1. Training Webinar # 5 David Halpern, MD, MPH January 25, 2012
Patient-Centered Medical Home NCQA’s PCMH 2011 Standards
Training Webinar # 5
David Halpern, MD, MPH
January 25, 2012

2. Legal Disclaimer
© Copyright 2011 North Carolina Community Care Networks, Inc.  All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure NCQA recognition as patient-centered medical homes.  All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with the permission of the respective copyright owners in each case. 2

3. Acknowledgements

4. Let’s Review Standard 1 – Enhance Access & Continuity
PCMH1A: Access During Office Hours – MUST PASS
PCMH1B: After-Hours Access
PCMH1C: Electronic Access
PCMH1D: Continuity
PCMH1E: Medical Home Responsibilities
PCMH1F: Culturally and Linguistically Appropriate Services
PCMH1G: The Practice Team 4

5. Today’s Agenda Standard 2 – Identify & Manage Populations
Standard 5 – Track & Coordinate Care 5

6. PCMH 2: Identify and Manage Populations
Elements
PCMH 2A: Patient Information
PCMH 2B: Clinical Data
PCMH 2C: Comprehensive Health Assessment
PCMH 2D: Use Data for Population Management - MUST PASS

7. PCMH 2A: Patient Information
Practice uses a searchable electronic system and records data more than 50% of the time for the following:
* Meaningful Use Requirement
1. Date of birth*
8. Dates of previous
2. Gender*
clinical visits
3. Race*
9. Legal guardian/health
4. Ethnicity*
care proxy
5. Preferred language*
10. Primary caregiver
6. Telephone numbers
11. Advance directives
7. address
(NA for pediatrics)
12. Health insurance

8. PCMH 2A: Patient Information
3 Points
Scoring
9-12 factors= 100%
7-8 factors= 75%
5-6 factors= 50%
3-4 factors= 25%
0-2 factors= 0%
Data Sources:
Report showing percentage of all patients seen in the last 3 months, for whom each factor is complete/entered in the electronic record. Requires numerator (patients for whom each field is complete) and denominator (all patients seen in last 3 months). (CHART REVIEW NOT ACCEPTABLE)

9. Note: a screenshot of the EMR is not sufficient without a report
PCMH 2A: Example
This report shows various domains and what % of patients have complete information entered for each field.
Note: a screenshot of the EMR is not sufficient without a report

10. PCMH 2A: Example – Factor 11
Note: a screenshot of the EMR alone is not sufficient without a report

11. PCMH 2B: Clinical Data
Practice uses a searchable electronic system to record the following data:
Up-to-date problem list of active diagnoses for 80% of patients
Allergies, including medications and reactions for 80% of patients
Blood pressure with the date of update for 50% of patients
Height for 50% of patients
Weight for 50% of patients
BMI for 50% of patients
Length/height, weight head circumference (less than 2 years); BMI percentile (2-20); for pediatric patients for 50% of patients
Tobacco use status for patients 13 and older for 50% of patients
List of prescription medications with date of update for 80% of patients

12. PCMH 2B: Clinical Data 4 Points Scoring Data Sources:
9-12 factors= 100%
7-8 factors= 75%
5-6 factors= 50%
3-4 factors= 25%
0-2 factors= 0%
Data Sources:
Report showing percentage of all patients seen in the last 3 months, for whom each factor is complete/entered in the electronic record. Requires numerator (patients for whom each field is complete) and denominator (all patients seen in last 3 months). (CHART REVIEW NOT ACCEPTABLE)

13. PCMH 2B: Example – Factor 1
Note: a screenshot of the EMR alone is not sufficient without a report

14. PCMH 2B: Example – Factor 2
Note: a screenshot of the EMR alone is not sufficient without a report

15. PCMH 2C: Comprehensive Health Assessment
Practice conducts and documents a health assessment:
Age and gender appropriate immunizations/screenings
Family/social/cultural characteristics
Communication needs
Medical history of patient and family
Advance care planning (NA for pediatrics)
Behaviors affecting health
Patient and family mental health/substance abuse
Developmental screening using standardized tool (NA for adult only practices)
Depression screening for teens/adults using standardized tool

16. PCMH 2C: Comprehensive Health Assessment
4 Points
Scoring
8-9 factors= 100%
6-7 factors= 75%
4-5 factors= 50%
2-3 factors= 25%
0-1 factors= 0%
Data Sources:
Report or a completed patient assessment (de-identified)

17. PCMH 2C: Example – Factor 6, 9

18. PCMH 2C: Example – Factor 4, 7

19. PCMH 2C: Example – Factor 1, 5, 6, 7

20. PCMH 2D: Use Data For Population Management
Practices uses patient data and evidence-based guidelines to generate lists and remind patients about needed services:
1. At least three different preventive care services**
2. At least three different chronic care services**
3. Patients not recently seen by the practice
4. Specific medications
** Meaningful Use Requirement

21. PCMH 2D: Use Data For Population Management
MUST PASS
5 Points
Scoring
4 factors = 100%
3 factors = 75%
2 factors = 50% (must-pass threshold)
1 factors = 25% (not sufficient for passing element)
0 factors = 0%
Data Sources:
Lists or summary reports of patients who need services
Reports must contain at least three different immunizations or screenings and three different acute/chronic care services
A registry is not specifically required but will facilitate the process
Materials demonstrating patient notification

22. PCMH 2D: Example – Factor 1
Patient list is blinded to protect confidentiality
List of patients who have
not received pneumovax

23. PCMH 2D: Example – Factor 2
patient
names
and
MRNs
have
been
blinded
List of patients who have
not received appropriate
hypertensive care

24. PCMH 2D: Example – Factor 3
List of diabetics who
have not been seen
in past 6 months

25. PCMH 2D: Example – Factor 4
List of patients in the practice taking Toprol XL
(names of patients blinded for HIPAA)

26. PCMH 5: Track & Coordinate Care
Elements
PCMH 5A: Test Tracking & Follow-Up
PCMH 5B: Referral Tracking & Follow-Up MUST PASS
PCMH 5C: Coordinate With Facilities & Care Transitions

27. PCMH 5A: Test Tracking & Follow-Up
Practice has documented process for and demonstrates:
Tracks lab tests and flags and follows-up on overdue results –CRITICAL FACTOR
Tracks imaging tests and flags and follows-up on overdue results –CRITICAL FACTOR
Flags abnormal lab results
Flags abnormal imaging results
Notifies patients of normal and abnormal lab/imaging results
Follows up on newborn screening (NA for adults)
Electronically order and retrieve lab tests and results
Electronically order and retrieve imaging tests and results
Electronically incorporates at least 40% of lab results in records**
Electronically incorporate imaging test results into records
** Meaningful Use Requirement

28. PCMH 5A: Test Tracking & Follow-Up
6 Points
Scoring
8-10 factors (including factors 1 and 2) = 100%
6-7 factors (including factors 1 and 2) = 75%
4-5 factors (including factors 1 and 2) = 50%
Fewer than 3 factors = 0%
Data Sources:
Process or procedure for staff and an example of how factors 1-6 are met
Electronic system examples for factors 7-10

29. PCMH 5A: Example – Factor 1

30. PCMH 5A: Example – Factor 1

31. PCMH 5A: Example – Factor 1

32. PCMH 5A: Example – Factor 2

33. PCMH 5A: Example – Factor 5

34. PCMH 5A: Example – Factor 7
Lab Test Order Screen

35. PCMH 5A: Example – Factor 8
Radiology Test Order Screen

36. PCMH 5B: Referral Tracking & Follow-Up
Practice coordinates referrals:
Provides specialist with reason and key information for the referral
Tracks referral status
Follows up to obtain specialist reports
Has agreements with specialists documented in the record
Asks patients about self-referrals and requests specialist reports
Demonstrates electronic exchange of key clinical information**
Provides electronic summary of care for more than 50% of referrals**
** Meaningful Use Requirement

37. PCMH 5B: Referral Tracking & Follow-Up
MUST PASS
6 Points
Scoring
5-7 factors= 100%
4 factors = 75%
3 factors = 50% (must-pass threshold)
1-2 factors= 25% (not sufficient for passing element)
0 factors = 0%
Data Sources:
Reports or logs demonstrating tracking system data collection
Documented processes with three examples
Reports from electronic system showing frequency of information exchange and summary of care records

38. PCMH 5B: Example – Factor 2

39. PCMH 5B: Example – Factor 2

40. PCMH 5B: Example – Factor 2
Patient Name
MRN
Referring Clinician
Reason for Referral
Date of Referral
Referred to
Completed?
Insurance
(Y/N & Date)
Joe Smith
12345
Halpern
Back Pain
6/16/11
Triangle Ortho No
BCBS-NC
Mary Jones
54321
Colonoscopy
Durham GI
Yes 6/21/11
Duke Select

41. PCMH 5C: Coordinate With Facilities and Care Transitions
Practice systematically demonstrates:
Process to identify patients with hospital admissions or ED visits
Process to share clinical information with hospital/ED
Process to obtain patient discharge summaries
Process to contact patients for follow-up care after discharge
Process to exchange patient information with hospital
It collaborates with patient to develop written care plan for transitions from pediatric to adult care (NA for adults)
Electronic exchange of key clinical information with facilities **
Provides electronic summary of care for more than 50% of transitions of care**
** Meaningful Use Requirement

42. PCMH 5C: Coordinate With Facilities and Care Transitions
6 Points
Scoring
5-8 factors= 100%
4 factors= 75%
2-3 factors= 50%
1 factor= 25%
0 factors = 0%
Data Sources:
Documented processes for patient identification, providing clinical information, systematic follow-up, obtaining discharge summaries and two-way communication
Copy of a written transition care plan
Reports illustrating electronic information exchange
Electronic report summarizing >50% care transitions

43. PCMH 5C: Example – Factor 3
Note: a screenshot of the discharge summary alone is not sufficient without a written process documenting how it was obtained

44. PCMH 5C: Example – Factor 5
Note: a screenshot of the transfer information alone is not sufficient without a written process documenting how it was obtained

45. PCMH 5C: Example – Factor 7
Note: a screenshot alone is not sufficient without a written process documenting the process

46. Next Steps (Homework)
Review the requirements for each standard, element and factor
What does the practice already do?
What does the practice need to create?
Are there elements the practice clearly does not have in place but does not wish to implement in the near-term?

47. Next Steps (Homework) Organize Your Documents
Create a place on your computer (server or hard-drive) for all of your documentation
You should have a folder for each standard
A checklist can help you determine what you already have created/saved and what you need to prepare from scratch

48. Next Steps (Homework)
Go to NCQA’s website and take advantage of the various (free) training presentations they have available:
2011 Standards
Using the ISS Interactive Survey System
Submitting As a Multi-Site Practice

49. Next Steps (Homework)
Begin To Think About 3 Important Conditions (e.g. diabetes, asthma, congestive heart failure, depression, etc) that you can track over time
Does your practice already follow evidence-based guidelines when caring for patients with these conditions?
Are these guidelines documented anywhere?

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

51. NCQA Contact Information
Contact NCQA Customer Support to:
Order FREE Copy of requirements
Order FREE Application Information
Purchase ISS Tool
Visit NCQA Web Site to:
View Frequently Asked Questions
View Recognition Programs Training Schedule
Send Questions to: 51

52. Feel free to contact me:
Questions?
Feel free to contact me:
David Halpern, MD, MPH
(215)