1. Patient-Centered Medical Home & Multi-Payer Demo Training Webinar # 5 Standards 3 and 4 David Halpern, MD, MPH July 20th, 2011

2. Acknowledgements

3. Let’s Review PPC 1B (Finished Standard 1) PPC 2A, 2B, 2C, & 2F (Finished Standard 2) Discussed “Record Review Workbook”

4. Today’s Agenda PPC 3B, 3C, 3D, & 3E (Finish Standard 3) PPC 4A, 4B (Finish Standard 4)

5. PPC 3B: Preventive Service Reminders

6. PPC 3B: Example of Factors 1, 2, & 3 Paper Reminder for Risk Assessments, Immunizations, Screening Tests

7. PPC 3B: Example of Factor 3 EHR Showing Reminders for Risk Assessments

8. PPC 3B: Example of Factor 4

9. PPC 3B: Example of Factors 1-4

10. PPC 3C: Practice Organization

11. PPC 3C: Example of Factors 1 & 2

12. PPC 3C: Example of Factor 2

13. PPC 3D: Care Management

14. PPC 3D: Example of Factor 2

15. PPC 3D: Example of Factors 3 & 5 Demonstrates medication review (Factor 5) Demonstrates treatment goals (Factor 3)

16. PPC 3D: Example of Factors 4, 6, & 7 Demonstrates patient progress (Factor 4) and self- monitoring results (Factor 6) Demonstrates barriers to patient’s ability to meet goals (Factor 7)

17. PPC 3D: Example Using the Record Review Workbook

18. PPC 3D: Important! “The physician may decide that patients already achieving good outcomes do not require care management; in those cases, a notation that the patient has good outcomes would suffice in place of a record of the care management processes.”

19. PPC 3D: Patient Met Treatment Goals If there is documentation in the medical record in the last three months that the patient is meeting treatment goals: —“patient stable”, “condition under control on current regimen”— Select “YES” If YES, then select “YES” for each box across the row for that patient If good outcomes NOT documented in medical record, enter “NO” and review record for all other items; may look back 12 mo. for documentation in record

20. PPC 3E: Continuity of Care

21. PPC 3E: Example of Factor 5 Information blocked out to protect sensitive personal information (HIPAA)

22. PPC 3E: Example of Factors 3, 4, & 5

23. PPC 4A: Documenting Communication Needs

24. PPC 4A: Example of Factor 1 **This chart demonstrates that a practice identifies language preference of its patients, but does not adequately document that the practice displays the language preference in the chart.**

25. PPC 4A: Example of Factors 1 & 2

26. your practice name here

27. PPC 4B: Self-Management Support

28. PPC 4B: Example of Factor 3 The practice provides patient with self- management tool (flowsheet) and then includes completed self-management tool in patient’s chart

29. PPC 4B: Example of Factor 4

30. PPC 4B: Example Using the Record Review Workbook

31. PPC 4B: IMPORTANT! “The physician may decide that patients already achieving good outcomes do not require self-management support; in those cases, a notation that the patient has good outcomes would suffice in place of a record of the self-management items in this element.”

32. PPC 4B: “Patient Met Outcomes” If there is documentation in the medical record in the last three months that the patient is meeting outcomes: —“patient stable”, “condition under control on current regimen”— Select “YES” If YES, then select “YES” for each box across the row for that patient If good outcomes NOT documented in medical record, enter “NO” and review record for all other items; may look back 12 mo. for documentation in record

33. Next Steps (Homework) Review Elements 3B, 3C, 3D, 3E, 4A, & 4B and decide which ones you’d like to tackle Begin work on those Elements Review the Record Review Workbook and begin to put in place the things you’ll need to complete the Workbook –**REMEMBER** you need 3 months of patient data to review, so start soon! We’ve now covered all 4 Elements that use the Record Review Workbook for documentation

34. Community Care PCMH Team David Halpern, MD, MPH Community Care of North Carolina (CCNC) R.W. “Chip” Watkins, MD, MPH, FAAFP Community Care of North Carolina (CCNC) Brent Hazelett, MPA North Carolina Academy of Family Physicians (NCAFP) Elizabeth Walker Kasper, MSPH North Carolina Healthcare Quality Alliance (NCHQA)

35. Partners

36. Questions? Feel free to contact me: David Halpern, MD, MPH (215) 498-4648 dhalpern@n3cn.org