Goals of NCQA Standards Increase patient-centeredness Align requirements with processes that improve quality and eliminate waste (i.e., ER visits, Hospital readmissions, using brand vs. generic, etc.) Increase emphasis on patient experience Enhance use of clinical performance measure results Integrate: unhealthy behaviors, mental health, and substance abuse Enhance coordination of care Enhance applicability to pediatric practices
Eligible Applicants Outpatient primary care practices that meet scoring criteria for either Level 1, 2, or 3 (3 is highest) NCQA defines a practice as a clinician or clinicians practicing together at a single geographic location, includes nurse-led practices in states where state licensing designates NPs as independent practitioners
Eligible Applicants (Cont’d) Recognition is at the practice-site level Assessment for recognition must include a survey for every site that the practices wants to identify as a recognized PCMH PCMH recognition identifies primary care clinicians practicing at the site, including nurse practitioners and physician assistants that have their own patient panels
Six Standards 1.Enhance Access and Continuity 2.Indentify and Manage Patient Populations 3.Plan and Manage Care 4.Provide Self-Care Support and Community Resources 5.Track and Coordinate Care 6.Measure and Improve Performance
Composition of Standards Consist of Standard, Element, and Factor There is always a MUST PASS Element and a Critical Factor in each standard EXAMPLE: Standard 1 Enhance Access and Continuity Element 1A (of 7): Access During Office Hours Factor 1 (of 4): Provide same-day appointments—CRITICAL FACTOR!
Must Pass Elements PCMH 1, Element A: Access During Office Hours PCMH 2, Element D: Use Data for Population Management PCMH 3, Element C: Care Management PCMH 4, Element A: Support Self-Care Process PCMH 5, Element B: Referral Tracking and Follow-up PCMH 6, Element C: Implement Continuous Quality Improvement
PCMH Scoring 6 standards = 100 pts 6 MUST PASS elements* LevelPointsMust Pass Elements at 50% Performance Level Level 385-1006 Level 260-846 Level 135-596 *Must pass elements require a ≥50% performance level to pass!
Standards Standard 1Enhanced Access & ContinuityPoints A.Access During Office Hours**4 B.After-Hours Access4 C.Electronic Access2 D.Continuity2 E.Medical Home Responsibilities2 F.Culturally & Linguistically Appropriate2 G.Practice Team4 TOTAL20 ** Must Pass
Standards (Cont’d) ** Must Pass Standard 3Plan & Manage CarePoints A.Implement Evidence-Based Guidelines4 B.Identify High-Risk Patients3 C.Care Management**4 D.Medication Management3 E.Use Electronic Prescribing3 TOTAL17 Standard 2Identify & Manage Patient PopulationsPoints A.Patient Information3 B.Clinical Data4 C.Comprehensive Health Assessment4 D.Use Data for Population Management**5 TOTAL16
Standards (Cont’d) ** Must Pass Standard 5Track & Coordinate CarePoints A.Test Tracking & Follow-Up6 B.Referral Tracking & Follow-Up6 C.Coordinate with Facilities/Care Transition 6 TOTAL18 Standard 4Provide Self-Care Support & Community Resources Points A.Support Self-Care Process**6 B.Provide Referrals to Community Resources 3 TOTAL9
Standards (Cont’d) ** Must Pass Standard 6Measure & Improve PerformancePoints A.Measure Performance4 B.Measure Patient/Family Experience4 C.Implement Continuous Quality Improvement 4 D.Demonstrate Continuous Quality Improvement 3 E.Report Performance2 F.Report Data Externally2 G.Use of Certified EHR Technology0 TOTAL20
Crosswalk Between MU and NCQA REQUIREMENTS REQUIREMENTMeaningful UseNCQA Certified EHRRequiredNot Required Unit of MeasurementClinicianPractice SITE Reporting Period12 months12 months IF EHR has been in place for > 1 year; if not, 3 months
Crosswalk: MU, NCQA Standards PA SPREAD Measures Meaningful Use NCQA PCMH 2011 Notes HbA1C >9% ☒☐ Can use any 3 of these diabetes measures to meet Meaningful Use Clinical Quality Measure reporting requirement. Can choose to use any 3 of these to meet NCQA PMCH 2, Element D (Must Pass Element): generate lists of patients who need chronic care management services and use the lists to remind patients of needed services for at least three chronic care services. HbA1C <8% ☒☐ BP <140/90 ☒☐ LDL <100 ☒☐ Urine Screening ☒☐ Eye Exam ☒☐ Foot Exam ☒☐ Self-Management Goal ☐☒ NCQA PCMH 4, Element A.4 (Must Pass Element and Critical Factor): develop and document self-management plans and goals in collaboration with at least 50% of all (not just diabetes) patients/families. Tobacco Query ☒☒ Meaningful Use Core Measure #9: Must record smoking status as structured data for more than 50% of patients ages 13 and older (tobacco query). Meaningful Use Clinical Quality Measure Core Set: Must report both the percentage of patients age 18 and older who have been asked about their tobacco use in the past 24 months and the percentage of patients age 18 and older who use tobacco who have been provided a tobacco cessation intervention. NCQA PCMH 2, Element B.8: use an electronic system to record as structured (searchable) data the status of tobacco use for patients 13 years and older for more than 50% of patients.
Practice Needs for PCMH Survey 1.Computer system and staff skill with: Email Internet access Microsoft Word Microsoft Excel Adobe Acrobat Reader (free online!) Document scanning and screen shots 2.Access to the electronic systems used by the practice, including billing system, registry, practice management system, electronic prescription system, EHR, Web portal, etc.
NCQA Recognition Process 1.Obtain standards and guidelines 2.Participate in trainings 3.Create online account 4.Purchase Survey Tool software license 5.Self-assess current performance on survey 6.Implement new PCMH capabilities at least three months prior to survey submission
Recognition Process (cont’d) 7. Complete online application information: electronic agreements, practice site & clinician details, and application for survey 8. Submit application 9. Receive email confirmation that the practice can submit survey tool and documentation 10. Submit survey tool and application fee when ready Receive decision in 30-60 days!
NCQA Educational Resources Free online training http://www.ncqa.org/tabid/109/Default.aspx Patient-Centered Medical Home (PCMH) Getting on Board with PCMH PCMH 2011 Standards The Online Application and How to Submit as a Multi-Site Practice The Online Application and How to Submit as a Multi-Site Practice
Other Resources PA SPREAD: http://www.paspread.com Patient Centered Primary Care Collaborative http://www.pcpcc.net/
Notes Need a person to coordinate process! Lots of policies and procedures, brochures/pt welcome letters, required for submission—not hard, just tedious! Need to report on THREE CONDITIONS (i.e., DM, Hypertension, well woman, stroke, whatever makes sense for your practice) PLUS a high risk population (lab or other values not improving? Uninsured? MA Population? Migrant worker? ESL? No Shows? Noncompliant with care plan?). Pick one you can easily retrieve data on!
Notes (cont’d) Screen shots of various screens required They are very willing to help and have lots of tools on their website Recommend spending the $80 for the survey tool so you can see what you will be required to submit and also be able to gauge where you are! Current standards and tools good until at least 2014 Aligns with Meaningful Use criteria!