1. Training Webinar # 6 David Halpern, MD, MPH February 15, 2012 Patient-Centered Medical Home NCQA’s PCMH 2011 Standards

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3. Acknowledgements

4. Let’s Review Standard 2 – Identify & Manage Populations –PCMH 2A: Patient Information –PCMH 2B: Clinical Data –PCMH 2C: Comprehensive Health Assessment –PCMH 2D: Use Data for Population Management - MUST PASS Standard 5 – Track & Coordinate Care –PCMH 5A: Test Tracking & Follow-Up –PCMH 5B: Referral Tracking & Follow-Up MUST PASS –PCMH 5C: Coordinate With Facilities & Care Transitions

5. Let’s Track Our Progress Standard 1 – Enhance Access/Continuity Standard 2 – Identify/Manage Populations Standard 3 – Plan/Manage Care Standard 4 – Self-Care Support/Resources Standard 5 – Track/Coordinate Care Standard 6 – Measure/Improve Performance

6. Today’s Agenda What Is The Record Review Workbook? Standard 4 – Self-Care Support & Community Resources –PCMH4A: Support Self-Care Process – MUST PASS –PCMH4B: Provide Referrals to Community Resources

7. Record Review Workbook (RRWB)

8. What Is the “Record Review Workbook”? Elements 3C, 3D, 4A –Require medical record abstraction of data –Need % of patients meeting the element (based on a numerator and a denominator) Two methods to collect and submit patient data –Method #1 - report from the electronic system –Method #2 - Record Review Workbook Excel workbook in the Survey Tool Tool to identify a sample of patients and abstract data needed for Elements 3C, 3D, 4A

9. Using The Workbook 1. Find Workbook in Survey Tool 2. Download and save file to computer 3. Review instructions and data needed from patient records 4. Select patient records to review 5. Review patient records for data 6. Enter data in Workbook 7. Enter numerical result in Survey Tool 8. Link Workbook to Survey Tool

10. Selecting Patients for Workbook ~ Use same 48 patients for EACH Workbook Element ~ STEP #1. START DATE = Today’s date February 15th STEP #2. Go back 30 days = January 15th STEP #3. Use appointment or billing system to identify patients with visit on June 5th Choose every patient with any of 3 clinically important conditions who had a visit on this date that was related to the important condition STEP #4. Continue choosing patients going back on consecutive dates until you have selected 48 patients

11. RRWB = Supplemental Worksheet Click here

12. RRWB Tabs Three tabs Instructions Patient Conditions Record Review

13. RRWB – Enter Important Conditions Enter three important conditions here including an unhealthy behavior/mental health or substance abuse AND high-risk or complex patients, IF you are including them.

14. RRWB – Enter Conditions Enter conditions from drop down menu, for example: Diabetes Hypertension Depression High Risk/Complex

15. RRWB – Enter Data Entering NOT USED in row 1 “grays” out the column Response Options Yes No Not Used Not applicable

16. RRWB – automatically calculates the % of Patients that met factor Patients that Met Factor Number (33/48) Percent (69%) Result for ISS

17. Enter RRWB Responses in Survey Tool Enter responses From RRWB Yes or No AND Percent

18. Elements PCMH4A: Provide Self-Care Support – MUST PASS PCMH4B: Provide Referrals to Community Resources PCMH 4: Self-Care Support & Community Resources

19. Practice conducts activities to support patients in self- management: (MUST PASS) 1.Provides education resources or refers at least 50% of patients to educational resources 2.Uses EHR to identify education resources and provide them to 10% of patients** 3.Collaborates with at least 50% of patients to develop and document self-management plans and goals-CRITICAL FACTOR 4.Documents self-management abilities for at least 50% of patients 5.Provides self-management result recording tools to at least 50% of patients 6.Counsels at least 50% of patients on adopting health lifestyles ** Meaningful Use Requirement PCMH 4A: Provide Self-Care Support

20. MUST PASS 6 Points Scoring –5-6 factors (including factor 3) = 100% –4 factors (including factor 3) = 75% –3 factors (including factor 3) = 50% (must-pass) –1-2 factors = 25% (not sufficient for passing element) –0 factors = 0% Data Sources: –Report from electronic system or submission of Record Review Workbook PCMH 4A: Provide Self-Care Support

21. Patient Self management tools are available by clicking on the last tab in Provider Portal or by going to the “Patient Mgmt Tools” tab at the CCNC website: www.communitycarenc.org www.communitycarenc.org These tools are all non-branded, evidence based, low literacy appropriate and have been vetted by physicians at CCNC PCMH 4A: Remember…

22. Provider Portal allows you to search AND download disease-specific self- management tools, handouts, and video demos, which patients can access from home

23. PCMH 4A: Example – Factor 1 Examples of self- management tools for patients/families

24. PCMH 4A: Example – Factor 1

26. PCMH 4A: Example – Factor 3

27. Your Goal HbA1c: Green Zone: Great Control  HbA1c is under 7  Average blood sugars typically under 150  Most fasting blood sugars under 150 Green Zone Means:  Your blood sugars are under control  Continue taking your medications as ordered  Continue routine blood glucose monitoring  Follow healthy eating habits  Keep all physician appointments Yellow Zone: Caution  HbA1c between 7 and 9  Average blood sugar between 150-210  Most fasting blood glucose under 200 Work closely with your health care team if you are going into the YELLOW zone Yellow Zone Means:  Your blood sugar may indicate that you need an adjustment of your medications  Improve your eating habits  Increase your activity level  Call your physician, nurse, or diabetes educator if changes in your activity level or eating habits don’t decrease your fasting blood sugar levels. Name:___________________________ Number:__________________________ Red Zone: Stop and Think  HbA1c greater than 9  Average blood sugars are over 210  Most fasting blood sugars are well over 200 Call your physician if you are going into the RED zone Red Zone Means: You need to be evaluated by a physician. If you have a blood glucose over ____, follow these instructions _____________ __________________________________  Call your physician Physician:_________________________ Number:__________________________ PCMH 4A: Example – Factor 3

28. Demonstrates patient progress and self- monitoring results Demonstrates barriers to patient’s ability to meet goals PCMH 4A: Example – Factor 4

29. The practice provides patient with self- management tool (flowsheet) and then includes completed self- management tool in patient’s chart, demonstrating patient’s self-management ability. PCMH 4A: Example – Factor 4 & 5

30. PCMH 4A: Example – Factor 5 Example of a diabetes log book

31. PCMH 4A: Example – Factor 5 Example of a hypertension log book

32. PCMH 4A: Example – Factor 5 Example of a CHF log book

33. PCMH 4A: Example – Factor 6 Example of counseling documentation in the EMR

34. PCMH 4A: Example – Factor 6 Example of counseling documentation in the EMR

35. PCMH 4A: Example Using the Record Review Workbook

36. Practice supports patients who need access to community resources: 1.Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support) 2.Tracks referrals provided to patients 3.Arranges for or provides treatment for mental health/substance abuse disorders 4.Offers opportunities for health education and peer support PCMH 4B: Provide Referrals to Community Resources

37. 3 Points Scoring –4 factors = 100% –3 factors = 75% –2 factors = 50% –1 factor = 25% –0 factors = 0% Data Sources: –List of community services or agencies –Referral log or report covering at least one month –Processes to provide/arrange for mental health/substance abuse treatment and health education support PCMH 4B: Provide Referrals to Community Resources

38. PCMH 4B: Example – Factor 2

39. Next Steps (Homework) Download the Record Review Workbook and start familiarizing yourself with it.

40. Next Steps (Homework) Organize Your Documents –Create a place on your computer (server or hard-drive) for all of your documentation –You should have a folder for each standard –A checklist can help you determine what you already have created/saved and what you need to prepare from scratch

41. Next Steps (Homework) –Decide which 3 “Important Conditions” (e.g. diabetes, asthma, congestive heart failure, depression, etc) you want to track over time. One must be related to unhealthy behaviors, mental health, or substance abuse. –Does your practice already follow evidence- based guidelines when caring for patients with these conditions? –Are these guidelines documented anywhere?

42. Community Care PCMH Team David Halpern, MD, MPH Community Care of North Carolina (CCNC) R.W. “Chip” Watkins, MD, MPH, FAAFP Community Care of North Carolina (CCNC) Brent Hazelett, MPA North Carolina Academy of Family Physicians (NCAFP) Elizabeth Walker Kasper, MSPH North Carolina Healthcare Quality Alliance (NCHQA)

43. Questions? Feel free to contact me: David Halpern, MD, MPH (215) 498-4648 dhalpern@n3cn.org