training webinar # 5 david halpern, md, mph january 25, 2012 patient-centered medical home ncqa’s...
TRANSCRIPT
Training Webinar # 5
David Halpern, MD, MPHJanuary 25, 2012
Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Legal Disclaimer
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Acknowledgements
Let’s Review• Standard 1 – Enhance Access &
Continuity– PCMH1A: Access During Office Hours –
MUST PASS– PCMH1B: After-Hours Access– PCMH1C: Electronic Access– PCMH1D: Continuity– PCMH1E: Medical Home Responsibilities– PCMH1F: Culturally and Linguistically Appropriate
Services– PCMH1G: The Practice Team
Today’s Agenda
• Standard 2 – Identify & Manage Populations
• Standard 5 – Track & Coordinate Care
Elements• PCMH 2A: Patient Information• PCMH 2B: Clinical Data• PCMH 2C: Comprehensive Health
Assessment• PCMH 2D: Use Data for Population
Management - MUST PASS
PCMH 2: Identify and Manage Populations
• Practice uses a searchable electronic system and records data more than 50% of the time for the following:
* Meaningful Use Requirement
PCMH 2A: Patient Information
1. Date of birth*2. Gender*3. Race*4. Ethnicity*5. Preferred language*6. Telephone numbers7. E-mail address
8. Dates of previous clinical visits9. Legal guardian/health care proxy10. Primary caregiver11. Advance directives (NA for pediatrics)12. Health insurance
• 3 Points• Scoring
– 9-12 factors= 100% – 7-8 factors= 75%– 5-6 factors= 50%– 3-4 factors= 25%– 0-2 factors= 0%
• Data Sources:– Report showing percentage of all patients seen in the last
3 months, for whom each factor is complete/entered in the electronic record. Requires numerator (patients for whom each field is complete) and denominator (all patients seen in last 3 months). (CHART REVIEW NOT ACCEPTABLE)
PCMH 2A: Patient Information
PCMH 2A: Example
This report shows various domains and what % of patients have
complete information entered
for each field.
Note: a screenshot of the EMR is not sufficient without a
report
PCMH 2A: Example – Factor 11
Note: a screenshot of the EMR alone is
not sufficient without a report
• Practice uses a searchable electronic system to record the following data:
1. Up-to-date problem list of active diagnoses for 80% of patients
2. Allergies, including medications and reactions for 80% of patients
3. Blood pressure with the date of update for 50% of patients
4. Height for 50% of patients
5. Weight for 50% of patients
6. BMI for 50% of patients
7. Length/height, weight head circumference (less than 2 years); BMI percentile (2-20); for pediatric patients for 50% of patients
8. Tobacco use status for patients 13 and older for 50% of patients
9. List of prescription medications with date of update for 80% of patients
PCMH 2B: Clinical Data
PCMH 2B: Clinical Data
• 4 Points• Scoring
– 9-12 factors= 100% – 7-8 factors= 75%– 5-6 factors= 50%– 3-4 factors= 25%– 0-2 factors= 0%
• Data Sources:– Report showing percentage of all patients seen in the last
3 months, for whom each factor is complete/entered in the electronic record. Requires numerator (patients for whom each field is complete) and denominator (all patients seen in last 3 months). (CHART REVIEW NOT ACCEPTABLE)
PCMH 2B: Example – Factor 1Note: a screenshot of the EMR alone is
not sufficient without a report
PCMH 2B: Example – Factor 2Note: a screenshot of the EMR alone is
not sufficient without a report
• Practice conducts and documents a health assessment:1. Age and gender appropriate immunizations/screenings
2. Family/social/cultural characteristics
3. Communication needs
4. Medical history of patient and family
5. Advance care planning (NA for pediatrics)
6. Behaviors affecting health
7. Patient and family mental health/substance abuse
8. Developmental screening using standardized tool (NA for adult only practices)
9. Depression screening for teens/adults using standardized tool
PCMH 2C: Comprehensive Health Assessment
PCMH 2C: Comprehensive Health Assessment
• 4 Points• Scoring
– 8-9 factors= 100% – 6-7 factors= 75%– 4-5 factors= 50%– 2-3 factors= 25%– 0-1 factors= 0%
• Data Sources:– Report or a completed patient assessment (de-
identified)
PCMH 2C: Example – Factor 6, 9
PCMH 2C: Example – Factor 4, 7
PCMH 2C: Example – Factor 1, 5, 6, 7
PCMH 2D: Use Data For Population Management
• Practices uses patient data and evidence-based guidelines to generate lists and remind patients about needed services:1. At least three different preventive care services**2. At least three different chronic care services**3. Patients not recently seen by the practice4. Specific medications
** Meaningful Use Requirement
PCMH 2D: Use Data For Population Management
• MUST PASS• 5 Points• Scoring
– 4 factors = 100%– 3 factors = 75%– 2 factors = 50% (must-pass threshold)– 1 factors = 25% (not sufficient for passing element)– 0 factors = 0%
• Data Sources:– Lists or summary reports of patients who need services
• Reports must contain at least three different immunizations or screenings and three different acute/chronic care services
• A registry is not specifically required but will facilitate the process– Materials demonstrating patient notification
PCMH 2D: Example – Factor 1
Patient list is blinded to
protect confidentiality
List of patients who havenot received pneumovax
PCMH 2D: Example – Factor 2
patientnames
andMRNs havebeen
blinded
List of patients who havenot received appropriate
hypertensive care
PCMH 2D: Example – Factor 3
List of diabetics who have not been seen
in past 6 months
PCMH 2D: Example – Factor 4
(names of patients blinded for HIPAA)
List of patients in the practice taking Toprol XL
Elements• PCMH 5A: Test Tracking & Follow-Up• PCMH 5B: Referral Tracking & Follow-Up
MUST PASS• PCMH 5C: Coordinate With Facilities &
Care Transitions
PCMH 5: Track & Coordinate Care
• Practice has documented process for and demonstrates:1. Tracks lab tests and flags and follows-up on overdue results –
CRITICAL FACTOR
2. Tracks imaging tests and flags and follows-up on overdue results –CRITICAL FACTOR
3. Flags abnormal lab results
4. Flags abnormal imaging results
5. Notifies patients of normal and abnormal lab/imaging results
6. Follows up on newborn screening (NA for adults)
7. Electronically order and retrieve lab tests and results
8. Electronically order and retrieve imaging tests and results
9. Electronically incorporates at least 40% of lab results in records**
10.Electronically incorporate imaging test results into records
** Meaningful Use Requirement
PCMH 5A: Test Tracking & Follow-Up
• 6 Points• Scoring
– 8-10 factors (including factors 1 and 2) = 100% – 6-7 factors (including factors 1 and 2) = 75%– 4-5 factors (including factors 1 and 2) = 50%– Fewer than 3 factors = 0%
• Data Sources:– Process or procedure for staff and an example of how
factors 1-6 are met– Electronic system examples for factors 7-10
PCMH 5A: Test Tracking & Follow-Up
PCMH 5A: Example – Factor 1
PCMH 5A: Example – Factor 1
PCMH 5A: Example – Factor 1
PCMH 5A: Example – Factor 2
PCMH 5A: Example – Factor 5
Lab Test Order Screen
PCMH 5A: Example – Factor 7
PCMH 5A: Example – Factor 8
Radiology Test Order Screen
PCMH 5B: Referral Tracking & Follow-Up
• Practice coordinates referrals:1. Provides specialist with reason and key information for the
referral
2. Tracks referral status
3. Follows up to obtain specialist reports
4. Has agreements with specialists documented in the record
5. Asks patients about self-referrals and requests specialist reports
6. Demonstrates electronic exchange of key clinical information**
7. Provides electronic summary of care for more than 50% of referrals**
** Meaningful Use Requirement
• MUST PASS• 6 Points• Scoring
– 5-7 factors= 100% – 4 factors = 75%– 3 factors = 50% (must-pass threshold)– 1-2 factors= 25% (not sufficient for passing element)– 0 factors = 0%
• Data Sources:– Reports or logs demonstrating tracking system data collection – Documented processes with three examples– Reports from electronic system showing frequency of
information exchange and summary of care records
PCMH 5B: Referral Tracking & Follow-Up
PCMH 5B: Example – Factor 2
PCMH 5B: Example – Factor 2
PCMH 5B: Example – Factor 2Patient Name
MRN Referring Clinician
Reason for Referral
Date of Referral
Referred to Completed? Insurance
(Y/N & Date)
Joe Smith 12345 Halpern Back Pain 6/16/11 Triangle Ortho
No BCBS-NC
Mary Jones 54321 Halpern Colonoscopy 6/16/11 Durham GI Yes 6/21/11 Duke Select
• Practice systematically demonstrates:
1. Process to identify patients with hospital admissions or ED visits
2. Process to share clinical information with hospital/ED
3. Process to obtain patient discharge summaries
4. Process to contact patients for follow-up care after discharge
5. Process to exchange patient information with hospital
6. It collaborates with patient to develop written care plan for transitions from pediatric to adult care (NA for adults)
7. Electronic exchange of key clinical information with facilities **
8. Provides electronic summary of care for more than 50% of transitions of care**
** Meaningful Use Requirement
PCMH 5C: Coordinate With Facilities and Care Transitions
• 6 Points• Scoring
– 5-8 factors= 100% – 4 factors= 75%– 2-3 factors= 50%– 1 factor= 25%– 0 factors = 0%
• Data Sources:– Documented processes for patient identification, providing
clinical information, systematic follow-up, obtaining discharge summaries and two-way communication
– Copy of a written transition care plan– Reports illustrating electronic information exchange– Electronic report summarizing >50% care transitions
PCMH 5C: Coordinate With Facilities and Care Transitions
PCMH 5C: Example – Factor 3
Note: a screenshot of the discharge summary alone is not sufficient
without a written process documenting how it was obtained
PCMH 5C: Example – Factor 5Note: a screenshot of
the transfer information alone is not sufficient
without a written process documenting how it was obtained
PCMH 5C: Example – Factor 7
Note: a screenshot alone is not sufficient
without a written process documenting
the process
Next Steps (Homework)
• Review the requirements for each standard, element and factor– What does the practice already do?– What does the practice need to create?– Are there elements the practice clearly does
not have in place but does not wish to implement in the near-term?
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
Next Steps (Homework)• Go to NCQA’s website and take
advantage of the various (free) training presentations they have available:– 2011 Standards– Using the ISS Interactive Survey System– Submitting As a Multi-Site Practice
• http://www.ncqa.org/tabid/109/Default.aspx
Next Steps (Homework)
• Begin To Think About 3 Important Conditions (e.g. diabetes, asthma, congestive heart failure, depression, etc) that you can track over time– Does your practice already follow evidence-
based guidelines when caring for patients with these conditions?
– Are these guidelines documented anywhere?
Community Care PCMH Team
• David Halpern, MD, MPHCommunity Care of North Carolina (CCNC)
• R.W. “Chip” Watkins, MD, MPH, FAAFPCommunity Care of North Carolina (CCNC)
• Brent Hazelett, MPANorth Carolina Academy of Family Physicians (NCAFP)
• Elizabeth Walker Kasper, MSPHNorth Carolina Healthcare Quality Alliance (NCHQA)
NCQA Contact InformationContact NCQA Customer Support to:• Order FREE Copy of requirements• Order FREE Application Information• Purchase ISS Tool• 1-888-275-7585
Visit NCQA Web Site to:• View Frequently Asked Questions• View Recognition Programs Training Schedule• www.ncqa.org/medicalhome.aspx
Send Questions to: [email protected]
