1. Training Webinar # 7 David Halpern, MD, MPH March 7, 2012 Patient-Centered Medical Home NCQA’s PCMH 2011 Standards

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3. Acknowledgements

4. Let’s Review What Is The Record Review Workbook? Standard 4 – Self-Care Support & Community Resources – PCMH4A: Support Self-Care Process – MUST PASS – PCMH4B: Provide Referrals to Community Resources

5. Let’s Track Our Progress Standard 1 – Enhance Access/Continuity Standard 2 – Identify/Manage Populations Standard 3 – Plan/Manage Care Standard 4 – Self-Care Support/Resources Standard 5 – Track/Coordinate Care Standard 6 – Measure/Improve Performance

6. Today’s Agenda Standard 3 – Plan & Manage Care – PCMH3A: Implement Evidence-Based Guidelines – PCMH3B: Identify High-Risk Patients – PCMH3C: Care Management - MUST PASS – PCMH3D: Medication Management – PCMH3E: Use Electronic Prescribing

7. PCMH 3A: Implement Evidence-Based Guidelines Practice implements guidelines through point of care reminders for patients with: 1)The first important condition * 2)The second important condition 3)The third condition, related to unhealthy behaviors or mental health or substance abuse * Meaningful Use Requirement

8. 4 Points Scoring – 3 factors = 100% – 2 factors (including factor 3) = 50% – 1 factor = 25% – 0 factors = 0% Data Sources: – Identification of 3 conditions; (these are not screening or a single preventive service process) – Name and source of guidelines – Demonstration of how guidelines are implemented PCMH 3A: Implement Evidence-Based Guidelines

9. Examples of eligible conditions include: COPD, hypertension, hyperlipidemia, HIV/AIDS, asthma, diabetes, or congestive heart failure. One of the 3 conditions (Factor 3) must be related to unhealthy behavior (e.g. obesity, smoking), substance abuse (e.g. illicit drug use, prescription drug addiction, alcoholism), or a mental health condition (e.g. depression, anxiety, bipolar disorder, ADHD, dementia). PCMH 3A: Choose Conditions

10. PCMH 3A: Provide Justification

11. PCMH 3A: Select Evidence-Based Guidelines

14. You must adopt AND implement the guidelines Guidelines can be implemented by embedding them into the EMR or using paper-based supporting documentation (flow sheets or templates used to document treatment plans or patient progress) PCMH 3A: Implement Evidence-Based Guidelines

15. Diabetes Management Flow Sheet PCMH 3A: Implement Evidence-Based Guidelines

18. The practice does the following to identify high-risk patients: 1)Establishes criteria and a process to identify high-risk or complex patients 2)Determines the percentage of high-risk patients in the population PCMH 3B: Identify High-Risk Patients

19. 3 Points Scoring – 2 factors = 100% – 1 factor = 25% – 0 factors = 0% Data Sources: – Process to identify patients – Report showing number and percentage of high-risk patients PCMH 3B: Identify High-Risk Patients

20. The practice should have specific criteria and a process for identifying complex or high-risk patients who need care planning and management services. This may be based on (alone or in combination): – High resource use (e.g. visits, medications, treatments, other cost measures) – Frequent visits for urgent or emergent care – Frequent hospitalizations – Multiple comorbidities (including mental health) – Non-adherence with prescribed treatments/meds – Terminal illness (palliative care/hospice involvement) – Barriers to care (e.g. lack of social/financial support) – Advanced age and frailty – Multiple risk factors (smoking, family history, obesity, etc) PCMH 3B: Explanation of Factor 1

21. The practice may identify patients through a billing or practice management system, through the EMR, through key staff members, or through profiles from health plan (as long as these encompass 75% or more of patients) The factor requires a report that shows a number and percentage of patients identified as high risk, meaning you need to show a numerator (# of high risk patients) and denominator (total # of patients) PCMH 3B: Explanation of Factor 2

22. The patients you use for the review in 3C and 3D are those who have one of the 3 conditions listed in 3A, or are designated “high-risk” as described in 3B You should only use visits that are “relevant” (i.e. related to the chronic condition in question or a combination of the factors which make them “high risk”) NCQA does NOT expect you to care manage every patient in your practice. PCMH 3C &3D: REMEMBER!

23. Care team performs the following for at least 75% of patients from Elements 3A and 3B: 1)Conducts pre-visit preparations 2)Collaborates with patient to develop care plan, including treatment goals 3)Gives patient written care plan 4)Assesses and addresses barriers to treatment goals 5)Gives patient clinical summary at relevant visits 6)Identifies patients who need more care management support 7)Follows up with patients who have not kept important appointments PCMH 3C: Care Management

24. MUST PASS 4 Points Scoring – 6-7 factors = 100% – 5 factors = 75% – 3-4 factors = 50% – 1-2 factors = 25% – 0 factors = 0% Data Sources: – Report from electronic system or submission of Record Review Workbook PCMH 3C: Care Management

25. PCMH 3C: Record Review Workbook

26. PCMH 3C: Example – Factor 1

27. PCMH 3C: Example – Factor 3

28. PCMH 3C: Example – Factor 4

29. PCMH 3C: Example – Factor 7

30. Practice manages medications in the following ways: 1)Reviews and reconciles medications for more than 50% of care transitions * - CRITICAL FACTOR 2)Reviews and reconciles medications for more than 80% of care transitions 3)Provides information about new prescriptions to more than 80% of patients 4)Assess patient understanding of medications for more than 50% of patients 5)Assesses patient response to medication and barriers to adherence for more than 50% of patients 6)Documents OTCs, herbal/supplements, for more than 50% of patients, with date of update * Meaningful Use Requirement PCMH 3D: Medication Management

31. 3 Points Scoring – 5-6 factors (including factor 1) = 100% – 3-4 factors (including factor 1) = 75% – 2 factors (including factor 1) = 50% – Factor 1 = 25% – 0 factors or does not meet Factor 1 = 0% Data Sources: – Report from electronic system or submission of Record Review Workbook PCMH 3D: Medication Management

32. PCMH 3D: Record Review Workbook

33. PCMH 3D: Example – Factor 2

34. PCMH 3D: Example – Factor 2 & 6

35. PCMH 3D: Example – Factor 2

36. Practice uses e-prescribing system with the following capabilities: 1)Generates and transmits at least 40% of prescriptions to pharmacies * 2)Generates at least 75% of eligible prescriptions * 3)Integrates with patient medical records 4)Performs patient-specific checks for drug-drug and drug-allergy interactions * 5)Alerts prescribers to generic alternatives 6)Alerts prescribers to formulary status * * Meaningful Use Requirement PCMH 3E: Use Electronic Prescribing

37. 3 Points Scoring – 5-6 factors (including factor 2) = 100% – 4 factors = (including factor 2) = 75% – 2-3 factors = (including factor 2) = 50% – 1 factor = 25% – 0 factors = 0% Data Sources: – Reports showing percent of electronic prescriptions written and transmitted, and demonstrating the system’s capabilities PCMH 3E: Use Electronic Prescribing

38. PCMH 3E: Example – Factors 1 & 2 EXPLANATION January to March 2009 prescribing method is documented in the table. Certain prescriptions (Schedule II) must be printed on special paper prescription pads in our state. 96% of prescriptions were generated from our electronic medical record.

39. PCMH 3E: Example – Factors 1 & 2

40. PCMH 3E: Example – Factors 3 & 4 Drug-Allergy Interaction

41. PCMH 3E: Example – Factor 4

42. PCMH 3E: Example – Factors 3, 5, 6

44. Capturing A Screenshot Press the Print Screen key on your keyboard. It may be labeled [PrtScn]. Open a word processing program like Microsoft Word. Go to the Edit tab and choose Paste (or press control V). Optional: Use your image editor's crop tool to crop out unnecessary portions of the screen shot. Annotate the image by typing above or below. Go to the File tab and choose Save As. Navigate to the folder where you want to save the image. Type a file name for the image. Click the Save button.

45. Screenshot Demo

46. 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)

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