Deb Barnett RN, MS, FNP-C HealthTeamWorks, Lakewood, Colorado Tracy Hofeditz, MD Belmar Family Medicine, Lakewood, Colorado Guest: Bruce Bagley, MD American Academy of Familly Physicians Colorado Medical Society/Specialty Society Systems of Care/Patient-centered Medical Home Initiative

On completion of this session participants/participating teams should be able to:  Describe NCQA’s basic scoring mechanism for the 2007 PPC-PCMH™ Recognition Program.  Identify their own practice’s NCQA PPC-PCMH Self-Assessment Score, including outstanding “Must Pass” elements, total points scored and self- assessed Level of Recognition.  Articulate basic understanding of the proposed NCQA PCMH Recognition Program™ scheduled to be released in January  Articulate a basic plan for next steps on working toward becoming a recognized Patient-Centered Medical Home, supported by resources provided for the practice during the seminar.

WHERE IT CAME FROMWHAT WE FOUND IT DOES  Needed a tool for Residency Gap Analysis  Short on time and attention  Scoring complicated and a burden on practices  Working through the “Standards” book created overwhelm  Brief—only 30 items long  Sets the stage for team discussion  Orients team to NCQA PCMH requirements AND scoring in a single session  Provides at-a-glance information about areas for practice to work on

Make selection here above the ruler 0%25%50%100% Workbook score

1. Enter percent from ruler here 2. Points will calculate 3. Cell highlight will clear with score >50%

 Assemble yourselves in your teams  What to do with solo participants?  Appoint one team member as facilitator  Appoint one team member to record scores  Locate Project Management Workbook on flash drive  Go through 30 individual Elements as a team and select answer to best of your knowledge  Enter scores in workbook  Faculty available for problem-solving/questions/keeping you on track  Allow minutes for this activity  We’ll call time and bring the group back together

NCQA PCMH 2011™ Special Guest: Bruce Bagley, MD Medical Director for Quality Improvement American Academy of Family Physicians

12 PCMH 2011: Link with Meaningful Use October 26, 2010 NCQA 2011: Raising the Bar PCMH 2011 is v 4 of NCQA practice level standards Increased requirements (yet maintained pathway for practices beginning to transform) Streamline requirements/documentation with greater focus on areas with strongest link to desired outcomes Move toward performance reporting/ benchmarking for clinical and patient experience measures Embed Meaningful Use criteria

13 PCMH 2011: Link with Meaningful Use October 26, 2010 Comparison of PPC-PCMH and PCMH 2011 PPC-PCMH (9 standards/30 elements) 1.Access and Communication – Processes – Results 2.Patient Tracking and Registry Function 3.Care Management – Continuity Between Settings 4.Self-Management Support 5.Electronic Prescribing 6.Test Tracking 7.Referral Tracking 8.Performance Reporting and Improvement – Measures of Performance – Patient Experience 9.Advance Electronic Communication PCMH 2011 (6 standards/27 elements) 1.Enhance Access and Continuity – Access – Medical Home Responsibilities – CLAS – Practice Team 2.Identify and Manage Populations 3.Plan and Manage Care – Identify High-Risk Patients – Care Management – Medication Management/E-Prescribing 4.Provide Self-Care and Community Resources 5.Track and Coordinate Care – Test/Referral Tracking – Coordinate with Facilities 6.Measure and Improve Performance – Measures of Performance – Patient Experience – Continuous Quality Improvement – Reporting

14 PCMH 2011: Link with Meaningful Use October 26, 2010 PCMH 2011 Key Components Access – Evening/weekend hours, agreement with facility for after-hours care Coordination of care – Information to/from specialists/facilities/patient, update care plan Team-based care – Defined roles and responsibilities, training, communication Role of medical home – Discuss roles/expectations for medical home and for patients Care management – Pre-visit planning, care planning during visit, patient self-care, point of care reminders – Medication management – Include mental health/substance abuse/behaviors affecting health Self-care management with community resources/referrals Identify/address population needs/risks Quality improvement – Performance measurement – Patient experience

Complementary Flash Drive Resource Index 1. HealthTeamWorks Project Management Workbook for the NCQA PPC®- PCMH™ Application 2. Expanded NCQA Standards & Guidelines for PPC®-PCMH™ 3. PPC®-PCMH™ NCQA Workbook by HealthTeamWorks 4. HealthTeamWorks Meaningful Use PCMH Gap Analysis 5. HealthTeamWorks PCMH Care Plan 6. Systems of Care PCMH Initiative Resource List 7. HealthTeamWorks PPC-PCMH Self-Assessment--Brief

What do you think? What are some of your next steps? What resources will you access? What is your timeline? Questions? Contact: Deb Barnett: Tracy Hofeditz: