Presentation on theme: "Delving Into PCMH Standards"— Presentation transcript:
1 Delving Into PCMH Standards 1Your Partner in PracticeDelving Into PCMH Standards(Working with Elements 3, 4 & 6)OP User’s ConferenceApril 23-25, 20151
2 AgendaConnect the dots in Elements 3 & 4 to understand the requirementsSelecting patients for ‘care reminders’ (3D)Selecting patients for ‘clinical decision support’ (3E)A look at Comprehensive Health Assessments (3C)Determining patients for ‘care management’ and managing that care (Element 4A & B)Utilizing the Workbook (3C, 4B, 4C)Setting up performance measurement and quality improvement processes (Element 6)
4 4Connecting the Dots3C reads as if you must implement ‘comprehensive health assessments’ (CHAs) for ALL your patients. You can, but realistically you will use the CHAs for data mining for 3D and 3E, and 4A and 4B. So we start at 3D & 3E and then implement 3C for those ‘conditions’ selected.Connect the dots this way:3.C (comprehensive health assessments)are used on the patients selected in 3.D and 3.E3.D (care reminders)2 different preventive care services2 different immunizations3 chronic / acute conditions3.E (clinical support / evidenced based medicine)1 mental health1 chronic condition1 acute condition1 unhealthy behavior condition1 well child care4
5 5Connecting the DotsFor 4A you use the same patients identified in 3D/E and 4B utilizes the patients ‘discovered’ in 4A. You can also use 3E6 (overuse) and 4A for improvement measures in 6B.Connect the dots this way:4.A (identifying patients needing care management)Behavioral healthHigh cost / utilizationPoorly controlled / complex conditionsOutside referrals4B (care planning & self support)Data mining the patients in 4A, you must utilize the CHAs (3C) to ensure that care planning and self-care support is addressed5
6 Preventive & Acute Care, Immunizations and Overdue Patients for Point of Care Reminders
7 PCMH 3D: Use Data for Population Management At least annually practice proactively identifiespopulations of patients and reminds them, or theirfamilies/caregivers, of needed care based on patient information, clinical data, health assessments and evidenced-based guidelines including:1. At least two different preventive care services.+2. At least two different immunizations.+3. At least three different chronic or acute care services.+4. Patients not recently seen by the practice.5. Medication monitoring or alert.+ Stage 2 Core Meaningful Use Requirement
9 PCMH 3D: Documentation Documentation • F1-5: 1) Reports or lists of patients needing services generated within the past 12 months (Health plan data okay if 75% of patient population)AND2) Materials showing how patients were notified for each service (e.g., template letter, phone call script, screen shot of e-notice).• Practice must perform these functions at least annually.
10 Choosing Preventive Measures 1010Choosing Preventive MeasuresKeep it simple and use what’s readily available. OP recommends using:PCMH/OP Reports:Demographic Analysis/RecallEvent ChronologyPCMH CQMs10
12 Choosing Chronic / Acute Services 1212Choosing Chronic / Acute Services3 services must be targeted and can be related to only one condition.Chronic care management services consider a practice’s entire population. Practices may focus on three chronic care services related to one condition.Examples in Pediatrics include services related to chronic conditions such as asthma, ADHD, ADD, obesity and depression.Example: One condition, three services could be Asthma -Flu shot reminderMedication follow up6-month visit follow up (newly diagnosed patient)12
13 Conditions and Behaviors for Evidence-Based Decision Support (3E) Choosing & WorkingConditions and BehaviorsforEvidence-Based Decision Support(3E)
14 PCMH 3E: Implement Evidence-Based Decision Support The practice implements clinical decisionsupport+ (e.g., point of care reminders) following evidence-based guidelines for:1. A mental health or substance use disorder. (CRITICAL FACTOR)2. A chronic medical condition.3. An acute condition.4. A condition related to unhealthy behaviors.5. Well child or adult care.6. Overuse/appropriateness issues.
15 PCMH 3E: Scoring and Documentation 4 PointsScoring•5-6 factors (including factor 1) = 100%•4 factors (including factor 1) = 75%•3 factors = 50%•1-2 factors = 25%•0 factors = 0%Documentation• Factors 1-6: ProvideConditions identified by the practice for each factor andSource of guidelines andExamples of guideline implementation
16 Developmental and Behavioral: 1616Developmental and Behavioral:Mental / substance abuse in PedsADHDDepressionSubstance abuse (tobacco, alcohol, drugs)Condition related to unhealthy behaviorsPediatric ObesityGreat resource for information and guidelines:Section on Developmental and Behavioral Pediatrics16
17 Acute and Chronic Conditions: 1717Acute and Chronic Conditions:Focus on chronic or recurring conditions such as asthma, eczema, allergic rhinitis, pharyngitis, bronchiolitis, sinusitis, otitis media and urinary tract infectionSome examples OP recommends using:AsthmaPharyngitisADD/ADHDDepressionTie them back to your MU measures if you are already making clinical decision support rules17
18 1818Well Child Measure:Any age well child visit can be used for this measure.Utilize Bright Futures as the clinical decision support guidelines.Protocol templates are included in the OP EMR and based on Bright FuturesUpdate orders on templatesAdjust Care Plan to meet your practice’s needs18
19 Overuse / Appropriateness 1919Overuse / AppropriatenessMay includeER visitsRedundant imaging or lab testsPrescribing generic medications vs. brand name medicationsNumber of specialist referrals.19
21 PCMH 3C: Comprehensive Health Assessment To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes:1. Age- and gender appropriate immunizations and screenings.2. Family/social/cultural characteristics.3. Communication needs.4. Medical history of patient and family.5. Advance care planning (NA for pediatric practices).6. Behaviors affecting health.
22 PCMH 3C: Comprehensive Health Assessment (cont.) 7. Mental health/substance use history of patient and family.8. Developmental screening using a standardized tool (NA for practices with no pediatric patients).9. Depression screening for adults and adolescents using a standardized tool.10. Assessment of health literacy.
23 PCMH 3C: Scoring 4 Points Scoring • 8-10 factors = 100% • NOTE• Factor 5 (NA for pediatric practices)• Written explanation needed for NA responses.
24 PCMH 3C: Documentation Documentation NOTE: USE THE WORKBOOK! • F1-10: Report with numerator and denominator based on all unique patients in a recent three month period indicating how many patients were assessed for each factor.OR• F1-10: Review of patient records selected for the record review required in elements 4B and 4C, documenting presence or absence of information in Record Review Workbook.NOTE: USE THE WORKBOOK!
25 Working With Care Management & Support (4A & B)
26 PCMH 4: Care Management and Support IntentMeaningful Use AlignmentThe practice systematically• Practice implementsidentifies individual patients and plans, manages and coordinates care, based on need.evidence-based guidelines• Practice reviews and reconciles medicationswith patients• Practice uses e- prescribing system• Patient-specificeducation materials
27 PCMH 4: Care Management and Support 20 PointsElements• Element A: Identify Patients for Care Management• Element B: Care Planning and Self-Care Support- MUST PASS• Element C: Medication Management• Element D: Use Electronic Prescribing• Element E: Support Self-Care and Shared Decision- Making
28 PCMH 4A: Identify Patients for Care Management The practice establishes a systematic process andcriteria for identifying patients who may benefit from caremanagement. The process includes consideration of thefollowing:1. Behavioral health conditions.2. High cost/high utilization.3. Poorly controlled or complex conditions.4. Social determinants of health.5. Referrals by outside organizations (e.g. insurers, health system, ACO), practice staff or patient/family/caregiver.6. The practice monitors the percentage of the total patientpopulation identified through its process and criteria. (CRITICAL FACTOR)
29 Identifying Patients for Care Management • Identify all patients in practice with conditions referenced in 4A, Factors 1-5.• Patients may “fit” more than one criterion (Factor).• Patients may be identified through electronic systems(registries, billing, EHR), staff referrals and/or health plandata.• Review comprehensive health assessment (Element 3C) as a possible method for identifying patients.• Factor 6 is critical - NO points if no monitoringThe concept is to use 3C: CHAs, to help identify these patients.
30 PCMH 4A: Scoring and Documentation 4 PointsScoring•5-6 factors (including factor 6) = 100%•4 factors (including factor 6) = 75%•3 factors (including factor 6) = 50%•2 factor (including factor 6) = 25%•0-1 factors (or does not meet factor 6) = 0%Documentation• F1-5: Documented process describing criteria for identifying patients for each factor• F6: Report with- Denominator = total number of patients in the practice- Numerator = number of unique patients identified indenominator as likely to benefit from care management.
31 4A1: Behavioral Health Pediatric populations Practices may identify children and adolescents with special health care needs, defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.”(Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)
32 PCMH 4B: Care Planning and Self-Care Support Care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual careplan that includes the following features for at least 75percent of the patients identified in 4A.1. Incorporates patient preferences and functional/ lifestyle goals.2. Identifies treatment goals.3. Assesses and addresses potential barriers to meeting goals.4. Includes a self-management plan.5. Is provided in writing to patient/family/caregiver.10
33 PCMH 4B: Scoring and Documentation 4 PointsScoring•5 factors = 100%•4 factors = 75%•3 factors = 50%•1-2 factors = 25%•0 factors = 0%Documentation• F1-5:Submission of Record Review Workbook andExamples of how each factor is met (e.g. copy of a care plan)
34 Record Review Workbook Using theRecord Review Workbook
37 Use all the same measures from Element 3D! 3737PCMH 6: Measure and ImproveUse all the same measures from Element 3D!
38 PCMH 6A4: Vulnerable Populations 3838PCMH 6A4: Vulnerable Populations4. Performance data stratified for vulnerable populations (to assess disparities in care).The data collected by the practice for one or more measures from factors 1–3 is stratified by race and ethnicity or by other indicators of vulnerable groups that reflect the practice’s population demographics, such as age, gender, language needs, education, income, type of insurance (i.e., Medicare, Medicaid, commercial), disability or health status.Vulnerable populations are “those who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability,” (AHRQ) and include people with multiple co-morbid conditions or who are at high risk for frequent hospitalization or ER visits.
39 6A – Identifying Vulnerable Populations 39396A – Identifying Vulnerable PopulationsAlso look back to 4A to help determine ‘vulnerable’ patients. They may include:High level of resource use e.g. visits, medication, callsFrequent visits for urgent or emergent care (2 or more visits in the last 6 months)Frequent hospitalizations (2 or more in the last year)Multiple co-morbidities, including mental healthNon-compliance with treatment or medicationsTerminal illnessMultiple risk factorsPsychosocial status, lack of social or financial support that impedes ability for care39
40 4040PCMH6B: Resource UseLook back to 4A2 for utilization measures affecting costs.
41 PCMH 6D: Implement Continuous QI MUST PASS! 4141PCMH 6D: Implement Continuous QI MUST PASS!Utilize previous measures: 3D, 3E tracked to 6A and 4A2 to 6B – reuse and recycle! 6D flows to 6E
42 PCMH6C: Continuous Improvement 4242PCMH6C: Continuous ImprovementThe practice sets goals and acts to improve performance, based on clinical quality measures (Element A), resource measures (Element B) and patient experience measures (Element C). The goal is for the practice to reach a desired level of achievement based on its self-identified standard of care.6A ties to 3D and 3E6B ties to 4A2USE the ‘Quality Measurement and Improvement Worksheet’
43 4343PCMH 6C: NCQA Quality Measurement and Improvement Worksheet
44 4444PCMH 6C: NCQA Quality Measurement and Improvement Worksheet
45 4545Q & AContact InformationThe Verden Group, IncYour Partner in PracticeSusanne Madden, MBA, NCQA CECJulie Wood, MSc, NCQA CEC45