1. Delving Into PCMH Standards1
Your Partner in Practice
Delving Into PCMH Standards
(Working with Elements 3, 4 & 6)
OP User’s Conference
April 23-25, 2015 1

2. Agenda
Connect the dots in Elements 3 & 4 to understand the requirements
Selecting patients for ‘care reminders’ (3D)
Selecting patients for ‘clinical decision support’ (3E)
A look at Comprehensive Health Assessments (3C)
Determining patients for ‘care management’ and managing that care (Element 4A & B)
Utilizing the Workbook (3C, 4B, 4C)
Setting up performance measurement and quality improvement processes (Element 6)

3. Connecting the Dots

4. 4
Connecting the Dots
3C reads as if you must implement ‘comprehensive health assessments’ (CHAs) for ALL your patients. You can, but realistically you will use the CHAs for data mining for 3D and 3E, and 4A and 4B. So we start at 3D & 3E and then implement 3C for those ‘conditions’ selected.
Connect the dots this way:
3.C (comprehensive health assessments)
are used on the patients selected in 3.D and 3.E
3.D (care reminders)
2 different preventive care services
2 different immunizations
3 chronic / acute conditions
3.E (clinical support / evidenced based medicine)
1 mental health
1 chronic condition
1 acute condition
1 unhealthy behavior condition
1 well child care 4

5. 5
Connecting the Dots
For 4A you use the same patients identified in 3D/E and 4B utilizes the patients ‘discovered’ in 4A. You can also use 3E6 (overuse) and 4A for improvement measures in 6B.
Connect the dots this way:
4.A (identifying patients needing care management)
Behavioral health
High cost / utilization
Poorly controlled / complex conditions
Outside referrals
4B (care planning & self support)
Data mining the patients in 4A, you must utilize the CHAs (3C) to ensure that care planning and self-care support is addressed 5

6. Preventive & Acute Care, Immunizations and Overdue Patients for
Point of Care Reminders

7. PCMH 3D: Use Data for Population Management
At least annually practice proactively identifies
populations of patients and reminds them, or their
families/caregivers, of needed care based on patient information, clinical data, health assessments and evidenced-based guidelines including:
1. At least two different preventive care services.+
2. At least two different immunizations.+
3. At least three different chronic or acute care services.+
4. Patients not recently seen by the practice.
5. Medication monitoring or alert.
+ Stage 2 Core Meaningful Use Requirement

8. PCMH 3D: Scoring MUST-PASS 5 Points Scoring • 4-5 factors = 100% •

9. PCMH 3D: Documentation Documentation • F1-5:
1) Reports or lists of patients needing services generated within the past 12 months (Health plan data okay if 75% of patient population)
AND
2) Materials showing how patients were notified for each service (e.g., template letter, phone call script, screen shot of e-notice).
• Practice must perform these functions at least annually.

10. Choosing Preventive Measures
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Choosing Preventive Measures
Keep it simple and use what’s readily available. OP recommends using:
PCMH/OP Reports:
Demographic Analysis/Recall
Event Chronology
PCMH CQMs 10

11. Choosing Preventive Measures
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Choosing Preventive Measures 11

12. Choosing Chronic / Acute Services
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Choosing Chronic / Acute Services
3 services must be targeted and can be related to only one condition.
Chronic care management services consider a practice’s entire population. Practices may focus on three chronic care services related to one condition.
Examples in Pediatrics include services related to chronic conditions such as asthma, ADHD, ADD, obesity and depression.
Example: One condition, three services could be Asthma -
Flu shot reminder
Medication follow up
6-month visit follow up (newly diagnosed patient) 12

13. Conditions and Behaviors for Evidence-Based Decision Support (3E)
Choosing & Working
Conditions and Behaviors
for
Evidence-Based Decision Support
(3E)

14. PCMH 3E: Implement Evidence-Based Decision Support
The practice implements clinical decision
support+ (e.g., point of care reminders) following evidence-based guidelines for:
1. A mental health or substance use disorder. (CRITICAL FACTOR)
2. A chronic medical condition.
3. An acute condition.
4. A condition related to unhealthy behaviors.
5. Well child or adult care.
6. Overuse/appropriateness issues.

15. PCMH 3E: Scoring and Documentation
4 Points
Scoring •
5-6 factors (including factor 1) = 100% •
4 factors (including factor 1) = 75% •
3 factors = 50% •
1-2 factors = 25% •
0 factors = 0%
Documentation
• Factors 1-6: Provide
Conditions identified by the practice for each factor and
Source of guidelines and
Examples of guideline implementation

16. Developmental and Behavioral:
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Developmental and Behavioral:
Mental / substance abuse in Peds
ADHD
Depression
Substance abuse (tobacco, alcohol, drugs)
Condition related to unhealthy behaviors
Pediatric Obesity
Great resource for information and guidelines:
Section on Developmental and Behavioral Pediatrics 16

17. Acute and Chronic Conditions:
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Acute and Chronic Conditions:
Focus on chronic or recurring conditions such as asthma, eczema, allergic rhinitis, pharyngitis, bronchiolitis, sinusitis, otitis media and urinary tract infection
Some examples OP recommends using:
Asthma
Pharyngitis
ADD/ADHD
Depression
Tie them back to your MU measures if you are already making clinical decision support rules 17

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Well Child Measure:
Any age well child visit can be used for this measure.
Utilize Bright Futures as the clinical decision support guidelines.
Protocol templates are included in the OP EMR and based on Bright Futures
Update orders on templates
Adjust Care Plan to meet your practice’s needs 18

19. Overuse / Appropriateness
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Overuse / Appropriateness
May include
ER visits
Redundant imaging or lab tests
Prescribing generic medications vs. brand name medications
Number of specialist referrals. 19

20. Comprehensive Health Assessments (3C)

21. PCMH 3C: Comprehensive Health Assessment
To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes:
1. Age- and gender appropriate immunizations and screenings.
2. Family/social/cultural characteristics.
3. Communication needs.
4. Medical history of patient and family.
5. Advance care planning (NA for pediatric practices).
6. Behaviors affecting health.

22. PCMH 3C: Comprehensive Health Assessment (cont.)
7. Mental health/substance use history of patient and family.
8. Developmental screening using a standardized tool (NA for practices with no pediatric patients).
9. Depression screening for adults and adolescents using a standardized tool.
10. Assessment of health literacy.

23. PCMH 3C: Scoring 4 Points Scoring • 8-10 factors = 100% •
NOTE
• Factor 5 (NA for pediatric practices)
• Written explanation needed for NA responses.

24. PCMH 3C: Documentation Documentation NOTE: USE THE WORKBOOK!
• F1-10: Report with numerator and denominator based on all unique patients in a recent three month period indicating how many patients were assessed for each factor. OR
• F1-10: Review of patient records selected for the record review required in elements 4B and 4C, documenting presence or absence of information in Record Review Workbook.
NOTE: USE THE WORKBOOK!

25. Working With Care Management & Support
(4A & B)

26. PCMH 4: Care Management and Support
Intent
Meaningful Use Alignment
The practice systematically
• Practice implements
identifies individual patients and plans, manages and coordinates care, based on need.
evidence-based guidelines
• Practice reviews and reconciles medications
with patients
• Practice uses e- prescribing system
• Patient-specific
education materials

27. PCMH 4: Care Management and Support
20 Points
Elements
• Element A: Identify Patients for Care Management
• Element B: Care Planning and Self-Care Support- MUST PASS
• Element C: Medication Management
• Element D: Use Electronic Prescribing
• Element E: Support Self-Care and Shared Decision- Making

28. PCMH 4A: Identify Patients for Care Management
The practice establishes a systematic process and
criteria for identifying patients who may benefit from care
management. The process includes consideration of the
following:
1. Behavioral health conditions.
2. High cost/high utilization.
3. Poorly controlled or complex conditions.
4. Social determinants of health.
5. Referrals by outside organizations (e.g. insurers, health system, ACO), practice staff or patient/family/caregiver.
6. The practice monitors the percentage of the total patient
population identified through its process and criteria. (CRITICAL FACTOR)

29. Identifying Patients for Care Management
• Identify all patients in practice with conditions referenced in 4A, Factors 1-5.
• Patients may “fit” more than one criterion (Factor).
• Patients may be identified through electronic systems
(registries, billing, EHR), staff referrals and/or health plan
data.
• Review comprehensive health assessment (Element 3C) as a possible method for identifying patients.
• Factor 6 is critical - NO points if no monitoring
The concept is to use 3C: CHAs, to help identify these patients.

30. PCMH 4A: Scoring and Documentation
4 Points
Scoring •
5-6 factors (including factor 6) = 100% •
4 factors (including factor 6) = 75% •
3 factors (including factor 6) = 50% •
2 factor (including factor 6) = 25% •
0-1 factors (or does not meet factor 6) = 0%
Documentation
• F1-5: Documented process describing criteria for identifying patients for each factor
• F6: Report with
- Denominator = total number of patients in the practice
- Numerator = number of unique patients identified in
denominator as likely to benefit from care management.

31. 4A1: Behavioral Health Pediatric populations
Practices may identify children and adolescents with special health care needs, defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.”
(Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)

32. PCMH 4B: Care Planning and Self-Care Support
Care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care
plan that includes the following features for at least 75
percent of the patients identified in 4A.
1. Incorporates patient preferences and functional/ lifestyle goals.
2. Identifies treatment goals.
3. Assesses and addresses potential barriers to meeting goals.
4. Includes a self-management plan.
5. Is provided in writing to patient/family/caregiver. 10

33. PCMH 4B: Scoring and Documentation
4 Points
Scoring •
5 factors = 100% •
4 factors = 75% •
3 factors = 50% •
1-2 factors = 25% •
0 factors = 0%
Documentation
• F1-5:
Submission of Record Review Workbook and
Examples of how each factor is met (e.g. copy of a care plan)

34. Record Review Workbook
Using the
Record Review Workbook

35. Workbook

36. ‘Measure & Improve’

37. Use all the same measures from Element 3D!
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PCMH 6: Measure and Improve
Use all the same measures from Element 3D!

38. PCMH 6A4: Vulnerable Populations
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PCMH 6A4: Vulnerable Populations
4. Performance data stratified for vulnerable populations (to assess disparities in care).
The data collected by the practice for one or more measures from factors 1–3 is stratified by race and ethnicity or by other indicators of vulnerable groups that reflect the practice’s population demographics, such as age, gender, language needs, education, income, type of insurance (i.e., Medicare, Medicaid, commercial), disability or health status.
Vulnerable populations are “those who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability,” (AHRQ) and include people with multiple co-morbid conditions or who are at high risk for frequent hospitalization or ER visits.

39. 6A – Identifying Vulnerable Populations
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6A – Identifying Vulnerable Populations
Also look back to 4A to help determine ‘vulnerable’ patients. They may include:
High level of resource use e.g. visits, medication, calls
Frequent visits for urgent or emergent care (2 or more visits in the last 6 months)
Frequent hospitalizations (2 or more in the last year)
Multiple co-morbidities, including mental health
Non-compliance with treatment or medications
Terminal illness
Multiple risk factors
Psychosocial status, lack of social or financial support that impedes ability for care 39

40. 4040
PCMH6B: Resource Use
Look back to 4A2 for utilization measures affecting costs.

41. PCMH 6D: Implement Continuous QI MUST PASS!
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PCMH 6D: Implement Continuous QI MUST PASS!
Utilize previous measures: 3D, 3E tracked to 6A and 4A2 to 6B – reuse and recycle! 6D flows to 6E

42. PCMH6C: Continuous Improvement
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PCMH6C: Continuous Improvement
The practice sets goals and acts to improve performance, based on clinical quality measures (Element A), resource measures (Element B) and patient experience measures (Element C). The goal is for the practice to reach a desired level of achievement based on its self-identified standard of care.
6A ties to 3D and 3E
6B ties to 4A2
USE the ‘Quality Measurement and Improvement Worksheet’

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PCMH 6C: NCQA Quality Measurement and Improvement Worksheet

44. 4444
PCMH 6C: NCQA Quality Measurement and Improvement Worksheet

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Q & A
Contact Information
The Verden Group, Inc
Your Partner in Practice
Susanne Madden, MBA, NCQA CEC
Julie Wood, MSc, NCQA CEC 45