Patient Centered Medical Home Halifax Health Family Medicine Residency Faculty Development Workshop

GOALS Explain the rationale for a PCMH Define the characteristics of a PCMH List the ways that we’re currently functioning as a PCMH Identify opportunities for improvement Initiate a process for PCMH certification

History of the PCMH Concept Introduced by American Academy of Pediatrics (AAP) in 1967 Initially referred to a central location for medical records The medical home concept was expanded in 2002 to include: Accessible Continuous Comprehensive Family-centered Coordinated Compassionate Culturally sensitive care

History of the PCMH Concept In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA), and the American College of Physicians (ACP) adopted a set of joint principles to describe a new level of primary care.

Joint Principles of the Patient Centered Medical Home A personal physician who coordinates all care for patients and leads the team. Physician-directed medical practice – a coordinated team of professionals who work together to care for patients. Whole person orientation – this approach is key to providing comprehensive care. Coordinated care that incorporates all components of the complex health care system. Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met. Enhanced access to care – such as through open-access scheduling and communication mechanisms. Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.

Does it Work? Where is the Evidence ?

NCQA The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality.

NCQA’s New Medical Home Standards Emphasis on patient-centeredness and patient experience of care Reinforces incentives for meaningful use (HIT) Focuses attention on aspects of primary care that improve quality and reduce cost Based on advances in evidence and changes in practice capability

PCMH Scoring 6 Standards = 100 points 6 Must Pass elements Must Pass elements require > 50% performance level to pass Level 3 = 85-100 points, 6 of 6 MPE Level 2 = 60-84 points, 6 of 6 MPE Level 1 = 35-59 points, 6 of 6 MPE Not recognized 0-34 points, <6 MPE

Must Pass Elements Rationale for Must Pass Elements Identifies critical concepts of PCMH Helps focus Level 1 practices on most important aspects of PCMH Guides practices in PCMH evolution and continuous quality improvement Standardizes “Recognition”

Must Pass Elements Must Pass Elements 1A: Access During Office Hours 2D: Use Data for Population Management 3C: Manage Care 4A: Self-Care Process 5B: Referral Tracking and Follow-Up 6C: Implement Continuous Quality improvement Possible Must Pass Points = 14.5 points (50% of score) to 29 points (100 %)

PCMH 2011 Standard #1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team

PCMH 2011 Standard #2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management**

PCMH 2011 Standard #3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Manage Medications E. Use Electronic Prescribing

PCMH 2011 Standard #4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources

PCMH 2011 Standard #5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions

PCMH 2011 Standard #6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally

PCMH 2011 and Meaningful Use 1. Electronic prescribing 2. Drug formulary, drug-drug, drug allergy checks 3. Maintaining an up-to date problem list of current and active diagnoses and medications 4. Recording demographics on preferred language gender, race, ethnicity and date of birth 1. 3E: Use Electronic Prescribing 2. 3E: Use Electronic Prescribing 3. 2B: Clinical Data 4. 2A: Patient Information

PCMH 2011 and Meaningful Use 5. Recording and charting changes in vital signs 6. Recording smoking status 7. Reporting ambulatory quality measures 8. Implementing clinical decision support rules… 5. 2B: Clinical Data 6. 2B: Clinical Data 7. 6F: Report Data Electronically 8. 3A: Implement Evidence-Based Guidelines

NCQA Recognition Where do we start?

Definitions Factors – A scored item in an element. For example, an element may require the practice to demonstrate how the practice team provides a range of patient care services. Each type of item, in this case a service, is a factor. Critical Factors- A factor that is required for practices to receive more than minimal points, or in some cases any points for the element. Critical factors are identified in the scoring section of the element. Explanation- Specific requirements that a practice must meet and guidance for demonstrating performance against the factor. Examples/Documentation- Descriptions of the evidence practices need to submit to demonstrate performance for specific factors. Each factor must be documented

NCQA Standards Standard 1: Access and Communication A. Has written standards for patient access and patient communication B. Uses data to show it meets its standards for patient access and communication

NCQA Standards Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information E. Uses data to identify important diagnoses and conditions in practice F. Generates lists of patients and reminds patients and clinicians of services needed (population management)

NCQA Standards Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care addressing progress, addressing barriers D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care, follow-up for patients who receive care in inpatient and outpatient facilities

NCQA Standards Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management

NCQA Standards Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks

NCQA Standards Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically B. Uses electronic systems to order and retrieve tests and flag duplicate tests

NCQA Standards Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system

NCQA Standards Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice B. Survey of patients’ care experience C. Reports performance for the practice or the physician D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities

NCQA Standards Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support