PCMH for Your Practice? Here’s a Place to Start R.W. “Chip” Watkins, MD, MPH, FAAFP SCORH Conference Columbia, SC 15 October 2013

Who am I? R.W. “Chip” Watkins, MD, MPH, FAAFP Senior Physician Consultant on CCNC’s PCMH Efforts NCQA Physician Review Oversight Committee (ROC) NCQA Reviewer NCQA’s Advisory Panel for CEC Exam Medical Director – High Country Community Health Past-President and Board Chair – NC Academy of Family Physicians Can delete this and the next slide if there is going to be an introduction…

What is a Patient-Centered Medical Home (PCMH)?

Patient-Centered Medical Home The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery. There is no single definition that has been universally accepted, but in general, the PCMH model: 1. Emphasizes the relationship between patients and their primary care physicians 2. Employs a team-based approach 3. Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology

The Challenge Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous Sir Cyril Chandler Chairman of the Board Great Ormond Street Hospital For Children NHS Trust Liverpool, England

What we have… What we need!! Atul Gawande, MD

Patient-Centered Medical Home Emphasizes the relationship between patients and their primary care physicians Employs a team-based approach to care Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology to improve population management and preventive care PCMH is a great model if you are a member of CCNC, simply because the PCMH model includes most, if not all, of the tools, resources, and services that are built into the CCNC model.

Medical Home “Joint Principles” Personal Physician Physician-Directed Practice Whole-Person Orientation Care Coordination/Integration Quality & Safety Enhanced Access Payment Each patient has an ongoing relationship with a personal physician, who provides comprehensive, continuous primary care. The physician is responsible for directing a team that takes collective responsibility for patient care. The physician is responsible for providing comprehensive care at all stages of life and for coordinating care as necessary with appropriate specialists. Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) in Febraury, 2007

Features of PCMH Four common features in demonstrations Dedicated care managers Expanded access to clinicians Data-driven analytic tools Use of incentives

Benefits of the PCMH Model Quality – Outcomes for seven medical home demonstrations Fewer ER visits (15%-50%) Fewer hospital admissions (6-24%) Lower mortality rates Better preventive service delivery Better chronic disease care Higher patient satisfaction Groups that have undertaken this redesign process have demonstrated: ER visits: Group Health Cooperative – 29% reduction in 2 years Health Partners – 39% reduction in 5 years Genesee – 50% reduction in 4 years Johns Hopkins – 15% reduction in 8 months SC BCBS – 32.2% reduction Hospitalization rates: Group Health – 6% reduction in admissions in 2 years Health Partners – 24% in admissions in 5 years Geisinger – 14% reduction in admissions in 2 years Genesee – 15% reduction in admissions in 4 years Intermountain – 10% reduction in admissions in 2 years Johns Hopkins – 24% reduction in inpatient days in 8 months SC BCBS – 10.7% reduction in admissions, 36.3% reduction in inpatient days Mortality rates: Intermountain – 3.5% reduction in 2-year mortality Preventive Service Delivery: Geisinger – 74% increase in preventive care in 2 years Genesee – 137% increase in mammography in 4 years Colorado Medicaid/SCHIP – 267% increase in well-child visits Chronic Disease Care: Health Partners – 129% increase in optimal diabetes care, 48% increase in optimal heart disease care in 5 years Geisinger – 22% increase in CAD care, 34.5% improvement in diabetes care Source: Fields, et al. (2010) and Reid RJ, Coleman K, et al. (2010).

Benefits of the PCMH Model Efficiency – Cost Lower total costs of care - (6.5-22%) Shorter patient wait times Less staff burnout/turnover (10% Vs. 30%) Higher staff satisfaction/productivity These same groups have demonstrated reductions in total costs of care, patient wait times, and staff burnout. Total Costs of Care: Group Health – savings of $10.30 PMPM at month 21 Health Partners – 8% reduction in total costs at 5 years Geisinger – 9% reduction in total costs at 2 years Intermountain – savings of $53.33 PMPM at 2 years Colorado Medicaid/SCHIP – 21.5% reduction in total costs SC BCBS – 6.5% lower total medical/pharmacy costs 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline Source: Fields, et al. 2010

This is a No-Brainer! Right? So Why Aren’t Practices RUNNING to implement PCMH for themselves?!? Time Resources Consultants are expensive Fear Gov’t interference Loss of control/independence Change

PCMH 2011 Overview (6 standards/27 elements) Enhance Access and Continuity Access During Office Hours Access After Hours Electronic Access Continuity (with provider) Medical Home Responsibilities Culturally/Linguistically Appropriate Services Practice Organization Identify/Manage Patient Populations Patient Information Clinical Data Comprehensive Health Assessment Use Data for Population Management Plan/Manage Care Implement Evidence-Based Guidelines Identify High-Risk Patients Manage Care Manage Medications Electronic Prescribing Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources Track/Coordinate Care Test Tracking and Follow-Up Referral Tracking and Follow-Up Coordinate with Facilities/Care Transitions Measure and Improve Performance Measures of Performance Patient/Family Feedback Implements Continuous Quality Improvement Demonstrates Continuous Quality Improvement Report Performance Report Data Externally Optional Patient Experiences Survey

Scoring Total 100 Points Recognition requires achieving all 6 must pass elements with a ≥50% score Level Points Required Must Pass 1 ≥ 35 6 Must Pass 2 ≥ 60 3 ≥ 85

Alignment with Measures of Meaningful Use E-prescribing – medication list, allergies Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance Care management – reminders for follow-up care, decision support, Rx reconciliation Electronic capability – e-health information to patient, visit summary, e-access to health information, provider information exchange Performance reporting/improvement

How Much Do You Know About CCNC?

CCNC - “How it works” Primary care medical home available to 1.6 million Medicaid patients in all 100 counties Provides 5,000 local primary care physicians (94% of all NC PCPs) with resources to better manage Medicaid population Not-for-profit networks link local community providers (health systems, hospitals, health departments and other community providers) to primary care physicians Resources include 600 local care managers, 26 pharmacists, 14 psychiatrists and 20 medical directors to improve local health care delivery

CCNC - “How it works” The state identifies priorities and provides financial support through an enhanced PMPM payment to community networks Networks pilot potential solutions and monitor implementation (physician led) Networks voluntarily share best practice solutions and best practices are spread to other networks – for ALL payors The state provides the networks (CCNC) access to data Cost savings/ effectiveness are evaluated by the state and third-party consultants (Treo Solutions, Milliman) CC pays the providers a PMPM for managing patient care, but THIS PMPM goes to the networks to support things like network infrastructure, hiring and managing their case managers, IT support, support physician leadership in terms of the medical director and psychiatrist, QI coordination staff, and support staff, and so on. Watkins - 2012

System-Wide Results Community Care is in the top 10 percent in US in HEDIS for diabetes, asthma, heart disease compared to commercial managed care. Which resulted in over 1.5 Billion dollars in savings to the state in the period of 2007-2009 Watkins - 2012

Community Care’s Informatics Center Informatics Center ─ Medicaid claims data Utilization (ED, Hospitalizations) Providers (Primary Care, Mental Health, Specialists) Diagnoses – Medications – Labs Costs Individual and Population Level Care Alerts Real-time data Hospitalizations, ED visits, provider referrals Multipayer Datafeeds Medicare, Medicaid, BCBSNC, and SEHP A huge part of our success is also attributable to getting physicians and networks access to actionable data. This includes the Provider Portal, through which treating physicians can access comprehensive patient information, including what other providers are doing for the patient. The Pharmacy Home is a project we’re working on to merge data from private sector organizations like Surescripts, Lab Corp and make it available to participating providers. Treo Solutions is helping us determine where we get the biggest “bang for the buck.” they’re helping us identify the most impactable patient, so we put our resources where they do the most good. CMIS is an electronic record of care management activities used by CCNC care managers since 2001, with over 1,500 active users statewide.  CMIS contains demographic data and claims data on over 2.8 million Medicaid recipients, including the 1 million currently enrolled with a practice in a CCNC network.  Intelligent data use is also critical to separating statistical “noise” and outliers from fraudulent activities as part of our clinical integrity efforts. Watkins - 2012

What is the Multi-Payer Advanced Primary Care Practice Demonstration Project (MAPCP)?

What is the Multi-Payer Demo? The purpose of the Multi-Payer Advanced Primary Care Practice “demonstration project” (MAPCP) is to evaluate the effectiveness of the PCMH model, when supported by both public and private payers NC is one of 8 states that was awarded an MAPCP demo

What is the Multi-Payer Demo? 7 rural counties across NC were chosen to participate in the demo: Ashe, Avery, Bladen, Columbus, Granville, Transylvania, and Watauga

What is the Multi-Payer Demo? To participate, practices in these counties must obtain PCMH recognition from the National Committee for Quality Assurance (NCQA) during their first year of the demo In return for implementing the PCMH model, practices will earn incentive payments from the largest public and private payers in NC: CMS and BCBS-NC/SHP.

Recognition of Added Value Incentive Payments from Medicare CMS will pay a per member per month fee for each Medicare patient in practices achieving PCMH recognition through NCQA: Level 1 = $2.50 PMPM ($30 each year) Level 2 = $3.00 PMPM ($36 each year) Level 3 = $3.50 PMPM ($42 each year) We are beginning to see initiatives from CMS in many other areas as well –CPCI – Comprehensive Primary Care Initative – 20-25 PMPM

Recognition of Added Value Increased Reimbursement from BCBS Eligibility for the Blue Quality Physicians Program (BQPP), a recognition program for primary care practices that builds on PCMH recognition from NCQA Once you qualify for the BQPP, BCBS will increase its fee structure by 10% or more for all of your BCBS/SEHP patients

Let’s Talk About Resources for Your NCQA Submission

Resources Available NCQA PCMH Standards and Guidelines – “The Rules” Standards, Elements, Factors Policies and Procedures Software Products Online Application Account Business and demographic information Free Interactive Survey System (ISS) Responses to the Standards and Guidelines ISS Survey Tool $80 Recognition Programs Section of NCQA’s Website These are free of charge from NCQA

Go to NCQA Home Then Programs Then Recognition Then PCMH 2011 Then Before, During, and After I’m Recognized for lists of online resources http://www.ncqa.org/Programs/Recognition.aspx

Comprehensive PCMH Document Library 2011 Resources Available CCNC Web-based 2011 PCMH Workbook Webinars for 2011 PCMH Submissions Introducing…. Comprehensive PCMH Document Library 2011 These are free of charge from NCQA

Resources Available Use the CCNC PCMH workbook, webinars

How Do You Get All This Done?

Watkins. Journal of Medical Practice Management, Sept/Oct 2012, Vol 28:2, pp. 134-6.

ASU Practicum in Primary Care ASU College of Health Science, School of Healthcare Management

Creation of Partnership with Appalachian State University Recruit ASU students from School of Health Care Management Develop curriculum, syllabus, website, core documents Create new practicum course with internship opportunity Teach students about PCMH, Provider Portal, Care management process Send students out to practices to assist in attaining PCMH certification, BQPP cert and QI initiatives

ASU Practicum in Primary Care Fall of 2011 – 5 students Spring 2012 – 9 students – BSBSNC Foundation Grant Obtained Summer 2012 internship – 8 students Fall 2012 – 14 students Spring 2013 – 15 students Fall 2013 – 16 students

ASU Practicum in Primary Care Developed curriculum, core documents, website https://sites.google.com/site/pcmhprac/

ASU Practicum in Primary Care Worked through curriculum and have weekly didactic meetings on ASU campus BAA for HIPPA compliance Students prepare PCMH PPT for “their” practice and give to group Go through the Standards and hit high points Students share successes/failures with facilitators/faculty Placed students in field and worked with the practices Students give PPT Work with practices – develop “PCMH Team”, schedule time with team, give weekly assignments, follow-up, etc. Also include care management process, managing change, PDSA cycles, and provider portal training

Program Growth ASU School of Health Care Management has made the “Practicum in Primary Care” a CORE curriculum class Students willing to spend 2 semesters with us get full credit for their internship (300 hours) “Keeping the Medical Home Fires Burning” is a new initiative where practices that have been recognized work with students on QI projects

Program Growth Remote Learning Initiative Students work with practices within 3 hours of Boone MOVI (secure) web-hosting Face-to-face visits every 3 weeks or so

CCNC’s PCMH Efforts Beginning of MP Project After a sustained effort to promote PCMH by medical practices, CCNC networks and CCNC’s PCMH Team. Network staff spent time in medical practices all over the state.  Web-based materials made available on the CCNC web site were snapped up quickly: approximately 1,700 copies of the 2011 and 2008 Workbooks have been downloaded since last Fall, and about 1,300 individuals downloaded videos or PowerPoint presentations from the PCMH webinar series. Today, 6 months after the start of the Multi-payer Advanced Primary Care Practices (MAPCP) demo, there are 366 PCMH-recognized practices — nearly ten times as many as in 2010. North Carolina currently has more PCMH-recognized practices than any other state except for New York and Pennsylvania. When adjusting for PCMH practices per capita, North Carolina is second in the nation, behind only New York.

Getting into the Weeds

Types of Documents

Time Periods

Organize the Documents 1. Create a folder on your network drive for documents the practice MAY want to attach 2. Develop a checklist of documents already used in the practice and documents that need to be prepared 3. Refer to published standards and use to identify what the practice has and what needs to be created 4. Save a copy of the Record Review Workbook and/or Quality Measurement and Improvement Worksheet to your document folder 5. Consider putting multiple examples in one document for a single element, e.g. screenshots 6. Identify documents that may be applicable for more than one element NOTE: NCQA advises a target of three (3) documents or fewer per element (some elements require more, others just one). This will depend on the number of factors in the element and the diversity of document types included.

Manage the Documents 1. Use a unique naming convention for each document, that is, don’t use the same name for multiple documents 2. Use a logical organizing principle such as:  PCMH 1 A—Name of Document.docx  PCMH 1 B—Name of Document.xls 3. Avoid special characters and punctuation in document name (e.g. quotation marks, question marks, commas, apostrophes, ampersands). NCQA’s system will not accept the documents. 4. Don’t put the same document in two different places in the document library; instead, enter it once and link to multiple elements 5. Use text boxes, arrows or other methods to identify important sections; briefly explain the importance to the element(s). 6. If N/A is marked, explain the reason in Text/Notes section in the Survey Tool.

Linking Documents

What is the oldest a submitted document can be?

Tips in Summary 1. Be efficient – use only what is needed. a. Read the documentation requirements and provide only what is necessary. b. Try to limit the documentation to one document per element for multiple factors. 2. Make sure documentation is legible. Legibility impacts NCQA’s review. 3. Clearly explain the documents and the section you want NCQA to see. a. Label documents with the appropriate title b. Make use of text boxes to explain, highlight, box in a targeted section or information and use arrows. c. Do not handwrite notes on documents to explain data, and then scan them into your computer. Handwritten notes are difficult to read. d. When using textboxes to hide information in non‐PDF documents, save the documents as ―read‐only, or convert to PDF. Otherwise, textboxes can moved and PHI revealed. e. For screen shots, print screens and scan, or paste print screen as a picture into a Word document or PowerPoint slide.

Tips in Summary 4. Combine “like” documents whenever possible. a. E.g., multiple policies written in MS Word may be combines into one document; refer to page number for individual elements. 5. Block PHI on all documents. Do not submit any protected health information. Keep a master list of patient files submitted in case of an NCQA audit. Physician names/information can remain on the files. 6. Do not use a flash drive (USB device) as the file path for your linked documents.

PCMH 1A – During Office Hours Practice has written process/defined standards, and demonstrates that it monitors performance against the standards to: Provide same-day appointments – CRITICAL FACTOR Provide timely advice by telephone Provide timely advice by electronic message (may be N/A if the practice does not advise patients via electronic systems) Document clinical advice in the medical record Critical Factors, such as PCMH 1A Factor 1, for Must Pass Elements are Essential to Achieving Recognition Applies to routine and urgent care – time reserved for same-day appointments. NA requires a statement from practice Can’t use “work-in” process or just fill in no-shows.

PCMH 1A: Scoring and Documentation MUST PASS 4 Points Scoring 4 factors = 100% 3 factors (including Factor 1) = 75% 2 factors (including Factor 1)= 50% Factor 1 = 25% (not 1 factor) 0 factors or missing factor 1 = 0% Documentation: F1-4: Documented process for scheduling appointments, providing clinical advice and documenting advice and F1-3: Reports with 5 days of data showing same-day access, response times compared to practice defined standards F4: Three examples of clinical advice or report with percent documented advice in record in recent one month period Must get at least 2 factors or 50% to PASS

Notes Section Ex. 1: This is an example of a practice writing an explanation to NCQA in the “Notes” section of the survey tool. NCQA Reviewer Note: The practice responded "Yes" to factors 1-2, 4 and "No" to factor 3. Reviewer agrees with the practice's self-assessment. ______________________________________________________________ 1A1, 1A2, 1A4. Attached policy demonstrates that: 1) 25% of appointment slots each day are reserved for same day appointments. These appointments are usually booked early in the morning for the same day but may be booked the afternoon prior if needed; 2) documenting phone conversations with patients in the medical record is expected and; 3)a response to patient phone calls is expected to occur within 24 hours. 1A1. A report shows the % of same day appointments. 1A1. Screenshots show that the schedule template is built to accommodate 4 total appointments per hour: 2 established patients, 1 new patient and 1 same day (work- in) patient each hour. This same template is applied to every provider, every day. 1A2. Audit results attached 1A3. marked "no" because, while we have recently enabled the electronic messaging feature through our patient portal, we have not yet received any messages from patients. 1A4. Three examples of clinical advice documented in medical records are attached.

PCMH 1A1- Process HCCH Process: Providing patients access to same-day appointments As primary care providers, it is essential that we maintain the capacity to see patients when they need to obtain care and services. As a patient-centered organization, our standard is that patients are able to schedule appointments at times that meet their needs. Each practice reserves appointment slots for all providers on each scheduled day in order to provide same-day access to patients requesting care or services. These slots are clearly identified in the provider’s schedule and may only be filled on the same day. (A slot may occasionally be filled after 3 pm on the day prior for a patient requesting an appointment the following morning.)

What’s missing from this document What’s missing from this document? How long should the process have been in place?

PCMH 1A - Documentation Same-Day Appts Marked by arrow and labeled SD

5 Day Audit for Same Day Appts You need to report on ALL the providers in the practice

5 Day Audit for Same Day Appts Report for Red and Blue Teams Same Day availability slots for 5 days (5/14-5/18): Red Team has 37 slots available. Blue Team has 34 slots available. RED TEAM You need to report on ALL the providers in the practice BLUE TEAM

Reviewer Comments 1A Ex. 1: Factor 4 - The practice provided examples that did not demonstrate clinical advice. Messages left for patients to make appointments does not meet the intent of clinical advice. Ex. 2: To receive credit for factor 4, the practice must submit two items, 1) a documented process for staff to follow for entering phone and electronic message clinical advice in the patient record and 2) at least three examples of clinical advice documented in a patient record or generates a report identifying how often advice is documented in the medical record. The practice submitted a process; however the three examples provided did not meet the intent of the factor. The three examples were communication between clinician and nurse. The examples should show clinical advice documented in a patient's medical record. Factor 4 was changed to no. Ex. 3: The practice scored factors 1-4 “yes”. The reviewer changed factors 1- 4 to “no” because the practice did not have a documented process with an implementation date or other evidences that it has been in place for at least 3 months. The reviewer requested additional documentation to support the practice’s “Yes” responses. The additional documentation was submitted and now the reviewer agrees with the practice’s assessment and has changed factors 1-4 from “No” back to “Yes”.

Top 10 Points To Remember About Your NCQA Submission!

Top 10 Points To Remember! Number 10 - Eligibility Recognitions are awarded at the geographic site level Clinicians Who Are Eligible MDs, DOs, NPs, PAs with panels of primary care patients 75% of those patients come for “first contact”, comprehensive, and continuous PCP care Clinicians who see patients routinely at more than one site should be listed on each site’s application Multi-Sites have: 3 or more sites The same EMR The same policies and procedures for staff The ability to be bound by a single contract

Top 10 Points To Remember! Number 9 – Timing of Application Submission Submit Online Applications and ISS Survey Tools in Pairs One application for each site first One ISS Tool for each site The Online Application Account can be used for multiple submissions over time A separate Online Application must be submitted 5 days before NCQA can accept any PCMH ISS Survey Tool Pair

Top 10 Points To Remember! Number 8 – Record Review Workbook Really understand how to use the Record Review Workbook Read and understand THE INSTRUCTIONS Watch the CCNC webinars and NCQA videos and webinars Condition 3A factor 3 must be included Double check you have the right number of patients in 3A and 3B Use the methodology outlined in the INSTRUCTIONS Method 1 and 2 can be mixed and matched

No. 8 - Look at the Instructions Three tabs Instructions Patient Conditions Record Review

Top 10 Points To Remember! Number 7 – Give Yourself Enough Time Online Application must precede the ISS tool by 5 days NCQA may take 60 days to review single site tools and 30 days for Multi-Site Corporate tools Thus Multi-site Recognitions may take 90 days It takes time for NCQA to set up a call to discuss the corporate tool and to copy elements into site tools Large Multi-sites should stagger site submissions to allow a single reviewer to keep up When NCQA asks for more documentation it adds TIME

Top 10 Points To Remember! Number 6 – Overestimate Pre-submission Work Time Takes 100-200 hours Develop a PLAN and TIMELINE Develop a PCMH TEAM in your office with responsibilities for each member Meet regularly – use Quick Look Give enough time to collect and upload all your documents – up to 150 documents or more

Quick Look Worksheet in CCNC PCMH Workbook

Top 10 Points To Remember! Number 5 – Don’t Let Recognitions Expire Before Renewing Expired Recognitions are not retroactively extended Expired practices and providers will fall off the lists NCQA sends to P4P program sponsors monthly They reappear when practices earn a new Recognition

Top 10 Points To Remember! Number 4 – Pay attention to Documentation Requirements Interpret the S&G document requirements LITERALLY All should attend S&G training and CCNC webinars to understand the requirements of each element Read all related FAQs If S&G requires X types of documents, be sure you include all of them NCQA does not pre-approve documentation

Top 10 Points To Remember! Number 3 – Use NCQA’s and CCNC’s PCMH 2011 Written and Archived Training Resources When a system doesn’t work, READ the instructions If it still doesn’t work, FOLLOW the instructions Have someone on your team attend a “Facilitating Patient-Centered Medical Home Recognition” conference if possible Plan on one person in your organization or 2 people in your network attending the Content Expert Certification

Top 10 Points To Remember! Number 2 – Prepare Reviewer-Friendly Documentation Organize by standards, elements, and factors Helps to organize in 1 PDF per element Efficient – limit to only what is necessary for the requirement Labeled and Highlighted – corresponding fields Dated or Date Range (where appropriate) Learn how to do a screenshot – think “Greenshot” or “SnagIT”

Processes for 5C 1,2,3,4,5

Top 10 Points To Remember! Number 1 – Focus on the Most Critical Factors First Have a Plan – Timeline it PCMH 1A factor 1 Providing same day appointments PCMH 4A factor 3 (RRWB element) Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families PCMH 6C – factors 1 and 2 There is no Recognition without these Good places to begin early practice transformation Assure that your documentation meets requirements

One More Thing… We need to motivate and reward patients for taking care of their OWN HEALTH!

Next Steps (Homework) Interested in building your own PCMH Team? Become a part of CCNC Identify a “PCMH Champion” who will help guide the practice through the quality transformation process Identify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff Identify a “Lead Administrator” who will track progress, organize materials, and complete the Survey Tool/PCMH application Use CCNC’s tools and resources for PCMH!

PCMH for Your Practice? Here’s a Place to Start R.W. “Chip” Watkins, MD, MPH, FAAFP SCORH Conference Columbia, SC 15 October 2013