1. August 2012 Webinar Planned Care at Every Visit
Planned Care PDSA Sharing
Planned Care Essential to NCQA, MU
Super Strategy: Site Visit
Learning Session #2

2. Planned Care at Every Visit
Process to identify all diabetes patients
Electronic population alert is best—accurate (once tested) and saves time—but stickers good too
Use for all visits (acute, chronic, walk-in)
Alerts and pre-visit planning to identify unmet needs
Highlights or flags on template/flow sheet incorporating evidence-based guidelines
Get as much done as possible
Max-packing!
Team-based care/standing orders
Plan/Schedule follow-up care
Higher-risk patients sooner, more often
Additional ideas for planning small scale tests.

3. PDSA Sharing General Internal Medicine Seneca More Sharing……
Population alert in EMR banner, registry cleaning, chart prep, addressing all needs, clarifying who does what, patient resistance, overdue patient list
Seneca
Diabetes template, completing documentation difficult when trying to max-pack, pre-visit planning team huddles, self-management goal sheet
More Sharing……
What is everyone else working on?

4. Planned Care Essential to NCQA PCMH Standards
Applies directly to 4 of 6 NCQA standards
PCMH 1: Element E (expectation of evidence-based care) and Element G (team-based care)
PCMH 2: Identify and Manage Patient Populations
Must Pass: Use Data for Population Management
PCMH 3: Plan and Manage Care
Must Pass: Care Management (pre-visit planning, risk assessment, follow-up care)
PCMH 5: Track and Coordinate Care
Must Pass: Referral Tracking and Follow-Up

5. Planned Care Essential to Attesting for Meaningful Use
Applies to 4 of 15 Meaningful Use Core Objectives
Core Measure #7: Patient demographics as structured data.
Core Measure #8: Vital signs as structured data.
Core Measure #9: Smoking status on patients age 13 or older.
Core Measure #11: Use and tracking of one clinical decision support rule.
Applies to 2 Menu Measures (5 of 10 required)
Menu Measure #2: Lab test results as structured data.
Menu Measure #3: Lists of patients by specific conditions.
Applies to all 3 Core Quality Measures (BP, tobacco, BMI)
Applies to 8 Additional Clinical Quality Measures related to diabetes (must report on 3)

6. Super Strategy: Site Visit
Medical Group of Corry site visit to Seneca Medical Center
Issue: Laboratory services
Goals: Quality care, structured data
Options: External, internal solutions
Investigation:
Interaction with vendors
Visit to Seneca Medical Center
Benefits of collaboration
Thanks!!

7. Learning Session #2 South Central PA North West PA
Thursday, Sept. 6: 5-9pm
Fitness/Conference Center at Hershey Med Center (same location as before)
North West PA
Thursday, Sept. 20: 5-9pm
Penn State Behrend (same location as before)

8. Tentative Topics What do you want/need? Data Review PDSA Sharing
Importance of clinical protocols, follow-up visits
PDSA Sharing
Self-Management Support
NCQA PCMH Recognition
What do you want/need?

9. Have Any Questions? South Central – Sharon Adams,
North West – Patty Stubber ,