1. Patient Centered Medical Home
Data and Recognition Review
for
Saint Luke’s Medical Group by
Jennifer Woods, RN, BSN
Director of Physician Practice Management

2. Goals of Presentation
Provide better understanding of the Patient Centered Medical Home as a care model.
Provide understanding of the credentialing process for Patient Centered Medical Home.
Explore areas where this model provided a guidance for improvement in care.
Review transformation in becoming a Patient Centered Medical Home.

3. What is a Patient-Centered Medical Home?
A patient-centered medical home (PMCH) is a model of primary care where each patient has a relationship with their primary care physician who leads their care team, and the care of the patient is coordinated to support their healthcare needs.
Enhanced care is achieved through open scheduling, expanded hours, and communication between patients, physicians and staff.

4. PMCH: Not a New Concept! Historical Review
1967: American Academy of Pediatrics (AAP) first introduced the term “medical home” which described primary care that was accessible, family-centered, coordinated, comprehensive, continuous, compassionate and culturally effective.

5. PMCH: Not a New Concept! Historical Review
2002: Seven national family medicine organizations created “The Future of Family Medicine” project. Recommendations from this report included “taking steps to ensure that every American has a personal medical home, developing reimbursement models to sustain family medicine and primary care.

6. PMCH: Not a New Concept! Historical Review
2005: Dr. Barbara Starfield published “Contribution of Primary Care to Health Systems and Health”, which acknowledged several primary care processes to benefit health:
Greater access
Better quality of care
Greater focus on prevention
Early management of health problems
Reducing unnecessary specialty or inpatient services

7. PMCH: Not a New Concept! Historical Review
2006: The Patient-Centered Primary Care Collaborative (PCPCC) is founded by numerous employers, primary care physician associations (American Academy of Family Physicians (AAFP). This new organization was charged with developing a national movement to endorse widespread adoption of the patient-centered medical home.

8. What is NCQA?
National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout healthcare, helping to elevate the issue of quality to the top of the national agenda.

9. What is NCQA’s PCMH Program?
In 2008, NCQA launched a Patient Centered Medical Home recognition program, which was revised in 2011.
NCQA’s program provides a roadmap for primary care to improve delivery and the experience of care for both clinicians and patients.

10. What is NCQA’s PCMH Program?
NCQA’s goals are to promote:
Improvement in health outcomes for the patient and their family
Enhance the patient’s experience of their care
Reduce expensive, unnecessary hospital and ED care
To the extent possible, NCQA has aligned the PCMH standards with the Centers for Medicare & Medicaid Services (CMS) Meaningful Use requirements.

11. NCQA PCMH Scoring 6 Standards = 100 points 6 Must Pass elements
Level of Qualifying
Points
Must Pass Elements at 50% Performance Level
Level 3
6 of 6
Level 2
Level 1
Not recognized
0 - 34
Less than 6
Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.

12. SLMG: Transformation to PCMH
SLMG selected NCQA’s recognition program, and began by utilizing their assessment tools to determine areas of compliance with standards, as well as opportunities for improvement.
PMCH Coordinating Committee established to govern the transformation process, and was supported by:
PMCH Site Coordinator and physician lead at each clinic to assist with implementation of new policies, procedures and reporting tools.

13. SLMG: Transformation to PCMH
Newsletters developed to keep staff apprised of next steps.
Educational presentations at staff and physician meetings on PMCH standards and requirements for recognition.
Standardization of policies and processes.
Partnership with outside vendor for patient registry to manage patient populations.

14. NCQA 2011 PCMH Standards Enhance Access and Continuity
Identify and Manage Patient Populations
Plan and Manage Care
Provide Self-Care Support and Community Resources
Track and Coordinate Care
Measure and Improve Performance

15. PCMH: Review of Standards PMCH 1: Enhance Access and Continuity
Element A: Access During Office Hours (Must Pass)
The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:
Providing same day appointments
Providing timely clinical advice by telephone during office hours
Providing timely clinical advice by secure electronic messages during office hours
Documenting clinical advice in the medical record

16. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element B: After-Hours Access
The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:
Providing access to routine and urgent-care appointments outside regular business hours
Providing continuity of medical record information for care and advice when the office is not open
Providing timely clinical advice by telephone when the office is not open
Providing timely clinical advice using a secure, interactive electronic system when the office is open
Documenting after-hours clinical advice in patient records

17. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element C: Electronic Access
The practice provides the following information and services to patients and families through a secure electronic system.
More than 50% of patients who request an electronic copy of the health information receive it within 3 business days
At least 10% of patients have electronic access to their current health information within 4 business days of when the information is available to the practice

18. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element C: Electronic Access cont.
3. Clinical summaries are provided to patient for more than 50% of office visits within 3 business days
4. Two-way communication between patients/families and the practice
5. Request of appointments or prescription refills
6. Request for referrals or test results

19. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element D: Continuity
The practice provides continuity of care for patients/families by:
Expecting patients/families to select a personal
clinician
Documenting the patient’s/family’s choice of clinician
Monitoring the percentage of patient visits with a selected clinician or team.

20. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element E: Medical Home Responsibilities
The practice has a process and materials that it provides patients/families on the role of the medical home, which include the following:
The practice is responsible for coordinating patient care across multiple settings
Instructions on obtaining care and clinical advice during offices hours and when the office is closed
The practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practice
The care team gives the patient/family access to evidenced-based care and self-management support

21. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element F: Culturally and Linguistically Appropriate Services (CLAS)
The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by:
Assessing the racial and ethnic diversity of its population
Assessing the language needs of its population
Providing interpretation or bilingual services to meet the language needs of its population
Providing printed materials in the languages of its population

22. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element G: The Practice Team
The practice uses a team to provide a range of patient care services by:
Defining roles for clinical and nonclinical team members
Having regular team meetings or a structured communication process
Using standing orders for services
Training and assigning care teams to coordinate care for individual patients

23. PCMH: Review of Standards PCMH 1: Enhance Access and Continuity
Element G: The Practice Team cont.
Training and assigning care teams to support patients and families in self-management, self-efficacy and behavior change
Training and assigning care teams for patient population management
Training and designating care team members in communication skills
Involving care team staff in the practice’s performance evaluation and quality improvement activities

24. PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element A: Patient Information The practice uses an electronic system that records the following as structured (searchable) data for more than 50% of its patients.
Date of birth
Gender
Race
Ethnicity
Preferred language
Telephone numbers
address
Dates of previous clinical visits
Legal guardian
10. Primary caregiver
Presence of advanced directive
Health insurance information

25. PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element B: Clinical Data The practice uses an electronic system to record the following as structured (searchable) data.
An up-to-date problem list with current and active diagnoses for more than 80% of patients
Allergies, including medication allergies and adverse reactions, for more than 80% of patients
Blood pressure, with the date of update for more than 50% of patients 2 years and older
Height for more than 50% of patients 2 years and older
Weight for more than 50% of patients 2 years and older
System calculates and displays BMI
System plots and displays growth charts and BMI %
Status of tobacco use for patients 13 years and older for more than 50% of patients
List of prescription medications with the date of updates for more than 80% of patients

26. PCMH: Review of Standards PCMH 2: Identify and Manage Patient Populations Element C: Comprehensive Health Assessment To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes:
Documentation of age and gender appropriate immunizations and screenings
Family/social/cultural characteristics
Communication needs
Medical history of patient and family
Advance care planning
Behaviors affecting health
Patient and family mental health/substance abuse
Developmental screening using a standardized tool
Depression screening for adults and adolescents using a standardized tool

27. PMCH Review of Standards PCMH 2: Identify and Manage Patient Populations
Element D: Use Data for Population Management (Must Pass)
The practice uses patient information, clinical data and evidenced-based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of services needed for:
At least three different preventive care services
At least three different chronic care services
Patients not recently seen by the practice
Specific medications

28. PCMH: Review of Standards PCMH 3: Plan and Manage Care The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidenced-based guidelines.
Element A: Implement Evidenced-Based Guidelines
The practice implements evidenced-based guidelines through point-of-care reminders for patients with:
The first important condition
The second important condition
The third condition, related to unhealthy behaviors or mental health or substance abuse

29. PCMH: Review of Standards PCMH 3: Plan and Manage Care cont.
Element B: Identify High-Risk Patients
To identify high-risk or complex patients, the practice:
Establishes criteria and a systematic process to identify high risk or complex patients
Determines the percentage of high-risk or complex patients in it’s population

30. PCMH: Review of Standards PCMH 3: Plan and Manage Care Cont.
Element C: Care Management (Must Pass)
The are team performs the following for at least 75% of the patients identified in Elements A and B.
Conducts pre-visit preparations
Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit
Gives the patient/family a written plan of care
Assesses and addresses barriers with the patient has not met treatment goals
Gives the patient/family a clinical summary at each relevant visit
Identifies patients/families who might benefit from additional care management support
Follows up with patients/families who have not kept important appointments

31. PMCH: Review of Standards PCMH 3: Plan and Manage Care cont.
Element D: Medication Management
The practice manages medications in the following ways:
Reviews and reconciles medications with patients/families for more than 50% of care transitions
Reviews and reconciles medications with patients/families for more than 80% of care transitions
Provides information about new prescriptions to more than 80% of patients/families
Assesses patient/family understanding of medications for more than 50% of patients with date of assessment
Assesses patient responses to medications and barriers to adherence for more than 50% of patients with date of assessment
Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients/families, with the date of updates

32. PCMH: Review of Standards PCMH 3: Plan and Manage Care
Element E: Use Electronic Prescribing
The practice uses an electronic prescription system with the following capabilities.
Generates and transmits at least 40% of eligible prescriptions to pharmacies
Generates at least 75% of eligible prescriptions
Enters electronic medication orders into the medical record for more than 30% of patients with at least one medication in their medication list
Performs patient-specific checks for drug-drug and drug-allergy interactions
Alerts prescribers to generic alternatives
Alerts prescribers to formulary status

33. PCMH: Review of Standards PCMH 4: Provide Self-Care Support and Community Resources The practice acts to improve patients’ ability to manage their health by providing a self-care plan, tools, educational resources and ongoing support
Element A: Support Self-Care Process (Must Pass)
The practice conducts activities to support patients/families in self-management.
Provides educational resources or refers at least 50% of patients/families to educational resources to assist in self-management
Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients, if appropriate
Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families
Documents self-management abilities for at least 50% of patients/families
Provides self-management tools to record self-care results for at least 50% of patients/families
Counsels at least 50% of patients/families to adopt healthy behavio

34. PCMH: Review of Standards PCMH 4: Provide Self-Care Support and Community Resources
Element B: Provide Referrals to Community Resources
The practice supports patients/families that need access to community resources.
Maintains a current resource list on five topics or key community service areas of importance to the patient population
Tracks referrals provided to patients/families
Arranges or provides treatment for mental health and substance abuse disorders
Offers opportunities for health education programs (such as group classes and peer support)

35. PCMH: Review of Standards PMCH 5: Track and Coordinate Care The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations
Element A: Test Tracking and Follow-Up
The practice has a documented process for and demonstrates that it:
Tracks lab tests until results are available, flagging and following up on overdue results
Tracks imaging tests until results are available, flagging and following up on overdue results
Flags abnormal lab results, bringing them to the attention of the clinician
Flags abnormal imaging results, bringing them to the attention of the clinician
Notifies patients/families of normal and abnormal lab and imaging test results
Follows up with inpatient facilities on newborn hearing and blood-spot screening
Electronically communicates with labs to order tests and retrieve results
Electronically communicates with facilities to order and retrieve imaging results
Electronically incorporates at least 40% of all clinical lab test results into structured fields in medical records
Electronically incorporates imaging test results into medical records

36. PCMH: Review of Standards PCMH 5: Track and Coordinate Care
Element B: Referral Tracking and Follow-Up (Must Pass)
The practice coordinates referrals by:
Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information
Tracking the status of referrals, including required timing for receiving a specialist’s report
Following up to obtain a specialist’s report
Establishing and documenting agreements with specialists in the medical record if co-management is needed
Asking patients/families about self-referrals and requesting reports from clinicians
Demonstrating the capability for electronic exchange of key clinical information between clinicians
Providing an electronic summary of care record to another provider for more than 50% of referrals

37. PCMH: Review of Standards PCMH 5: Track and Coordinate Care Cont.
Element C: Coordinate with Facilities and Manage Care Transitions
On its own or in conjunction with an external organization, the practice systematically:
Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visit
Demonstrates its process for sharing clinical information with admitting hospitals and emergency departments
Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities
Demonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit
Demonstrates its process for exchanging patient information with the hospital during a patient’s hospitalization
Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care
Demonstrates the capability for electronic exchange of key clinical information with facilities
Provides an electronic summary of care record to another care facility for more than 50% of transitions of care

38. PCMH: Review of Standards PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.
Element A: Measure Performance
The practice measures or receives data on the following:
At least three preventive care measures
At least three chronic or acute care clinical measures
At least two utilization measures affecting health care costs
Performance data stratified for vulnerable populations (to assess disparities in care).

39. PCMH: Review of Standards PCMH 6: Measure and Improve Performance The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.
Element B: Measure Patient/Family Experience
The practice obtains feedback from patients/families on their experiences with the practice and their care.
The practice conducts a survey to evaluate patient/family experiences on at least three of the following categories:
Access
Communication
Coordination
Whole-person care/self management support
2. The practice uses the CAHPS Patient Centered Medical Home tool
3. The practice obtains feedback on the experiences of vulnerable patient groups
4. The practice obtains feedback from patients/families through qualitative means.

40. PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont.
Element C: Implement Continuous Quality Improvement (Must Pass)
The practice uses an ongoing quality improvement process to:
Set goals and act to improve performance on at least three measures from Element A.
Set goals and act to improve performance on at least one measure from Element B.
Set goals and address at least one identified disparity in care or service for vulnerable populations.
Involve patients/families in quality improvement teams or on the practice’s advisory council.

41. PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont.
Element D: Demonstrate Continuous Quality Improvement
The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:
Tracking results over time
Assessing the effect of its actions
Achieving improved performance on one measure
Achieving improved performance on a second measure

42. PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont.
Element E: Report Performance
The practice shares performance data from Element A and Element B:
Within the practice, results by individual clinician
Within the practice, results across the practice
Outside the practice to patients or publicly, results across the practice or by clinician.

43. PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont.
Element F: Report Data Externally
The practice electronically reports:
Ambulatory clinical quality measures to CMS or states.
Ambulatory clinical quality measures to other external entities.
Data to immunization registries or systems
Syndromic surveillance data to public health agencies.

44. PCMH: Review of Standards PCMH 6: Measure and Improve Performance Cont.
Element G: Use Certified EHR Technology
This element is for your practice site Meaningful Use report only and will not be scored for your PCMH Recognition decision.
To meet the federal Core and Menu Meaningful Use requirements:
The uses an EHR system that has been certified
The practice attests to conducting a security risk analysis of its EHR system.

45. NCQA PCMH Recognition Outcome .
On October 13, 2013 Saint Luke’s Medical Group received notification that all 11 primary care clinics were recognized as a Level 3 Patient Centered Medical Home.

46. NCQA PCMH Clinics Saint Luke’s Internal Medicine (SLIM)
Saint Luke’s Medical-Barry Road
Saint Luke’s Medical Group-Barry Road Internal Medicine
Saint Luke’s Medical-Clinton
Saint Luke’s Medical-Smithville
Saint Luke’s Medical Group-Cushing
Saint Luke’s Medical Group-Lansing
Saint Luke’s Medical Group-Lee’s Summit
Saint Luke’s Medical Group-Platte City
Saint Luke’s Medical Group-Southridge
Saint Luke’s South Primary Care

47. Results of Transformation
Same Day Access available at all clinics.
Goals developed for responding to patients by telephone, electronically and after hours.
Summary of each visit provided to patients.
Defining each staff’s role on the care team.
Training of staff for population management, communication skills, and their role in quality improvement.

48. Outcomes of Transformation
Reports available to proactively remind patients of services needed for:
Preventive Care
Chronic Care
Missed Appointments
Reconciling patient medications at each visit and after hospital or ED discharge.
Development of a community resource list.
Standardization of self-management tools.
Formalized process of tracking tests, referrals and care at other facilities

49. Outcomes of Transformation
New positions of RN Care Coordinators to call every patient following in-patient discharge from hospital and emergency room. Coordinators will:
Set up follow up appointment as needed
Medication reconciliation
Review discharge instructions
Review if any resources are needed
Answer questions

50. Lessons Learned
Have a designated IT expert assigned for the entire project.
Have an analyst who can build your reporting tools.
Have support staff who can receive and manage all reports and documents.
Have an onsite point person to provide ongoing education and support to staff.

51. Questions?