1. Feb. 13, 2019 | In partnership with IPHCA
HITEQ Highlights: Tools and Tips to Prepare for NCQA Patient Centered Medical Home 2017
My name is Julie Hook from Health Information Technology, Evaluation and Quality Center (or HITEQ Center) and I will be your moderator for this webinar. We have a member of our HITEQ team who I will introduce you to in a moment who will be presenting today on tools and tips to prepare for NCQA Patient Centered Medical Home
If you want to download our slides for today, they are available now on our website and the link is being chatted out right now. Lea to chat out link to slides.
If you have any questions during the webinar, please chat them into the chat box and we will answer as many as we can at the end of the call.
Just wanted to put a plug in for our evaluation: Your feedback is important to us as it helps us to plan effective webinars and other trainings.  At the end of this webinar you’ll be asked to complete an evaluation survey. It will pop up on your screen immediately after this webinar. We thank you in advance for taking the time to provide your feedback.
Feb. 13, 2019 | In partnership with IPHCA

2. Jillian Maccini, MBA, PMP, PCMH CCE HITEQ Knowledge Base Lead HITEQ Quality Improvement Lead Health Center Supporter | Overall Data Lover
Now I’d like to introduce Jillian Maccini, who is the Quality Improvement lead for the HITEQ Center, curating and developing a resource set for Health IT-enabled Quality Improvement. She also supports comprehensive analysis of historical health center data, identifying areas for Health IT evaluation and quality improvement and has worked closely with health centers, Primary Care Associations, and Health Center Controlled Networks to identify additional needs, as well as develop and provide supplemental health IT-enabled quality improvement tools and resources.  For the past six years, she has worked closely with Federally Qualified Health Centers on Uniform Data System reporting, as a reviewer, trainer, and analyst. She is a certified Project Management Professional as well as a PCMH Certified Content Expert.
Jillian?

3. Three Pathways to Recognition
Accelerated Renewal
Annual Renewal
Submit evidence for 40 core criteria and min. of 25 elective credits.
Attest to 18 core criteria and submit evidence for 22 core criteria. Achieve min. of 25 elective credits from 34 criteria requiring attestation and 16 criteria requiring submitted evidence.
Bypass submission of evidence for core and elective criteria, move to next phase.

4. PCMH 2017 Concepts Team Based Care + Practice Org. (TC)
Knowing + Managing Your Patients
(KM)
Patient-Centered Access + Continuity (AC)
Care Management + Support
(CM)
Care Coord. + Care Transition
(CC)
Performance Measurement + Quality Improvement
(QI)
Provide continuity of care, communicate roles and responsibilities of the medical home to patients/ families/ caregivers, and organize and trains staff to work to the top of their license and provide effective team-based care.
Capture and analyze information about the patients and community being served and use the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.
The PCMH model requires continuity of care. Patients/ families/ caregivers have round the clock access to clinical advice and care is facilitated by their designated clinician/ care team and supported by access to their medical record. The practice considered the needs and preferences of the patient population when establishing and updating standards for access.
Identify patient needs at the individual and population levels to effectively plan, manage, and coordinate patient care in partnership with patients/ families/ caregivers. Emphasis is placed on supporting patients at highest risk.
Systematically track tests, referrals, and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.
Establish a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/ families/ caregivers in quality improvement activities.

5. First Steps Contact HRSA, submit NOI through EHBs
Prior to Completing Enrollment in Q-PASS, which starts the clock on your 12 months to complete.
Contact HRSA, submit NOI through EHBs
Expectation is to start within the quarter, and complete within the fiscal year.
No more that 3 months prior to anticipated first check-in.
Contact EHR/ health IT vendor for pre-validation, auto/transfer credit, ONC cert.
Create Q-PASS account
Complete NCQA Eligibility/ Readiness Survey
Claim/ create/ add organization
Use education and self-assessment tools.
Within 6-8 weeks of Enrolling, for review in Virtual Check-In 1
Remaining time, Virtual Check-In 2 and 3

6. Team Based Care + Practice Org.
Competency A: The practice is committed to transforming the practice into a sustainable medical home. Members of the care team serve specific roles as defined by the practice’s organizational structure and are equipped with the knowledge and training necessary to perform those functions.
2 core
5 elective credits
Competency B: Communication among staff is organized to ensure that patient care is coordinated, safe and effective.
2 elective credits
Competency C: The practice communicates and engages patients on expectations and their role in the medical home model of care.
1 core
No elective credits
As a federally qualified health center, you have community members on your board– as long as those are patients or caregivers of patients, that addresses TC04. If your EHR is a certified EHR (if you're participating in Meaningful Use), then you are meeting TC05.
Are you… participating in Meaningful Use? Convening staff in a cross functional QI team? Sharing Medical Home information with patients (perhaps along with patient portal or consent information)?

7. Knowing + Managing Your Patients
Competency A: Practice routinely collects comprehensive data on patients to understand the background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.
3 core
6 elective credits
Competency B: The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs. The practice uses this information to ensure linguistic and other patient needs are met.
2 core
1 elective credits
Competency C: The practice proactively addresses the care needs of the patient population to ensure needs are met.
1 core
2 elective credits
Many of these overlap with UDS measures– you can likely use your UDS reports as your documentation.
Competency B is almost certainly being met if you are doing your annual UDS report– this is all the information you report on Table 3B. So use those reports! You’ll also need to act on this information, such as providing services in various languages, employing interpreters, etc.
Are you… doing depression screening? SBIRT? Oral health risk assessment? Using PRAPARE? Leveraging population health management tools (i2i, Azara) or reports to identify care gaps and disparities?

8. Knowing + Managing Your Patients
Competency D: The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers.
2 core
5 elective credits
Competency E: The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients.
Consistent with Objective 3 for Meaningful Use
1 core
No elective credits
Competency F: The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support.
8 elective credits
Are you… consistently doing med rec? Using CDS tools in your EHR? Involved in community collective impact or asset mapping? Providing patients resource lists or referral to community resources?

9. Patient-Centered Access + Continuity
Competency A: The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs.
5 core
4 elective credits
Competency B: Practices support continuity through empanelment and systematic access to the patient’s medical record.
2 core
Are you… gathering social determinants and monitoring outcomes, or otherwise assessing equity? Effectively leveraging your patient portal? Using telehealth/ telemedicine?

10. Care Management and Support
Competency A: The practice systematically identifies patients who may benefit from care management.
2 core
2 credits
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.
4 credits
Are you… Risk stratifying? Implementing Care Coordination? Chronic Disease Self Management programs? Using patient engagement tools?

11. Care Coordination + Care Transitions
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result.
1 core
3 elective credits
Competency B: The practice provides important information in referrals to specialists and tracks referrals until the report is received.
14 elective credits
Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.
3 core
7 elective credits
Are you… using referral coordinators? integrating BH in primary care? Part of an RHIO or HIE? Systematically receiving ADT information? Using state immunization information systems or registries?

12. Performance Measurement + Quality Improvement
Competency A: The practice measures to understand current performance and to identify opportunities for improvement.
4 core
4 elective credits
Competency B: The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies.
5 elective credits
Competency C: The practice is accountable for performance. The practice shares performance data with the practice, patients and/or publicly for the measures and patient populations identified in the previous section.
1 core
7 elective credits
Are you… Participating in Learning Collaboratives or ongoing QI projects? Do you use dashboards, data visualizations?

13. PCMH Self Assessment Tool
Excel-based tool
Allows you to track core and elective criteria met
Use as planning document

14. PCMH AirTable Tracking Tool
Excel-based tool
Allows you to track core and elective criteria met
Use as planning document
Chat out this link:

15. Tips to Get you Started Prior to Completing Enrollment in Q-PASS
Review the Standards and Guidelines to ensure that you meet the requirements (including primary care requirements, etc.)
Reach out to your Health IT vendor for Prevalidation Summary Approval Table and NCQA Letter of Product Autocredit Approval
Conduct regular meeting with your PCMH or practice transformation team
Leverage current activities/ structure for evidence:
UDS data for KM05, KM03, KM06, KM09, KM10, QI01, QI02
OC3/other QI activities with care teams involved: TC07
Consumer representation on health center board (as required by BPHC): TC04
Autocredit from Health IT vendor
Complete remaining core criteria
Complete any remaining elective criteria
Within 6-8 weeks of Enrolling, for review in Virtual Check-In 1
Remaining time, Virtual Check-In 2 and 3