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

2. 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

3. 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

4. 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.

5. 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.

6. Does it Work?
Where is the Evidence ?

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

8. 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

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

10. 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”

11. 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 %)

12. 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

13. 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**

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. NCQA Recognition
Where do we start?

21. 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

22. 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

23. 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)

24. 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

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

26. 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

27. 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

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

29. 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

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