1. NCQA Standards Workshop Patient-Centered Medical Home PCMH 2011
Part 2: Standards 4 - 6

2. Documentation examples* Survey processes
Agenda: Part 2
Content of PCMH 2011
Standards 4 – 6
Documentation examples*
Survey processes
Upgrades, Renewals, Add-on Surveys
Multi-site requirements
* Examples in the presentation only illustrate the element intent.
They are NOT definitive nor the only methods of documenting how the elements may be met. 2

3. PCMH 2011 Content and Scoring
PCMH1: Enhance Access and Continuity
Access During Office Hours**
After-Hours Access
Electronic Access
Continuity
Medical Home Responsibilities
Culturally and Linguistically Appropriate Services
Practice Team
Pts 4 2 20
PCMH2: Identify and Manage Patient Populations
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management** 3 5 16
PCMH3: Plan and Manage Care
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Care Management**
Manage Medications
Use Electronic Prescribing 17
PCMH4: Provide Self-Care Support and Community Resources
Support Self-Care Process**
Provide Referrals to Community Resources
Pts 6 3 9
PCMH5: Track and Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up**
Coordinate with Facilities/Care Transitions 18
PCMH6: Measure and Improve Performance
Measure Performance
Measure Patient/Family Experience
Implement Continuously Quality Improvement**
Demonstrate Continuous Quality Improvement
Report Performance
Report Data Externally 4 2 20
**Must Pass Elements 3

4. PCMH 4: Provide Self-Care Support and Community Resources
Meaningful Use Criteria
Use EHR to identify patients who need education resources
Intent of Standard
Practice provides self-care tools and support to patients
Practice identifies and refers patients to community resources

5. PCMH 4: Provide Self-Care Support and Community Resources
Elements
PCMH4A: Support Self-Care Process – MUST PASS
PCMH4B: Provide Referrals to Community Resources
Find new pics

6. PCMH4A: Support Self-Care Process
Practice conducts activities to support patients in self-management:
Provides education resources or refers at least 50% of patients to educational resources
Uses EHR to identify education resources and provide them to 10% of patients**
Collaborates with at least 50% of patients to develop and document self-management plans and goals-CRITICAL FACTOR
Documents self-management abilities for at least 50% of patients
Provides self-management result recording tools to at least 50% of patients
Counsels at least 50% of patients on adopting health lifestyles
** Menu Meaningful Use Requirement

7. PCMH 4A: Scoring and Documentation
MUST PASS
6 Points
Scoring
5-6 factors (including factor 3)= 100%
4 factors (including factor 3)= 75%
3 factors (including factor 3)= 50%
1-2 factors= 25%
0 factors = 0%
Data Sources:
Report from electronic system or submission of Record Review Workbook

8. PCMH 4A: Example Support Self-Care Process
Response Options
Yes No
Not Used

9. PCMH 4B: Provide Referrals to Community Resources
Practice supports patients who need access to community resources:
Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support)
Tracks referrals provided to patients
Arranges for or provides treatment for mental health/substance abuse disorders
Offers opportunities for health education and peer support

10. PCMH 4B: Scoring and Documentation
3 Points
Scoring
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
List of community services or agencies
Referral log or report covering at least one month
Processes to provide/arrange for mental health/substance abuse treatment and health education support

11. PCMH 5: Track and Coordinate Care
Meaningful Use Criteria
Incorporate clinical lab test results into the medical record
Electronically exchange of clinical information with other clinicians and facilities
Provide electronic summary of care record for referrals and care transitions
Intent of Standard
Track and follow-up on lab and imaging results
Track and follow-up on referrals
Coordinates care received at hospitals and other facilities

12. PCMH 5: Track and Coordinate Care
Elements
PCMH5A: Test Tracking and Follow-Up
PCMH5B: Referral Tracking and Follow-Up – MUST PASS
PCMH5C: Coordinate with Facilities and Care Transitions
Find new pics

13. PCMH 5A: Test Tracking and 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
**Menu Meaningful Use Requirement

14. PCMH 5A: Scoring and Documentation
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

15. PCMH 5A: Example Comment Text
All tests (laboratory and imaging) are tracked electronically. The EMR has several functions which will track all tests, show results, date results received, shows appropriate ranges, and highlights abnormal results by providing a color visual cue for clinicians. The EMR also provides functionality for printing out results letters, and tracking verbal delivery of results through the messaging system. In addition, there are several reports used on a daily basis to ensure that all tests that have been ordered, are resulted. These reports show the status of the test, whether a result has been received or is pending, and if received, whether or not the clinician has verified (seen) the result. It also provides an aging of the test, showing the user how long it has been outstanding. For additional detail and to view samples of this, please refer to the document titled "Results Tracking" which provides screen shots. Also see the document titled "Results documentation" for additional screen shots, details on how the system functions, and examples of how abnormal results are flagged.  

16. PCMH 5A: Example Test Tracking Log
DATA COLLECTED
Patient name
DOB
Provider
Order date
Test ordered
Urgency
Date results received
Results normal/abnormal
Date results to provider
Date results to patient
Factors 1 (no flagging), 3 (no flagging), 5 (only lab)

17. PCMH 5A: Example Electronic Test Tracking
All lab and imaging tests are tracked until results are available
Overdue results are flagged
Abnormal results are flagged
Practice tracks:
Date ordered
Overdue
Abnormal
Priority
Patient name
Provider
Order description
Last appointment
Next appointment
Factor 1, 2, 3, 4,
I would like to see us blind MD names.

18. PCMH 5A: Example Notifies Patient of Abnormal Results
Factor 5

19. PCMH 5A: Example EHR Order Screens
Laboratory Test Order Screen
Radiology Test Order Screen
Factor 7, 8 (but show ordering, not retrieving)

20. 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**
* Core Meaningful Use Requirement
**Menu Meaningful Use Requirement

21. PCMH 5B: Scoring and Documentation
MUST PASS
6 Points
Scoring
5-7 factors= 100%
4 factors = 75%
3 factors = 50%
1-2 factors= 25%
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

22. PCMH 5B: Example Referral Tracking Log
No. maybe 2 but doesn’t include timing

23. PCMH 5B: Example Referral Tracking
Tracking Table Includes
Referring physician
Referral date
Patient name/DOB
Facility/physician
Diagnosis/reason for referral
Appointment date
Insurance information/if
pre-authorization needed
Stat?
Received report
Report overdue?
Notified patient
Factor 2 (iffy),

24. 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**
* Core Meaningful Use Requirement
**Menu Meaningful Use Requirement

25. PCMH 5C: Scoring and Documentation
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

26. PCMH 5C: Example Identifying Patients in Facilities
Practice receives admission reports electronically from hospital
Factor 1 (not a process tho)

27. PCMH 5C: Example Follow-Up Care after Hospital Admission
Factor 4 (hospital specific, isn’t a process or report

28. PCMH 6: Measure and Improve Performance
Meaningful Use Criteria
Report:
Ambulatory quality measures to CMS
Immunization data to registries
Syndromic surveillance data to public health agencies
Intent of Standard
Measure preventive, chronic and acute care; utilization affecting costs; patient experience and report performance
Use and monitor effectiveness of quality improvement process

29. PCMH 6: Measure and Improve Performance
Elements
PCMH6A: Measure Performance
PCMH6B: Measure Patient/Family Experience
PCMH6C: Implement Continuous Quality Improvement – MUST PASS
PCMH6D: Demonstrate Continuous Quality Improvement
PCMH6E: Report Performance
PCMH6F: Report Data Externally
Find new pics

30. PCMH 6A: Measure Performance
Practice measures or receives the following data:
Three (3) preventive care measures
Three (3) chronic or acute care measures
Two (2) utilization measures affecting health care costs
Vulnerable population data
DO:
Attach actual policies and procedures written for staff and patients
Policies should be specific
Factor 11: must include a note in text box stating % of patients needing language services and languages staff speak; if designating. N/A, must state why in text box
Factor 11: relate to PPC2B, Factor 5 and PPC4A, Factor 1 language service. Must assess patient population
Factors 7 and 8 - need specific times in policy
DON’T:
Do not provide policies in the text box
Policies should not repeat the 1A Factors
Explanations are helpful but don't replace the need for written policies that are available to train staff and inform patients

31. PCMH 6A: Scoring and Documentation
4 Points
Scoring
4 factors= 100%
2-3 factors = 75%
1 factor 25%
0 factors = 0%
Data Sources:
Reports showing performance

32. PCMH 6A: Example Chronic Care Clinical Measures
Factor 2

33. NCQA Clinical Program Recognition Where Can it Be Used to Meet Elements?
NCQA Clinical Recognition Programs
Diabetes Recognition Program (DRP)
Heart/Stroke Recognition Program (HSRP)
Back Pain Recognition Program (BPRP)
Credit for Clinical Program Recognition may be used for meeting requirements in 7 elements if majority of physicians are Recognized:
PCMH 3A, 3C (for selected conditions used for survey)
PCMH 6A, 6C, 6E, 6F
update 33

34. PCMH 6B: Measure Patient/Family Experience
Practice obtains feedback on patient experience with the practice and their care:
Practice conducts survey measuring experience on at least three (3) of the following: access, communication, coordination, whole-person care
Practice uses PCMH CAHPS-CG survey tool
Practice obtains feedback from vulnerable populations
Practice obtains feedback through qualitative means

35. PCMH6B: Scoring and Documentation
4 Points
Scoring
4 factors = 100%
3 factors = 75%
2 factors= 50%
1 factor = 25%
0 factors = 0%
Data Sources:
Reports showing results of patient feedback

36. PCMH6B: Example Patient Experience Survey Results
Survey questions include:
Access
Communication

37. PCMH 6C: Implement Continuous Quality Improvement
Practice uses ongoing quality improvement process:
Set goals and act to improve performance on three (3) measures from Element 6A
Set goals and act to improve performance on one (1) measure from Element 6B
Set goals and address at least one (1) identified disparity in care for vulnerable populations
Involve patients in QI teams or on the practice’s advisory council

38. PCMH 6C: Scoring and Documentation
Must Pass
4 Points:
3-4 factors = 100%
2 factors= 50%
1 factor= 25%
0 factors = 0%
Data Sources:
Report or completed PCMH Quality Measurement and Improvement worksheet
Process demonstrating how it involves patients/families in QI teams or advisory council

39. PCMH 6C: Example NCQA Quality Measurement and Improvement Worksheet
2011
Clinical Activities
Patient Feedback
Other
Area for Analysis
Data Source or Measure
Opportunity Identified
Current Performance
Performance Goal
Action Taken and Date
update

40. PCMH 6D: Demonstrate Continuous Quality Improvement
Practice demonstrates ongoing monitoring of the effectiveness of its improvement process:
Tracks results over time
Assesses effect of its actions
Achieves improved performance on one measure
Achieves improved performance on a second measure

41. PCMH 6D: Scoring and Documentation
3 Points:
4 factors= 100%
3 factors = 75%
2 factors= 50%
1 factor= 25%
0 factors = 0%
Data Sources:
Reports showing measures over time, recognition results or completed Quality Improvement Measurement and Improvement Worksheet

42. PCMH6D: Example Patient Survey Results Over Time

43. PCMH 6E: Report Performance
Practice shares data from Element A and B:
Individual clinician results within the practice
Practice results within the practice
Individual clinician or practice results to patients or public

44. PCMH 6E: Scoring and Documentation
3 Points:
3 factors= 100%
2 factors= 75%
1 factors= 50%
0 factors = 0%
Data Sources:
Reports (blinded) showing summary data and how it provides results within the practice
Example of patient/public report

45. PCMH 6E: Example Reporting by Clinician1 2 3 4 5 6
Factor 1

46. PCMH 6E: Example Reporting Across Practice(s)
Shows data for multiple sites
Factor 2

47. PCMH 6F: Report Data Externally
Practice electronically reports:
Ambulatory clinical quality measures to CMS*
Data to immunization registries or systems**
Syndromic surveillance data to public health agencies**
*Core Meaningful Use Requirement
**Menu Meaningful Use Requirement

48. PCMH 6F: Scoring and Documentation
2 Points:
3 factors= 100%
2 factors= 75%
1 factor= 50%
0 factors = 0%
Data Sources:
Reports demonstrating data submission

49. Overview of Recognition Process
NCQA
Reviews submitted Survey Tool after all application information received: NCQA Agreement (contract with NCQA) and Business Associate Addendum (BAA), Application, Clinician information, Application fee
Checks licensure of all clinicians
Evaluates Survey Tool responses, documentation, and explanations
Conducts 5% audit by , teleconference, or on-site visit
Executive reviewer conducts a secondary review
Peer review by trained Recognition Program Oversight Committee (RP-ROC) member
Issues final decision and status to the practice within 30 – 60 days
Reports results
Recognition posted on NCQA Web site
Not passed - not reported
Mails PCMH certificate and Recognition packet
Comment from Kathi:
First bullet: I think you may need to clarify what the “NCQA agreement” is>
Sixth bullet: The correct reference is the Recognition Program Review Oversight Committee (RP-ROC).

50. Add-On Surveys When will a practice utilize an add-on survey? Process
Practices with Level 1 or 2 Recognition who want to increase their Level with additional documentation and scoring
Practice may submit an add-on survey anytime within the current Recognition period, application fee is discounted
Process
Complete application information from your online application account
NCQA merges data from previous Survey Tool into new PCMH Survey Tool and makes available to practice
Practice may change response in any element with score of <100%; no need to reattach already submitted documents
Once completed, practice uploads new documents and submits survey and payment
New status based on
Score achieved on saved scores and new assessment
Comment from Kathi:
Sub-bullet under Process: the last word should be “submits” and not “submit”
Might want to re-word last bullet as “Score and number of Must Pass elements passed.”
Twice now, I’ve looked at this slide and not connected the dots that the process described applies only to Add-on Surveys. Also, I think “on line” needs to either be “online” or “on-line”

51. What Are Multi-Site Surveys?
The multi-site application process is an option for organizations or medical practices that have 3 or more sites that share policies and procedures and electronic systems across all of their physician sites.
NCQA does not give organization-wide Recognition
Multi-site surveys enable practices to complete specified PCMH assessments once for multiple practice sites
Elements where responses and documentation are always required for each site:
1A* 3A 3B
3C* 3D
4A* 6A 6B
6C* 6D 6E
* Must Pass
Comment from Kathi:
I am assuming that this slide has been updated to reflect the 2011 requirements? I can’t tell.

52. Multi-site Eligibility and Policies
Requires electronic systems implemented at 3 or more practice sites for at least 3 months
Application fees are determined by site along with a multi-site review fee and based on listed clinicians for each site
Clinicians can be listed at multiple sites
Not all sites need to be included
All sites must be submitted within 12 months
Practices may not combine sites for one Recognition survey
Comment from Kathi:
Third bullet: Please check with Mina. I thought this policy had changed.
Last bullet: submitted within 12 months of what?

53. Online Multi-Site Survey Process
Through the online application system, organization completes eligibility questions
If eligible, proceed to multi-site resource screen for instructions, FAQs and fee calculator
Review the Self-Assessment Element Table to self-assess the Elements that may be submitted once in the group survey tool and the Elements that will require site specific responses in each of the practice site survey tools.
Generate an order form following the instructions given and purchase the required number of survey tools for the sites identified
Comment from Kathi:
Title: This content seems more about determining eligibility for a MSS rather than the actual MSS process.
First bullet: To be consistent with the other bullets, we should probably just say; “through the online application system, complete the eligibility questions”.

54. Multi-Site Survey Process, con’t
Complete and submit multi-site applications and multi-site practice site information (in online system)
Record survey tool license numbers in your online applications
Complete and submit multi-site survey (group) tool when ready
Complete and submit individual practice site survey tools within 12 months
NCQA will merge the score of the multi-site survey with each submitted site to determine the Recognition Level for each site
Comment from Kathi:
I thought we were getting rid of the requirement to enter the 3 important conditions into the ST?

55. Renewal Requirements
Goal for PCMH 2011 to streamline documentation requirements for renewal submissions
Requirements
Practices must be Recognized at Level 2 and 3
Practice must respond to all standards/elements
Practice provides documentation for subset of elements (12)
PCMH 1C and PCMH 1G
PCMH 2C and PCMH 2D
PCMH 3A, PCMH 3B, PCMH 3C, and PCMH 3D
PCMH 4A
PCMH 5C
PCMH 6A and PCMH 6C

56. Upgrades and Renewals Streamlined process for upgrades or renewals with fewer documentation requirements
Upgrade: PPC-PCMH to PCMH 2011
PCC-PCMH Level 2 or 3
No extension of Recognition
Practice must purchase and complete the entire survey
Submit documentation for 12 designated elements*
Multi-sites – only site-level
Add-on survey pricing
Renewal : PPC-PCMH to PCMH 2011
PPC-PCMH Level 2 or 3
Practice must purchase and complete the entire survey
Submit documentation for 12 designated elements*
Multi-site process is followed
Full survey pricing
*12 Designated elements:
1C, 1G, 2C, 2D, 3A, 3B, 3C, 3D, 4A, 5C, 6A, 6C

57. NCQA Contact Information
Contact NCQA Customer Support to:
Acquire standards documents, application account, and survey tools
Questions about your user ID, password, access
Visit NCQA Web Site to:
View Frequently Asked Questions
View Recognition Programs Training Schedule
Submit to questions to
Please use this box to:
Ask about interpretation of standards or elements
Request registration for ISS Survey Tool demonstration (Web-ex)