Regional Care Collaborative March 26, 2015

2011/2014 Crosswalk (Standards 1-6) Maia Bhirud

Standard 1 Crosswalk PCMH 1: Enhance Access and Continuity 2011 Access during office hours After-hours access Electronic access Continuity Medical home responsibilities Culturally and linguistically appropriate services The Practice Team PCMH 1: Patient- Centered Access 2014 Patient-centered appointment access 24/7 Access to clinical advice Electronic access PCMH 1: Enhance Access and Continuity 2011 Access during office hours After-hours access Electronic access Continuity Medical home responsibilities Culturally and linguistically appropriate services The Practice Team 2011 standard split in half to become 2014 standards 1 and 2

2014 Standard 1: Must Pass PCMH 1A: Patient-Centered Appointment Access The practice has a written process and defined standards for providing access to appointments and regularly assesses its performance on: Providing same-day appointments for routine and urgent care (critical factor) Providing routine and urgent-care appointments outside of regular business hours Providing alternative types of clinical encounters Availability of appointments Monitoring no-show rates Acting on identified opportunities to improve access Very similar to 2011; combination 1A & 1B 1) providing same day apts…the same as before. Documentation: 5 days apts fr routine and urgent care apts 2) outside regular business hours…proof extended hours evenings and weekends (formerly 1B1) 3) [New} Alternative type of clinical encounter using real time mode of communication (telephone, video chat, secure instant messaging) Documentation: report showing the frequency of scheduled alternative encounters over a 30 day period 4) [New} apt availability Documentation: 5 day report showing appointment wait times (third next available – measures length of time from when a pt contact the practice to request an apt to the third next available apt on the clinician’s schedule) 5) [New} No Show Rates Documentation: 30 day calendar period # pts not show to pre scheduled apts/ # pts w pre scheduled apts that came 6) Identify opportunities to improve factors 1-5….suggest PDSA cycle format (critically evaluation your activities and institute real quality improvement)

Standard 1C: Electronic Access Standard 1B: 24/7 Access Basically the same as 2011. Telephone access during and after hours has been combined into one factor Standard 1C: Electronic Access Also basically the same as 2011 – MU reports but MU stage 2

Standard 2 PCMH 1: Enhance Access and Continuity 2011 D. Continuity Medical Home Responsibilities Culturally and linguistically Appropriate Services G. The Practice Team PCMH 2: Team-Based Care 2014 Continuity Medical Home Responsibilities Culturally and Linguistically Appropriate Services The Practice Team PCMH 1: Enhance Access and Continuity 2011 D. Continuity Medical Home Responsibilities Culturally and linguistically Appropriate Services G. The Practice Team

Standard 2A: Continuity Mapped to 2011 1D Continuity Factor 3: process to orient pts to staff and they really are looking for a process Factor 4: transition plan for pts transitioning from pediatric to adult care (formerly 5B) Documentation: written transition plan Standard 2B: Medical Home Responsibilities Same idea with added criteria to add into your brochure or website Standard 2C: Culturally and Linguistically Appropriate Services Unchanged

2014 Standard 2: Must Pass PCMH 2D: The Practice Team (10 factors) The practice uses a team to provide a range of patient care services by: Defining roles for clinical and nonclinical team members. Identifying the team structure and the staff who lead and sustain team based care. Holding scheduled patient care team meetings or a structured communication process focused on individual patient care (critical factor). Using standing orders for services.

2014 Standard 2: Must Pass Training and assigning members of the care team to coordinate care for individual patients. Training and assigning members of the care team to support patients/ families/caregivers in self-management, self-efficacy and behavior change. Training and assigning members of the care team to manage the patient population. Holding schedule team meetings to address practice functioning. Involving care team staff in the practice’s performance evaluation and quality improvement activities. Involving patients/families/caregivers in quality improvement activities or on the practice’s advisory council. 2D: The Practice Team [Must Pass} Factor 2: [New] delineates responsibilities for sustaining team based care Documentation: Overview of team-base care structure (org chart) Factor 3: Critical factor – process for structured communication of care team – want to know the frequency of communication and at least 3 samples of meeting summaries, checklists, apt notes or chart notes as evidence Factor 8: scheduled team meetings to routinely improve care for all patients (general care of patients as different from factor 3 which is individual care of specific patients) Documentation: description of team meetings and at least one example of meeting minutes, agenda, staff memos-- discussion about staff roles and responsibilities, performance measurement data, team member training and areas for improvement Factor 9: [New] formal quality improvement initiatives – documented process for quality improvement Factor 10: Process and examples of patient participation

Standard 3 Crosswalk PMCH 2: Identify and Manage Patient Populations PCMH 3: Population Health Management 2014 Patient Information Clinical Data Comprehensive Health Assessment Use of Data for Population Management Implement Evidence-Based Decision Support PMCH 2: Identify and Manage Patient Populations 2011 Patient Information Clinical Data Comprehensive Health Assessment Use of Data for Population Management PMCH 2: Identify and Manage Patient Populations 2011 Patient Information Clinical Data Comprehensive Health Assessment Use of Data for Population Management Patients have access by same day request Patients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and after office hours The practice provides electronic access Patients select their PCP The focus is on team-based care with trained staff

3A: Patient Information (2011 2A) 3B: Clinical Data (2011 2B) (remember now aligned with MU Stage 2) 3C: Comprehensive Health Assessment (2011 2C) Review of completeness Report clearly showing how many patients had incomplete or complete assessments for all factors Or Review of patient records (using record review workbook)

2014 Standard 3: Must Pass PCMH 3D: Use Data for Population Management At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence based guidelines including: At least two different preventive care services At least two different immunizations At least three different chronic or acute care services Patients not recently seen by the practice Medication monitoring or alert The practice collects demographic and clinical data for population management The practice assesses and documents patient risk factors The practice identifies patients for proactive and point-of-care reminders

3E: Implement Evidence Based Decision Support Different from proactive pop mngt activities that are reminding pts to come in to receive specific services - Point of care reminders related to your clinical decision support. – Pick conditions and show templates of the tools or electronic system organizer

Standard 4 PCMH 4: Care Management and Support PCMH 3: Plan and Manage 2011 Implement Evidence-Based Guidelines Identify High-Risk Patients Care Management (Must Pass) Medication Management Use Electronic Prescribing PCMH 4: Provide Self-Care Support and Community Resources Support Self-Care Process (Must Pass) Provide Referrals to Community Resources 2014 Identify Patients for Care Management Care Planning and Self-Care Support Medication Management Use Electronic Prescribing Support Self-Care and Shared Decision Making

4A: Care Management and Support (2011 3A) New from 2011 is designation of specifically high cost/utilization population as well as a population specifically made vulnerable by a social determinant of health (such as exposure to crime, access to education, housing status, etc. Documentation: process and criteria for identifying populations; percentage of the total patient population to benefit from care management based on the number/type of conditions selected for factors 1-5

Standard 4: Must Pass PCMH 4B: Care Planning and Self-Care Support The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75% of the patients identified in Element A: Incorporates patient preferences and functional/lifestyle goals. Identifies treatment goals. Assesses and addresses potential barriers to meeting goals. Includes a self-management plan. Is provided in writing to the patient/family/caregiver.

4C: Medication Management (2011 3D) Just like 3D although now aligned w Meaningful Use Stage 2 4D: Use Electronic Prescribing (2011 3E) Just like 3E in 2011 4E: Support Self-Care and Shared Decision Making Adapted from 2011 4A and 4B, emphasis on providing educational resources to patients for their use in self management, including referrals to available community resources.

Standard 5 2011 Test Tracking and Follow-Up PCMH 5: Track and Coordinate Care PCMH 5: Care Coordination and Care Transitions 2011 Test Tracking and Follow-Up Referral Tracking and Follow-Up (Must-Pass) Coordination with Facilities and Care Transitions 2014 Test Tracking and Follow-Up Referral Tracking and Follow-Up (Must-Pass) Coordinate Care Transitions

5A: Test Tracking and Follow Up Very closely aligned with 5A from 2011. Larger thresholds for the percent of lab and radiology orders that are electronically recorded in the pt record.

Standard 5: Must Pass The practice: PCMH 5B: Referral Tracking and Follow-Up The practice: Considers available performance information on consultants/specialists when making referral recommendations. Maintains formal and informal agreements with a subset of specialists based on established criteria. Maintains agreements with behavioral healthcare providers. Integrates behavioral healthcare providers within the practice site. Gives the consultant or specialists pertinent demographic and clinical data, including test results and the current care plan.

Standard 5: Must Pass The practice: PCMH 5B: (continued) The practice: Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan. Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50% of referrals.+ Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports. (critical factor) Documents co-management arrangements in the patient’s medical record. Asks patients/families about self-referrals and requesting reports from clinicians.

5C: Coordinate Care Transitions very similar to 2011

Standard 6 PCMH 6: Measure and Improve Performance 2011 PCMH 6: Performance Measurement and Quality Improvement 2011 Measure Performance Measure Patient/Family Experience Implement Continuous Quality Improvement (Must Pass) Demonstrate Continuous Quality Improvement Report Performance Report Data Externally 2014 Measure Clinical Quality Performance Measure Resource Use and Care Coordination Measure Patient/Family Experience Implement Continuous Quality Improvement (Must Pass) Demonstrate Continuous Quality Improvement Report Performance Use Certified EHR Technology

6A: Measure Clinical Quality Performance Like Population management, separated measurement of immunization measures from other preventative care measures 6B: Measure resource use and care coordination Added two measures related to care coordination. Examples include: biopsy follow up, patient follow up after ER visit (see pg. 82 in standards for more examples) 6C: Measure Patient/Family Experience Exactly aligned 2011 standards for measuring patient experience(2011 6B)

Standard 6: Must Pass PCMH 6D: Implement Continuous Quality Improvement The practice uses an ongoing quality improvement process to: Set goals and analyze at least three clinical quality measures from Element A. Act to improve at least three clinical quality measures from Element A. Set goals and analyze at least one measure from Element B. Act to improve at least one measure from Element B. Set goals and analyze at least one patient experience measure from Element C. Act to improve at least one patient experience measure from Element C. Set goals and address at least one identified disparity in care/service for identified vulnerable populations.

6E: Demonstrate Continuous Quality Improvement Closely aligned with 2011 6D…credit for achieving improvement on measures from elements A through C 6F: Report Performance Report performance data internally and publicly by individual clinician and at the practice-level 6G: Use Certified EHR Technology Not scored so no impact on points but they want you to report whether or not you use an EHR to perform a number of capabilities