.
8 What is NCQA?National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout healthcare, helping to elevate the issue of quality to the top of the national agenda.
9 What is NCQA’s PCMH Program? In 2008, NCQA launched a Patient Centered Medical Home recognition program, which was revised in 2011.NCQA’s program provides a roadmap for primary care to improve delivery and the experience of care for both clinicians and patients.
10 What is NCQA’s PCMH Program? NCQA’s goals are to promote:Improvement in health outcomes for the patient and their familyEnhance the patient’s experience of their careReduce expensive, unnecessary hospital and ED careTo the extent possible, NCQA has aligned the PCMH standards with the Centers for Medicare & Medicaid Services (CMS) Meaningful Use requirements.
11 NCQA PCMH Scoring 6 Standards = 100 points 6 Must Pass elements Level of QualifyingPointsMust Pass Elements at 50% Performance LevelLevel 36 of 6Level 2Level 1Not recognized0 - 34Less than 6Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.
12 SLMG: Transformation to PCMH SLMG selected NCQA’s recognition program, and began by utilizing their assessment tools to determine areas of compliance with standards, as well as opportunities for improvement.PMCH Coordinating Committee established to govern the transformation process, and was supported by:PMCH Site Coordinator and physician lead at each clinic to assist with implementation of new policies, procedures and reporting tools.
13 SLMG: Transformation to PCMH Newsletters developed to keep staff apprised of next steps.Educational presentations at staff and physician meetings on PMCH standards and requirements for recognition.Standardization of policies and processes.Partnership with outside vendor for patient registry to manage patient populations.
14 NCQA 2011 PCMH Standards Enhance Access and Continuity Identify and Manage Patient PopulationsPlan and Manage CareProvide Self-Care Support and Community ResourcesTrack and Coordinate CareMeasure and Improve Performance
15 PCMH: Review of Standards PMCH 1: Enhance Access and Continuity Element A: Access During Office Hours (Must Pass)The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:Providing same day appointmentsProviding timely clinical advice by telephone during office hoursProviding timely clinical advice by secure electronic messages during office hoursDocumenting clinical advice in the medical record
16 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element B: After-Hours AccessThe practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:Providing access to routine and urgent-care appointments outside regular business hoursProviding continuity of medical record information for care and advice when the office is not openProviding timely clinical advice by telephone when the office is not openProviding timely clinical advice using a secure, interactive electronic system when the office is openDocumenting after-hours clinical advice in patient records
17 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element C: Electronic AccessThe practice provides the following information and services to patients and families through a secure electronic system.More than 50% of patients who request an electronic copy of the health information receive it within 3 business daysAt least 10% of patients have electronic access to their current health information within 4 business days of when the information is available to the practice
18 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element C: Electronic Access cont.3. Clinical summaries are provided to patient for more than 50% of office visits within 3 business days4. Two-way communication between patients/families and the practice5. Request of appointments or prescription refills6. Request for referrals or test results
19 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element D: ContinuityThe practice provides continuity of care for patients/families by:Expecting patients/families to select a personalclinicianDocumenting the patient’s/family’s choice of clinicianMonitoring the percentage of patient visits with a selected clinician or team.
20 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element E: Medical Home ResponsibilitiesThe practice has a process and materials that it provides patients/families on the role of the medical home, which include the following:The practice is responsible for coordinating patient care across multiple settingsInstructions on obtaining care and clinical advice during offices hours and when the office is closedThe practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practiceThe care team gives the patient/family access to evidenced-based care and self-management support
21 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element F: Culturally and Linguistically Appropriate Services (CLAS)The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by:Assessing the racial and ethnic diversity of its populationAssessing the language needs of its populationProviding interpretation or bilingual services to meet the language needs of its populationProviding printed materials in the languages of its population
22 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element G: The Practice TeamThe practice uses a team to provide a range of patient care services by:Defining roles for clinical and nonclinical team membersHaving regular team meetings or a structured communication processUsing standing orders for servicesTraining and assigning care teams to coordinate care for individual patients
23 PCMH: Review of Standards PCMH 1: Enhance Access and Continuity Element G: The Practice Team cont.Training and assigning care teams to support patients and families in self-management, self-efficacy and behavior changeTraining and assigning care teams for patient population managementTraining and designating care team members in communication skillsInvolving care team staff in the practice’s performance evaluation and quality improvement activities
24 PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element A: Patient Information The practice uses an electronic system that records the following as structured (searchable) data for more than 50% of its patients.Date of birthGenderRaceEthnicityPreferred languageTelephone numbersaddressDates of previous clinical visitsLegal guardian10. Primary caregiverPresence of advanced directiveHealth insurance information
25 PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element B: Clinical Data The practice uses an electronic system to record the following as structured (searchable) data.An up-to-date problem list with current and active diagnoses for more than 80% of patientsAllergies, including medication allergies and adverse reactions, for more than 80% of patientsBlood pressure, with the date of update for more than 50% of patients 2 years and olderHeight for more than 50% of patients 2 years and olderWeight for more than 50% of patients 2 years and olderSystem calculates and displays BMISystem plots and displays growth charts and BMI %Status of tobacco use for patients 13 years and older for more than 50% of patientsList of prescription medications with the date of updates for more than 80% of patients
26 PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element C: Comprehensive Health Assessment To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes:Documentation of age and gender appropriate immunizations and screeningsFamily/social/cultural characteristicsCommunication needsMedical history of patient and familyAdvance care planningBehaviors affecting healthPatient and family mental health/substance abuseDevelopmental screening using a standardized toolDepression screening for adults and adolescents using a standardized tool
27 PMCH Review of Standards PCMH 2: Identify and Manage Patient Populations Element D: Use Data for Population Management (Must Pass)The practice uses patient information, clinical data and evidenced-based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of services needed for:At least three different preventive care servicesAt least three different chronic care servicesPatients not recently seen by the practiceSpecific medications
28 PCMH: Review of Standards PCMH 3: Plan and Manage Care The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidenced-based guidelines.Element A: Implement Evidenced-Based GuidelinesThe practice implements evidenced-based guidelines through point-of-care reminders for patients with:The first important conditionThe second important conditionThe third condition, related to unhealthy behaviors or mental health or substance abuse
29 PCMH: Review of Standards PCMH 3: Plan and Manage Care cont. Element B: Identify High-Risk PatientsTo identify high-risk or complex patients, the practice:Establishes criteria and a systematic process to identify high risk or complex patientsDetermines the percentage of high-risk or complex patients in it’s population
30 PCMH: Review of Standards PCMH 3: Plan and Manage Care Cont. Element C: Care Management (Must Pass)The are team performs the following for at least 75% of the patients identified in Elements A and B.Conducts pre-visit preparationsCollaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visitGives the patient/family a written plan of careAssesses and addresses barriers with the patient has not met treatment goalsGives the patient/family a clinical summary at each relevant visitIdentifies patients/families who might benefit from additional care management supportFollows up with patients/families who have not kept important appointments
31 PMCH: Review of Standards PCMH 3: Plan and Manage Care cont. Element D: Medication ManagementThe practice manages medications in the following ways:Reviews and reconciles medications with patients/families for more than 50% of care transitionsReviews and reconciles medications with patients/families for more than 80% of care transitionsProvides information about new prescriptions to more than 80% of patients/familiesAssesses patient/family understanding of medications for more than 50% of patients with date of assessmentAssesses patient responses to medications and barriers to adherence for more than 50% of patients with date of assessmentDocuments over-the-counter medications, herbal therapies and supplements for more than 50% of patients/families, with the date of updates
32 PCMH: Review of Standards PCMH 3: Plan and Manage Care Element E: Use Electronic PrescribingThe practice uses an electronic prescription system with the following capabilities.Generates and transmits at least 40% of eligible prescriptions to pharmaciesGenerates at least 75% of eligible prescriptionsEnters electronic medication orders into the medical record for more than 30% of patients with at least one medication in their medication listPerforms patient-specific checks for drug-drug and drug-allergy interactionsAlerts prescribers to generic alternativesAlerts prescribers to formulary status
33 PCMH: Review of Standards PCMH 4: Provide Self-Care Support and Community Resources The practice acts to improve patients’ ability to manage their health by providing a self-care plan, tools, educational resources and ongoing supportElement A: Support Self-Care Process (Must Pass)The practice conducts activities to support patients/families in self-management.Provides educational resources or refers at least 50% of patients/families to educational resources to assist in self-managementUses an EHR to identify patient-specific education resources and provide them to more than 10% of patients, if appropriateDevelops and documents self-management plans and goals in collaboration with at least 50% of patients/familiesDocuments self-management abilities for at least 50% of patients/familiesProvides self-management tools to record self-care results for at least 50% of patients/familiesCounsels at least 50% of patients/families to adopt healthy behavio
34 PCMH: Review of Standards PCMH 4: Provide Self-Care Support and Community Resources Element B: Provide Referrals to Community ResourcesThe practice supports patients/families that need access to community resources.Maintains a current resource list on five topics or key community service areas of importance to the patient populationTracks referrals provided to patients/familiesArranges or provides treatment for mental health and substance abuse disordersOffers opportunities for health education programs (such as group classes and peer support)
35 PCMH: Review of Standards PMCH 5: Track and Coordinate Care The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizationsElement A: Test Tracking and Follow-UpThe practice has a documented process for and demonstrates that it:Tracks lab tests until results are available, flagging and following up on overdue resultsTracks imaging tests until results are available, flagging and following up on overdue resultsFlags abnormal lab results, bringing them to the attention of the clinicianFlags abnormal imaging results, bringing them to the attention of the clinicianNotifies patients/families of normal and abnormal lab and imaging test resultsFollows up with inpatient facilities on newborn hearing and blood-spot screeningElectronically communicates with labs to order tests and retrieve resultsElectronically communicates with facilities to order and retrieve imaging resultsElectronically incorporates at least 40% of all clinical lab test results into structured fields in medical recordsElectronically incorporates imaging test results into medical records
36 PCMH: Review of Standards PCMH 5: Track and Coordinate Care Element B: Referral Tracking and Follow-Up (Must Pass)The practice coordinates referrals by:Giving the consultant or specialist the clinical reason for the referral and pertinent clinical informationTracking the status of referrals, including required timing for receiving a specialist’s reportFollowing up to obtain a specialist’s reportEstablishing and documenting agreements with specialists in the medical record if co-management is neededAsking patients/families about self-referrals and requesting reports from cliniciansDemonstrating the capability for electronic exchange of key clinical information between cliniciansProviding an electronic summary of care record to another provider for more than 50% of referrals
37 PCMH: Review of Standards PCMH 5: Track and Coordinate Care Cont. Element C: Coordinate with Facilities and Manage Care TransitionsOn its own or in conjunction with an external organization, the practice systematically:Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visitDemonstrates its process for sharing clinical information with admitting hospitals and emergency departmentsDemonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilitiesDemonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visitDemonstrates its process for exchanging patient information with the hospital during a patient’s hospitalizationCollaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult careDemonstrates the capability for electronic exchange of key clinical information with facilitiesProvides an electronic summary of care record to another care facility for more than 50% of transitions of care
38 PCMH: Review of Standards PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.Element A: Measure PerformanceThe practice measures or receives data on the following:At least three preventive care measuresAt least three chronic or acute care clinical measuresAt least two utilization measures affecting health care costsPerformance data stratified for vulnerable populations (to assess disparities in care).
39 PCMH: Review of Standards PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.Element B: Measure Patient/Family ExperienceThe practice obtains feedback from patients/families on their experiences with the practice and their care.The practice conducts a survey to evaluate patient/family experiences on at least three of the following categories:AccessCommunicationCoordinationWhole-person care/self management support2. The practice uses the CAHPS Patient Centered Medical Home tool3. The practice obtains feedback on the experiences of vulnerable patient groups4. The practice obtains feedback from patients/families through qualitative means.
40 PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont. Element C: Implement Continuous Quality Improvement (Must Pass)The practice uses an ongoing quality improvement process to:Set goals and act to improve performance on at least three measures from Element A.Set goals and act to improve performance on at least one measure from Element B.Set goals and address at least one identified disparity in care or service for vulnerable populations.Involve patients/families in quality improvement teams or on the practice’s advisory council.
41 PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont. Element D: Demonstrate Continuous Quality ImprovementThe practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:Tracking results over timeAssessing the effect of its actionsAchieving improved performance on one measureAchieving improved performance on a second measure
42 PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont. Element E: Report PerformanceThe practice shares performance data from Element A and Element B:Within the practice, results by individual clinicianWithin the practice, results across the practiceOutside the practice to patients or publicly, results across the practice or by clinician.
43 PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont. Element F: Report Data ExternallyThe practice electronically reports:Ambulatory clinical quality measures to CMS or states.Ambulatory clinical quality measures to other external entities.Data to immunization registries or systemsSyndromic surveillance data to public health agencies.
44 PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont. Element G: Use Certified EHR TechnologyThis element is for your practice site Meaningful Use report only and will not be scored for your PCMH Recognition decision.To meet the federal Core and Menu Meaningful Use requirements:The uses an EHR system that has been certifiedThe practice attests to conducting a security risk analysis of its EHR system.
45 NCQA PCMH Recognition Outcome . On October 13, 2013 Saint Luke’s Medical Group received notification that all 11 primary care clinics were recognized as a Level 3 Patient Centered Medical Home.
46 NCQA PCMH Clinics Saint Luke’s Internal Medicine (SLIM) Saint Luke’s Medical-Barry RoadSaint Luke’s Medical Group-Barry Road Internal MedicineSaint Luke’s Medical-ClintonSaint Luke’s Medical-SmithvilleSaint Luke’s Medical Group-CushingSaint Luke’s Medical Group-LansingSaint Luke’s Medical Group-Lee’s SummitSaint Luke’s Medical Group-Platte CitySaint Luke’s Medical Group-SouthridgeSaint Luke’s South Primary Care
47 Results of Transformation Same Day Access available at all clinics.Goals developed for responding to patients by telephone, electronically and after hours.Summary of each visit provided to patients.Defining each staff’s role on the care team.Training of staff for population management, communication skills, and their role in quality improvement.
48 Outcomes of Transformation Reports available to proactively remind patients of services needed for:Preventive CareChronic CareMissed AppointmentsReconciling patient medications at each visit and after hospital or ED discharge.Development of a community resource list.Standardization of self-management tools.Formalized process of tracking tests, referrals and care at other facilities
49 Outcomes of Transformation New positions of RN Care Coordinators to call every patient following in-patient discharge from hospital and emergency room. Coordinators will:Set up follow up appointment as neededMedication reconciliationReview discharge instructionsReview if any resources are neededAnswer questions
50 Lessons LearnedHave a designated IT expert assigned for the entire project.Have an analyst who can build your reporting tools.Have support staff who can receive and manage all reports and documents.Have an onsite point person to provide ongoing education and support to staff.