1. Your Partner in Practice1 1
Your Partner in Practice
Is PCMH Right For You?
OP User’s Conference
April 23-25, 2015 1

2. Why become a recognized medical home?2
Why become a recognized medical home?

3. Why Become a Medical Home?3 3
Why Become a Medical Home?
Improve patient care coordination
Take advantage of incentive payments
Help lower overall healthcare costs
Ensure continued viability in Payer networks
Compete with / prepare for ACO models
Realize ROI on technology investments 3

5. As of 2/2014

6. First and Foremost 6 6 Do you fully understand the concept?
Research the guidelines, the benefits and the statistics
Visit practices who are already medical homes and talk to colleagues about the practicalities of it
A medical home is not just a reimbursement model!
Read the Joint Principles of a Medical Home Visit
Will it be financially worthwhile?
Maybe! Depends upon region and Payer mix
Biggest benefit is streamlined practice operations and continued viability in this new ‘era’ 6

7. 7 7
PCMH Payment Models 7

8. Relationship Between Payment Methods and Organizational Models8

9. 9
About the 2014 Standards

10. Key Components of PCMH*10
1010
Key Components of PCMH*
Personal Clinician
First contact, continuous, comprehensive, care team
Whole Person Orientation
All patient health care needs; all stages of life; acute; chronic; preventive; end of life
Coordinated
When and where needed/wanted; culturally and linguistically appropriate; use information technology
* Based on The Joint Principles 10

11. Focus of 2014 PCMH Standards11
Focus of 2014 PCMH Standards
More emphasis on team-based patient care
Care management focus on high-need populations
Alignment of quality improvement activities
Reinforces incentives for meaningful use (HIT)
Further integration of behavioral health
Sustained transformation

12. 12
PCMH & MU
NCQA emphasizes HIT because highly effective primary care is information-intensive
PCMH 2014 reinforces incentives to use HIT to improve quality
Stage 2 Meaningful Use language is embedded in PCMH 2014 standards
Synergy: PCMH 2014 Recognized medical practices are well-positioned to qualify for meaningful use, and vice versa

13. PCMH 2014 / MU ✓ Only 3 Objectives are new in MU2 versus MU1 for PCMH13
PCMH 2014 / MU
✓ Only 3 Objectives are new in MU2 versus MU1 for PCMH
✓ 10 MU2 Objectives for PCMH have increased the percentages required over MU1
✓ PCC MU1 reports can be used for MU2 requirements – just meet the increased percentages

14. PCMH 2014 Content and Scoring
Must Pass Elements require a >50% performance level to pass

15. MUST PASS ELEMENTS 1A: Patient Centered Appointment Access
2D: The Practice Team
3D: Use of Data for Population Management
4B: Care Planning and Self-Care Support
5B: Referral Tracking and Follow-Up
6D: Implement Continuous Quality Improvement

16. CRITICAL FACTORS
Required to receive more than minimal or, for some factors, any points
Identified in the scoring section of the element

17. DOCUMENTATION TYPES Documented process Reports Records or files
Written procedures, protocols, processes, workflow forms (not explanations); these should show the practice name and date of implementation
Reports
Aggregated data showing evidence
Records or files
Patient files or registry entries documenting action taken; data from medical records for important conditions
Materials
Information for patients or clinicians, e.g. clinical guidelines, self-management and educational resources
NOTE: Screen shots or electronic “copy” may be used as examples (EHR capability), materials (Web site resources), reports (logs) or records (advice documentation)

18. DOCUMENTATION TIME PERIODS
Report Data, Files, Examples and Materials
Should display information that is current within the last 12 months
Documented Process
Policies, procedures and processes should be in place for at least 3 months prior to survey submission
Reporting Period (Meaningful Use)
12 months, or 3 months if 12 months is not available
Reporting Period (Log or Report)
Refer to documentation guidelines for other references to minimum data for logs and reports (one week, one month, etc.)
** ALL DOCUMENTS NEED TO SHOW DATES **

19. Vulnerable & High Risk Populations
“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
High Risk:
High-risk patients with clinical conditions and other factors that could lead to poor outcomes for those conditions. E.G. premies, downs, etc
Vulnerable:
Characteristics that could lead to different access or quality of care
Look for disparities in care/service. E.G. Lack of transport, money
Vulnerable patients need not have current clinical conditions

20. 20
The 2014 Standards

22. PCMH 1: Patient-Centered Access
Intent of Standard
Meaningful Use Alignment
The practice provides access to team-based care for both routine and urgent needs of patients/families/care-givers at all times
• Patients receive electronic:
- On-line access to their health
• Patient-centered
appointment access
information
- Clinical summaries of office visits
•24/7 Access to clinical advice
- Secure messages from the practice
• Electronic access

23. PCMH 2: Team-Based Care Intent of Standard
The practice provides continuity of care using culturally and linguistically appropriate, team- based approaches.

24. PCMH 3: Population Health Management
Intent of Standard
Meaningful Use Alignment
The practice uses a comprehensive health assessment and evidence- based decision support based on complete patient information and clinical data to manage the health of its entire patient population
•Practice has searchable
electronic system:
- Race/ethnicity/preferred language
-Clinical information
•Practice uses clinical
decision support and electronic system for patient reminders

25. 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

26. PCMH 5: Care Coordination and Care Transitions
Meaningful Use Alignment
Intent of Standard
• Incorporate clinical lab
• Track and follow-up on all lab and imaging
test results into the medical record
results
• Electronically exchange clinical information with
• Track and follow-up on all important referrals
other clinicians and facilities
• Coordination of care
patients receive from
• Provide electronic
summary of care record
specialty care, hospitals, other facilities and
for referrals and care transitions
Community organizations

27. PCMH 6: Performance Measurement and Quality Improvement
Intent of Standard
Meaningful Use Alignment
Practice uses certified EHR to: • Protect health information
• Uses performance data to identify opportunities for
• Generate preventive and follow-up care reminders
improvement
• Acts to improve clinical quality, efficiency
• Submit electronic data to
registries
• Acts to improve patient experience
• Submit electronic syndromic surveillance data
• Identify and report cases

28. 28
Submission & Beyond

30. Standard Pricing – as of June 201430
Standard Pricing – as of June 2014

31. Multi-Location

32. Multi-Location – cont.

33. 33
Multi-Location Fees +

34. What Happens After Submission?34
What Happens After Submission?

35. Payment for Recognition
3535
Payment for Recognition
You’ve got the recognition, now get paid!
Find out what programs are available to you (if you don’t ask, you don’t get)
If they don’t have an identified path, educate them and leverage your recognized medical home status
Negotiate new contracts for enhanced fees, per- member-per-month payments, and quality performance bonuses 35

36. Is It Worth It? Who Is Doing What? Aetna = PMPM ($3) UHC = PBC (1-2%)
Cigna = Peds coming 2015?
Blues = Homegrown programs for Peds

37. NCQA PCMH INFORMATION 3737 NCQA Web Site 37 NCQA General Information:
Standards:
Purchase Survey Tool ($80) 37

38. 3838
Q & A
Contact Information
The Verden Group, Inc
Your Partner in Practice
Susanne Madden, MBA, NCQA CEC
Julie Wood, MSc, NCQA CEC 38