PCMH 2014 NCQA Standards and Guidelines

PCMH 2014 NCQA Standards and Guidelines

http://www.uvm.edu/medicine/vchip/ Training Objectives
Overview of process and timeline including new Renewal Option Overview of 2014 Standards Review updates and new concepts with focus on “Must Pass” Elements Hello everyone and thank you for joining us today. This is _______________from the Vermont Child Health Improvement Program, also known as “VCHIP”. This PCMH 2014 webinar has been developed by VCHIP to review the patient centered medical home recognition process for the 2014 standards. Patient Centered Medical Home recognition is required for participation in the Vermont Blueprint for Health. This webinar is one of many resources available to your practice as you pursue medical home recognition. I’d like to begin by sharing with you the training objectives for the next hour. We will review the VCHIP timeline for multi-site and single-site scoring, information about the streamlined renewal option, and the EHR pre-validation option. We will discuss the general changes from the 2011 to the 2014 Standards, then we’ll review the Standards and factors that have resulted in some great discussions and questions, and the “Must Pass” elements of the 2014 Patient Centered Medical Home Standards. Today’s session is NOT interactive. We encourage you to write down your questions and follow-up with your facilitator or project manager. You may also contact VCHIP evaluators directly. This presentation will be posted on VCHIP’s website soon.

VCHIP Timeline First, let’s talk about applying as a “Multi-Site”, an option that is available for organizations that have 3 or more practices that follow the same processes and use the same EHR. In general, for a “Multi-Site” Corporate Survey Tool, the organization would have their policies, procedures, and processes in place at least 90 days before the Corporate survey tool score date. The Corporate Survey tool with approved multi-site elements would be submitted at a minimum of 45 days before the first practice site’s score date. So for example using the timeline shown here, and looking at it working backwards, if your 1st practice is due July 1st, then your Corporate survey tool is due for submission mid-May, and would mean all policies, procedures, and processes should be in place by mid-February. You will want to make sure you have received approval from NCQA for a Multi-Site Corporate Survey Tool Submission, before you begin your process.

VCHIP Timeline This is a sample timeline for a single site.
As with the multi-site submission, Site-Specific Practices will want to make certain that all policies, procedures, and/or processes are in place, at least 90 days before the survey tool is scheduled to be submitted. This is intended to allow adequate time for practice staff to make any changes and to ensure a systematic approach to patient care and practice operations. The scoring date is when VCHIP submits your estimate to the Blueprint, and survey tool to NCQA.

VCHIP Timeline This table should help give you a visual of dates to consider for specific scoring dates.

Streamlined Renewal Option
Practices with Level 2 or 3 Recognition with the ability to demonstrate panel management and quality improvement for at least two years. Organizations/practice sites must be able to provide documentation if they are selected for audit. Attestation Documentation Required 1B 4D 1A 5B 1C 4E 2D 6B 2A 5A 3C 6D 2B 5C 3D 6E 2C 6A 4A 3A 6C 4B 3B 6F 4C 3E 6G N/A For recognition under the 2014 standards, the Blueprint allows the NCQA streamlined renewal process through reduced documentation requirements. To be eligible for the Streamlined Renewal Option a practice needs to have been Recognized as a Level 2 or Level 3 PCMH and can attest to having been doing panel management and quality improvement for at least two years. While some elements can be attested to and do not require submission of documentation, organizations/practices must be able to provide documentation for the factors for which they are asking credit (a “yes” response on the survey tool) if they are selected for audit.

Streamlined Renewal Option – Multi-site
Multi-Site Organizations with Practices that have achieved Level 2 or Level 3 Recognition Must be able to provide documentation if selected for audit. Attestation Documentation Required 1B Corporate 4D 1A Site-specific 5B 1C 4E 2D 6B 2A 5A 3C 6D 2B 5C 3D 6E 2C 6A 4A 3A 6C 4B 3B 6F 4C 3E 6G N/A The Streamlined Renewal option is also available for the Multi-Site Corporate Survey tool. For more information on this process please contact NCQA directly, or VCHIP or your facilitator can help. OR search on multi-site streamlined renewal

Electronic Health Record Pre-Validation
NCQA offers a Pre-validation Program Review for Certified Electronic Health Record Vendors All PCMH-eligible practices that utilize functions associated with their vendor’s prevalidated products are eligible for autocredit toward PCMH 2014 recognition Please see NCQA website for a list of certified vendors and for a review of the process to receive autocredit or A practice may be able to attest to some factors if it has an EHR that has been pre-validated by NCQA. NCQA provides a list of certified vendors on their website. Please visit the NCQA website for instructions on how to receive EHR prevalidation through your certified vendor

NCQA 2014 PCMH Standards Focus on team-based care, integration of behavioral health, measuring costs, quality improvement, and care coordination NCQA want practices to understand this “is a process, not an event” Changes reflect evidence-based trends Focus on the Triple Aim Require practices to follow standards over time Now we will begin discussing the 2014 PCMH Standards. In general changes and updates in the 2014 Standards reflect NCQA’s focus on team-based care, integration of behavioral health, measuring costs, quality improvement, and care coordination. NCQA wants practices to understand that this is a process rather than an event. The changes in the standards reflect evidence-based care trends, focus on the Triple Aim, and require practices to follow standards over time. The three domains of the Triple Aim are: 1) Improve population health and patient experiences, 2) Improve the quality of health care, and 3) Control health care costs.

PCMH 1 Includes the Following Elements:
PCMH 1: PATIENT-CENTERED ACCESS The practice provides access to team-based care for both routine and urgent needs of patients, families, and caregivers at all times. PCMH 1 Includes the Following Elements: A: Patient-Centered Appointment Access B: 24/7 Access to Clinical Advice C: Electronic Access Standard 1: Patient Centered Access includes elements A, B, and C. Today we will focus mainly on Element A as it is the must pass element.

Update and Changes PCMH 1: PATIENT-CENTERED ACCESS
PCMH 1A & 1B have been reorganized by type of access (appointment-oriented and clinical advice- oriented) rather than access during office hours and outside of office hours Several new concepts addressed Breaking things out by type of appointment (e.g., urgent vs. routine) and tracking availability of appointments Monitoring no-shows Actively working to improve access PCMH 1 of the 2014 Standards is similar to PCMH 1 of the 2011 Standards in terms of content. PCMH 1A and 1B have been reorganized by type of access rather than access during office hours and outside of office hours. Several new concepts are being addressed. Appointments are being sorted by type of appointment (ie: urgent vs. routine), tracking the availability of appointments, monitoring no shows and actively working to improve access. Many practices already have procedures in place and have been doing this on an ongoing basis.

PCMH 1A: Patient-Centered Appointment Access
MUST PASS = 2 factors including Factor 1 for 50% The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on: Providing same-day appointments for routine and urgent care. CRITICAL FACTOR Providing routine and urgent care outside of regular business hours. Providing alternative types of clinical encounters. Availability of appointments Monitoring no-show rates Acting on identified opportunities for improved access Element 1A, Patient Centered Appointment Access, requires practices to pass two factors including factor 1. Factor 1 is the Critical Factor. 1A of the 2014 Standards is similar to 1A of the 2011 Standards

PCMH 1: PATIENT-CENTERED ACCESS
Patient-Centered Appointment Access (Must Pass) Critical Factor: providing same-day appointments for routine and urgent care. Documented process for scheduling same day appointments (including definitions for routine and urgent and how requests are triaged) At least 5 days of data, showing availability and use of same-day appointments for routine and urgent care The critical factor for element 1A is providing same-day appointments for routine and urgent care. NCQA expects to see a documented process for scheduling same day appointments. Please be sure to include the practice’s definition for routine and urgent. Please show how requests for same-day appointments are triaged. NCQA expects to see at least 5 days of data showing availability of same-day appointments for both routine and urgent care. Practices have often submitted a template of the day’s schedule with same-day appointments reserved for the day and then an example of the schedule after the same-day appointments have been used. Caution: same day appointments are appointments that have specifically been reserved. A cancellation that is then filled with an urgent or same-day request does not meet NCQA’s intent for this element. Now, I am going to turn our presentation over to my colleague, Patti Lutton.

team-based approaches PCMH 2 Includes the following elements:
PCMH 2: Team-Based Care The practice provides continuity of care using culturally and linguistically appropriate team-based approaches PCMH 2 Includes the following elements: A Continuity B Medical Home Responsibilities C Culturally and Linguistically Appropriate Services D The Practice Team (MUST PASS) Now we’ll review PCMH Standard 2 Team Based Care. PCMH 2 includes elements A through D. After reviewing some of the changes in PCMH 2, we will focus primarily on element D as it is the must pass element.

Update and Changes PCMH 2: Team-Based Care 2A Continuity
Builds on concepts from PCMH D and 5C Practice must now show how they help patient pick PCP Practice must show new patient orientation 2A of the 2014 Standards integrates concepts from 1D (Continuity of Care) and 5C (Coordinate with facilities and manage care transitions) of the 2011 Standards. NCQA expects practices to show their process for patient and family selection of a personal clinician and how they orient new patients to the practice.

2C Culturally and Linguistically Appropriate Services
PCMH 2: Team-Based Care Update and Changes 2C Culturally and Linguistically Appropriate Services Practice asked to asses diversity instead of race and ethnicity. PCMH 2C Culturally and Linguistically Appropriate Services. Practices are now asked to assess diversity rather than race and ethnicity. Diversity includes race, ethnicity, and at least one other meaningful characteristic (e.g., gender identity, sexual orientation, disability). Can be based on data collected from all patients or about the community served by the practice.

2D Practice Team (Must Pass-with critical factor)
PCMH 2: Team-Based Care Update and Changes 2D Practice Team (Must Pass-with critical factor) Show how different members of the care team are involved in improvement activities Care team expected to support patients, families and caregivers in self-management, self-efficacy and behavior Show job descriptions or policies/procedures describing how staff is involved (ie: care coordination, self-management, population management) Show a description of training & schedule or materials from staff training PCMH 2D Practice Team. 2D of the 2014 Standards is similar to 1G of the 2011 Standards READ SLIDE

PCMH 2D: The Practice Team
MUST PASS = 5-7 factors including Factor 3 for 50% The practice uses a team to provide a range of patient care services by: Defining roles for clinical and nonclinical team members. Identifying the team structure and the staff who lead and sustain team-based care. Holding scheduled patient care team meetings or a structured communication process focused on individual patient care. CRITICAL FACTOR Using standard orders for services Training and assigning members of the care team to coordinate care for individual patients. PCMH 2D is a must pass element. In order to pass this element, practices must meet 5 to 7 factors including factor 3 for 50% of the available points. This slide shows factors 1 through 5 [5 second hold]

PCMH 2D: The Practice Team - Continued
Training and assigning members of the care team to support patients, families, caregivers in self-management, self-efficacy, and behavior change. Training and assigning members of the care team to manage the patient population. Holding scheduled team meetings to address practice functioning Involving care team staff in the practice’s performance evaluation and quality improvement activities Involving patients/families/caregivers in quality improvement activities or on the practice’s advisory council. This slide shows factors 6 through 10 [5 second hold]

PCMH 2: Team-Based Care 2D Practice Team Continued (Must Pass-with critical factor) Critical factor: scheduled patient care team meetings or structured communication process focused on individual patient care documented process and at least 3 examples (meeting summaries, checklists, appointment notes or chart notes) Describe team meetings and give example Documented process for practice QI and for involving patients/ families/caregivers Show a description of training & schedule or materials from staff training PCMH 2D Factor 3, scheduled patient care team meetings or structured communication process, is the critical factor. This meeting or process should be FOCUSED ON PATIENTS. A structured communication process may include a huddle, regular exchanges, or tasks or messages about a patient in the medical record. The practice should show how the clinician or team leader is engaged in the communication. For Factors 5 through 7, training is designed for staff identified in factor 1. Documentation should include a description of the training process, learning objectives, materials used, and a schedule of training, and attendance logs.

PCMH 2: Team-Based Care Community Support Services
Front Desk Referrals Administrative Support Clinician Clinician Patients Nursing Team Community Support Services Behavioral Health, Specialists, Hospitals 2D Factor 2 is new to the NCQA 2014 Standards. This slide shows an example of a practice organizational chart used in combination with the practice’s standard operating procedure to identify team structure and the staff who will lead and sustain team based care.

PCMH 2: Team-Based Care RN Team Patients and Families NP MD MD MD MD
MA MA MA MA Here is another example of a practice organizational chart used to identify team structure and the staff who will lead and sustain team based care. Registration, Care Coordination, Lab, Referral & Business Community Support Services, Behavioral Health, Specialists, Hospitals

PCMH 3 Includes the following elements:
PCMH 3: Population Health Management 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. PCMH 3 Includes the following elements: A Patient Information B Clinical Data C Comprehensive Health Assessment D Use data for Population Management (MUST PASS) E Implement Evidenced-Based Decision Support We’ll now discuss standard three. Standard three is about population management and the intent of standard three is that 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. PCMH 3 contains elements A,B,C, D and E. Please note that Element 3C comprehensive assessment, is part of the chart review. 3C is similar to 2C of the 2011 Standards. Please keep in mind that you will need to provide an example of a comprehensive assessment to NCQA Today, after reviewing some general changes of each element, we’re going to primarily focus on the must pass element 3D which is Use Data for Population Management.

Update and Changes PCMH 3: Population Health Management
3A Patient Information Patient Information: crosswalks with MU Stage 2 Core 3 (change from >50 to >80% and from gender to sex) Same as 2A with a few additions Occupation Name/contact info for other health care providers (does not have to be searchable field—can provide a written process, screen shots showing source, and 3 examples) There have been some updates and changes to Standard 3 in the 2014 Standards. 3A is similar to 2A of the 2011 Standards with a few additions. NCQA now expects practices to have searchable data for greater than 80 percent of their patients. Occupation has been added to the list of information that should be gathered, and NCQA would like practices to maintain the name and contact information of other health care professionals involved in the patient’s care. Please provide 3 examples of this contact information as well as a written process /screen shots showing source.

Update and Changes PCMH 3: Population Health Management
3B Clinical Data Clinical Data: MU Stage 2 MU Core #4 – 3B3 MU Core #5 – 3B8 MU Menu #4 – 3B10 MU Menu #2 -3B11 Small changes to several factors 3B corresponds to several of the Stage 2 meaningful use reports. These reports can be used to obtain credit for specific factors in 3B.

3C Comprehensive Health Assessment
PCMH 3: Population Health Management Updates and Changes 3C Comprehensive Health Assessment Adds “regularly updates” to element Adds health literacy Show that the practice does the assessment regularly/for all patients (>50%). documentation is some sort of report, chart review, or other method defined by the practice. 3C is a chart review element. Reports may be used for specific factors if they can be generated. NCQA expects practices to understand the health risks and information needs of patients and families. In order to do this, NCQA expects practices to collect and regularly update a comprehensive health assessment. One of the important additions to 3C is Factor #10 Assessment of Health Literacy. It is important to note that assessment of health literacy DOES NOT mean assessment of language barriers. Some practices are using the REALM or a tool from AHRQ to assess health literacy. PCMH 3C may be a good source of information to help you in your selection of patients for element 4A; patients that could benefit from care management. [ARK]

PCMH 3D: Use Data for Population Management
MUST PASS = 2 factors for 50% At least annually the 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 evidence based guidelines including: At least two different preventive care services At least two different immunizations At least three different chronic or acute care services Patients not recently seen by the practice Medication monitoring or alert. Stage 2 MU Core 11 Factors 1,2,3 Now for the Must Pass Element, 3D Use Data for Population Management. PCMH 3D of the 2014 Standards is similar to PCMH 2D of the 2011 Standards. Practices must meet at least 2 factors to obtain 50% of the available points in order to pass this element. The practice must proactively identify populations of patients and remind them or their families or caregivers of needed care based on patient information, clinical data, health assessments and evidence based guidelines For factor 1, practices should focus on at least TWO different preventive care services. For factor 2, practices should focus on at least two different immunizations. For factor 3, Practices should focus on at least three different chronic or acute care services. These chronic care services may be related to one condition. If the practice plans to complete factor 4, they should identify and remind patients who have not recently been seen by the practice And for factor 5, practices should monitor medications or notify patients of medication changes or alerts. For factors 1, 2, and 3, Stage 2 Meaningful Use Core 11 Report may be used. NCQA expects practices to provide lists of patients for each factor submitted (ie: a list for each preventive service, a list for each immunization service, a list for each chronic or acute care condition). NCQA also expects practices to provide examples and track outreach. Examples may include a reminder card or letter in the patient chart, or documentation of the telephone call in the chart. If patients are being reminded verbally, a description of the dialogue should be included.

Updates and Changes PCMH 3: Population Health Management
3E Implement Evidence-Based Decision Support (expansion of 3A), focus on point-of-care reminders Critical Factor Mental health/substance use disorder-- required to get % Chronic medical condition Acute condition Condition related to unhealthy behaviors Well child or adult care Overuse/appropriateness issues (choosing wisely) Potential connection to Stage II, MU Core 6 PCMH Element 3E: Factor 1 is a critical factor and must be met for practices to receive 75% or 100% of the points available for this element. It is important to note that for this factor NCQA has indicated that smoking does not constitute a mental health or substance use disorder but that smoking can be used for factor 4. Factor 6, Overuse/appropriateness issues, focuses on not sending patients for unnecessary testing. NOW I WILL TRANSITION TO MY COLLEAGUE, GREG DANA

PCMH 4 Includes the Following Elements:
PCMH 4: Care Management and Support The practice systematically identifies individual patients and plans, manages and coordinates care, based on need. PCMH 4 Includes the Following Elements: A Identify Patients for Care Management B Care Planning and Self-Care Support MUST PASS C Medication Management D Use Electronic Prescribing E Support Self-Care and Shared Decision Making Moving on to PCMH 4: PCMH 4 includes the following 5 elements. 4A is used as part of the process for identifying patients for chart review. And 4B is must pass. We’ll talk more about this in a few minutes.

4A Identify Patients for Care Management
PCMH 4A: Identify Patients for Care Management Updates and Changes 4A Identify Patients for Care Management Rather than identifying patients who are high risk or complex, this element focuses on developing a list of patients that may benefit from care management Must have a report (% may benefit from care management) to get any credit (critical factor) Will be used in chart review The difference in the selection process for selecting patients for chart review in the 2014 standards and the 2011 standards is that now this element is focused on developing a list of patients who may most benefit from care management rather than identifying patients who are at high risk or have specific disease conditions.

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: Behavioral health conditions High cost utilization Poorly controlled or complex conditions Social determinants of health Referrals by outside organizations, practice staff or patient/ family/caregiver The practice monitors the percentage of the total patient population identified through its process and criteria (CRITICAL FACTOR) 4A is the criteria that practices will use to select patients for chart review. The practice is expected to provide a process for identifying patients who fit into the criteria for factors 1-5 and the number of patients who fit into each category. Practices do not have to complete every factor to receive credit. The practice must identify at least 30 patients as the chart review must include 30 charts. Factor #6 is a critical factor. Practices must pass factor 6 to receive credit for 4A

PCMH 4A: Identifying Patients
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 FACTOR – NO points if no monitoring Patients identified in Factor 6 may be used ONLY once even if a patient meets more than one Factor Patients identified in Factors (minus any duplicate patients) = numerator. Denominator = total patient population In 4A, practices are expected to provide criteria/procedure for how patients are identified for each category. Patients may fit more than one criterion. Practices may identify patients through electronic systems, registries, billing, EHR , staff referrals or health plans. Review of 3C, the comprehensive health assessment, is a possible source of information for identifying patients. Patients may fall into more than one of the factors However, each patient may be counted only once for factor 6. Factor 6 is the critical factor. Without factor 6, practices do not pass this element. Patients for chart review are selected in factors 1 through 5. Therefore it is expected that there will be greater than 30 patients in all factors combined charts will be reviewed during the NCQA/VCHIP chart review. Reminder: numerator must equal at least 30 patients as the chart review will be based on patients identified for Factors 1-5

PCMH 4A: Identify Patients for Care Management
This is a diagram directly from NCQA showing that F6 encompasses patients identified for factors 1 through 5.

PCMH 4A: Documentation Factors 1-5
Documented process describing criteria for identifying patients for each factor Suggest providing a report with number of patients identified for each factor Factor 6: Report with Numerator = number of unique patients likely to benefit from care management Denominator = total number of patients in the practice Suggest showing number of patients categorized by factor in this report if not shown in factors 1-5 NCQA expects a documented process describing the criteria for identifying patients for each factor. We suggest that practices provide a report with the number of patients identified for each factor (1-5). For Factor 6, add up each unique patient in factors This is the numerator. The denominator is the total number of patients of the practice. The percent will reflect the proportion of patients in the practice identified who may benefit from care management.

Patient Selection Using Visit Date
Selecting Patient Charts/Planning Chart Review Patient Selection Using Visit Date Choose patients meeting criteria from PCMH 4A Based on visit dates, go back one month from the date you are selecting your patient sample (to be included in chart review). Choose weekday nearest that date. Go back one day at a time (up to 12 months) until you have identified 30 (+4) patients who meet the criteria from PCMH4A and who had a care visit related to any one or more of the selected criteria in 4A. Here is the slide reviewing the process for chart selection via visit date. [PAUSE 5 Seconds]

4B Care Planning and Self-Care Support
PCMH 4: Care Management and Support Update and Changes 4B Care Planning and Self-Care Support must pass 75% of patient charts reviewed have to get a “yes” to get credit for the factor Submit an example from a patient’s medical record of each “yes” factor to NCQA When thinking about the chart review, remember that 75% of patients have to get a “yes” for credit for that factor and that the practice needs to submit to NCQA an example for each “yes” factor. For example, if 75% of patients reviewed had an identified treatment goal, factor 2 is met, and the practice should provide an example of a care plan that includes a treatment goal.

PCMH 4B: Care Planning and Self-Care Support
MUST PASS = 3 factors for 50% The 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 Element 4A. Incorporates patient preferences and functional/lifestyle goals Identifies treatment goals Assesses and addresses potential barriers to meeting goals Includes a self-management plan Is provided in writing to the patient/family caregiver (encompasses factors 1-4) PCMH 4B: Care Planning and Self-Care support is a must pass element. Practices must get 3 factors for 50% of the points available in order to pass this element. This means that the care team, patient, family/caregiver collaborate at relevant visits to develop and update an individual care plan for at least 75% of the patients identified in Element 4A. Let’s take a look at Factor 1 – Incorporates patient preferences and functional lifestyle goals: NCQA’s intent in this factor is to see that the patient has some input into the care plan. When compiling the care plan, the practice recognizes and integrates the patient preferences and lifestyle goal into the patient’s plan. A preference or lifestyle goal may be something like the patient prefers to control high cholesterol with diet rather than with a statin so the patient is going to meet with a nutritionist to implement a diet prior to going on a statin medication. Another example of patient preference or functional lifestyle goal is a patient who wishes to live at home as long as possible. And now Factor 2: Identifies treatment goals: With the 2014 Standards these treatment goals do not need to be measureable goals (e.g.: Diabetics HGB A1C less than 7.5 percent) though they still can be. The care plan does not necessarily involve just the MD. It can involve social work, nursing, and several members of the care team. The treatment goal can be social or medical and is based on the patients’ needs. For Factor 3 it is important to pay attention to ASSESS and ADDRESS. Individual care plans are expected to identify any barriers to achieving goals and describe how these barriers will be addressed. Simply identifying barriers will not be enough to meet the intent of this factor. Factor 4: Self-management plan is similar to 2011 Standards. The practice works with the patient to develop a self management plan that reflects what the patient intends to do. Finally in factor 5, NCQA expects to see evidence that the care plan was given to the patient. The care plan can be one document or may be a combination of documents.

PCMH 4B: Care Plan A care plan considers and/or specifies:
Patient/preference and functional/lifestyle goal Assessment of potential barriers to meeting goals Strategies for addressing potential barriers to meeting goals Care team members, including primary care provider of record and team members beyond the referring or transitioning provider and the receiving provider Current problems (may include historical problems, at the practice’s discretion) Current Medications Medication Allergies A self-care plan NCQA indicates that a care plan considers and or specifies the criteria on this slide.

PCMH 4B: Care Plan CMS defines a care plan as:
“The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: Problem (the focus of the care plan) Goal (the target outcome) Any instructions that the provider has given to the patient A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome)” And CMS defines a care plan as the items listed on this slide.

PCMH 4B: VCHIP Review Minimum components of a care plan for chart review Patient preferences and functional/lifestyle goals Treatment Goals Assessment of potential barriers to meet goals Strategies for addressing potential barriers to meeting goals A self-care plan When VCHIP reviews the chart, we will be looking for these items as minimum components of the care plan. We can look for items such as allergies, care providers and medications elsewhere in the EHR The care plan can be presented in many different formats and is not always contained in one document. If the care plan involves several members of the care team, the care plan can come from several different individuals such as the physician, nurse practitioner, or the mental health or social worker.

PCMH 4B: Care Plan Examples
Case Note #1: Assessment & Plan DM TYPE II, NO COMPLICATION, UNCONTROLLED (250.02) Today’s Impression: Greatly improved and so will continue to work on more weight loss. Patient is shooting for 160 pounds which is much better than her 215 pounds when she started. Patient with good control of Diabetes. Suggested eliminating carbs, increasing protein and green vegetables. DM foot exam done today. Weight loss a must so as to prevent the need for increasing medications. Patient aware Current Plans: Reading comprehension assessment (REALM-SF (96105) Routine Word List: Menopause, Antibiotics, Exercise, Jaundice, Rectal, Anemia, Behavior. EXAM SCORE: 7 points 4B Factor 2 This is an example of a care plan from a practice here in Vermont submitted to NCQA for credit. Please note that the practice identifies that the patient has a weight loss control of 160 pounds as her treatment goal. The practice notes that the patient has good control of diabetes but that weight loss is required. The practice identifies health literacy as a potential barrier to the patient reaching her goal. 4B Factor 3: Assesses Health Literacy as potential barrier

PCMH 4B: Example Case Note #1: Assessment & Plan (con’t.)
Met with patient today after her visit with the doctor. Patient is doing well with an A1C of 5.8. The patient has gained some weight. She is an accountant. The patient plans to use portion control and will start to bring a bagged lunch instead of eating out daily. Care Plan and Goals: Manage your diabetes Status: Started Patient Engagement: Making the Change 4B Factor 1,4 4B Factor 2 4B Factor 3 4B Factor 4 Plan(s) Barrier(s) Progress Maintain a healthy weight Low activity in job Started Preferred Self-Management: Portion Control/Bring bagged lunch to work Enjoys eating out. Started Please bring care plan to next visit for review This practice shows that the patient has a self management plan. The practice assesses and addresses any barriers to the patient goals. Remember, NCQA expects to see evidence that the care plan was given to the patient. Assess and address

PCMH 5 Includes the following 5 factors:
PCMH 5: Care Management and Care Transitions The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations. PCMH 5 Includes the following 5 factors: A Test Tracking and Follow-Up B Referral Tracking and Follow-Up (MUST PASS) C Coordinate Care Transitions Now let’s look at PCMH 5 Care Management and Care Transitions. The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations. PCMH 5 includes Elements A, B, and C. Element B is the “must pass” element and will be primarily what we focus on today.

5A Test Tracking and Follow-up
PCMH 5: Care Management and Care Transitions Update and Changes 5A Test Tracking and Follow-up Test Tracking and Follow-Up (2 critical factors to get any points) Same critical factors as before (tracking labs & images, flagging & follow-up on overdue results) Similar to 5A in 2011 Standards Differences in MU: Stage 2 Core 1 & 10, Menu 3 Before moving to Element 5B, we want to give a brief mention of updates/changes to 5A. There are 2 critical factors that must be met in order to receive credit. The difference is in the Meaningful use Stage 2 Core 1 & 10, Menu 3 can be used for factors in 5A.

5B Referral Tracking and Follow-up
PCMH 5: Care Management and Care Transitions Update and Changes 5B Referral Tracking and Follow-up Referral Tracking and Follow-Up (must pass) Tracking referrals is a critical factors (factor 8) MU Stage 2 Core 15 may apply Examples and in some cases, processes too Here is an overview of the important points of PCMH 5B. It is a MUST PASS element with factor 8 as the critical factor. [PAUSE 5 seconds]

PCMH 5B: Referral Tracking and Follow-up
MUST PASS = 4-6 factors including Factor 8 for 50% The practice: Considers available performance information on consultants/specialists when making referral recommendations Maintains formal and informal agreements with a subset of specialists based on established criteria. Maintains agreements with behavioral healthcare providers Integrates behavioral healthcare providers within the practice site Gives the consultant or specialist the clinical question, the required timing, and the type of referral. Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan. Now we will discuss 5B in more detail. PCMH 5B is a must pass element. Practices must pass 4 to 6 factors including factor 8 to pass this element. Factor 8 is the critical factor,. 5B2 – Agreements may be formal or informal. May describe expectations or expectations may be embedded in a tool such as a referral request form. Agreement articulates arrangements for the exchange of information, the type of information that will be provided, timeframe for receiving a response and content of the response from the specialist. Factor 5: (Read it) NCQA has defined the reason for the referral as the clinical question that the PCP wants the specialist to answer. NCQA expects that there is some indication that the clinical reason was sent along with examples of what was sent. A log documenting referrals, the diagnosis, with the reason such as MRI L-Spine, chest x-ray, incontinence does not meet the intent for factor 5 as this does not show the clinical question. The clinical question is: What question(s) does the PCP want the specialist to answer? An example of a clinical reason that would meet the intent would be: breast lump, referral to oncologist to rule out breast cancer.

PCMH 5B: Referral Tracking and Follow-up continued
Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50 percent of referrals Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports CRITICAL FACTOR Documents co-management arrangements in the patient’s medical record Asks patients/families about self-referrals and requesting reports from clinicians. Factor 8 is tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports. Please note the different parts to factor 8. #1: Tracking Referrals until available. #2: The practice flags the overdue reports. #3: The practice follows up on overdue reports. Practices must show evidence of all 3 components of Factor 8 in order to receive credit for this must pass critical factor. This can be documented in a log with examples of phone notes to the specialist as an attempt to follow-up on overdue items. It may be screenshots of the EHR showing items that are flagged and overdue. The tracking log can show the date that the reports were actually received from the specialist. NCQA is looking for evidence that reports from specialists do not fall through the cracks. It is important to provide a thorough process of how referrals are made, tracked, and followed up on when overdue including the timeframe for when the practice considers a specialist report to be overdue. For factors 5,6,8,10 NCQA expects a documented process, a report, log or other means of demonstrating that the process is followed. NCQA will accept screenshots showing electronic capabilities. This should be based on one week (5 days) of referrals with de-identified patient data. Factors 6, 8, 10: NCQA expects a process and example Factor 9: NCQA reviews at least 3 examples.

5C Coordinate Care Transitions
5C Care Coordination and Care Transitions Update and Changes 5C Coordinate Care Transitions Process required for each element, supplemented by examples/logs Very similar to C PCMH 5C is very similar to 5C of the 2011 Standards. A process supplemented by examples and logs will be required for each element just as it was in the 2011 Standards. NOW WE WILL TURN THE PRESENTATION OVER TO RACHEAL MCLAUGHLIN

PCMH 6 Includes the following elements:
PCMH 6: Performance Measurement and Quality The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. PCMH 6 Includes the following elements: A Measure Clinical Quality Performance B Measure Resource Use and Care Coordination C Measure Patient/Family Experience D Implement Continuous Quality Improvement (MUST PASS) E Demonstrate Continuous Quality Improvement F Report Performance G Use Certified EHR Technology PCMH 6: Performance Measurement and Quality includes elements A through G. PCMH 6 of the 2014 standards is similar to PCMH 6 in the 2011 Standards. 6D is the Must Pass element in PCMH 6. We will focus more on that in a few minutes.

6A Measure Clinical Quality Performance
PCMH 6: Performance Measurement and Quality Update and Changes 6A Measure Clinical Quality Performance Similar to 2011 version Immunizations and preventive care measures get their own factors Expectation is that these are measured at least annually PCMH 6A is similar to 6A in the 2011 Standards. Immunizations and preventive care measures have been split into separate factors for the 2014 standards. NCQA expects to see two measures for immunizations and two preventive care measures.

Update and Changes = Rate
PCMH 6: Performance Measurement and Quality Update and Changes 6A Measure Clinical Quality Performance # of patients meeting measure criteria # of eligible patients Expectation is that these are measured at least annually = Rate Be sure to include a report that reflects the period of the measurement, the # of patients measured meeting the criteria, the number of patients in the practice and the rate. NCQA expects that these are measured at least annually.

6B Measure Resource Use and Care Coordination
PCMH 6: Performance Measurement and Quality Update and Changes 6B Measure Resource Use and Care Coordination Care coordination measures Utilization measures 6B Measure Resource Use and Care Coordination is a new element. NCQA wants to see how well practices are assessing care coordination. The National Quality forum is a good resource for care coordination performance measures. While 6B factor 1 is a new factor, 6B2 “Utilization Measures” was a factor in the 2011 standards.

6C Measure Patient/Family Experience
PCMH 6: Performance Measurement and Quality Update and Changes 6C Measure Patient/Family Experience Aligns with B Expectation is that renewing practices have measured at least annually PCMH 6C aligns with Standard 6B of the 2011 Standard. The expectation is that the practice measures at least annually.

PCMH 6D Implement Continuous Quality Improvement MUST PASS
PCMH 6: Performance Measurement and Quality Update and Changes PCMH 6D Implement Continuous Quality Improvement MUST PASS Similar to 6C of 2011 Standards but breaks up goal setting and taking actions PCMH 6D is similar to 6C of the 2011 Standards but breaks up goal setting and action. 5 of the 7 factors must be passed in order to pass this element. In the 2014 Standards, “act” is now a separate item” as you can see on this next slide.

PCMH 6D: Implement Continuous QI
MUST PASS = 5 factors for 50% The practice uses an ongoing quality improvement process to: Set goals and analyze at least three clinical quality measures from Element A. Act to improve at least three clinical quality measures from Element A. Set goals and analyze at least one measure from Element B Act to improve at least one measure from Element B Set goals and analyze at least one patient experience measure from Element C. Act to improve at least one patient experience measure from Element C Set goals and address at least one identified disparity in care/service for identified vulnerable populations. PCMH 6D is the Must Pass Element. Practices must pass at least 5 factors in order to meet requirements for this element. 6D Continuous QI correlates to 6C of the 2011 Standards. The practice must have an ongoing quality improvement strategy and process that includes regular review of performance data and evaluation of performance against goals or benchmarks. QI a continuous process but QI measures may change over time. For instance, if a practice’s actions have resulted in meeting or exceeding their goal, the practice may then decide that they’re ready to focus on a new measure. On the other hand, if the actions did NOT provide the expected results, the practice may consider a change in tactics and determine a new action to take. NCQA expects a report or a completed PCMH Quality Measurement and Improvement Worksheet that shows how the practice meets the requirement.

PCMH 6: Performance Measurement and Quality
We’ll give a very brief overview of the Quality improvement worksheet. .. In this example the three rows show 3 examples submitted for 6A factor 3 each row will represent a quality measure that you are working on. Column Headings at the top of the page guide you as to which element goes in each column; Column C shows baseline report data as a percentage collected in 6A, B or C Columns D and E represent 6D. For example column D requires the goal, stated as a percentage, for each action, and corresponds to the factors in 6D 1,3,5 and 7. Column E is where you will describe the corresponding action taken for 6D factors 2,4, and 6. Columns F and G represent 6E. The practice’s remeasurement reports for 6 E factor 1 are shown in column F and any improvements achieved for 6E factors 2,3 and 4 are noted in column G .

Update and Changes PCMH 6: Performance Measurement and Quality
6E Demonstrate Continuous Quality Improvement Measuring effectiveness Achieving improvements 6E of the 2014 Standards correlates to 6D of the 2011 Standards. Practices will be measuring effectiveness of QI and describing the improvements achieved.

Update and Changes PCMH 6: Performance Measurement and Quality
6F Report Performance Report practice level and provider level performance within the practice Report practice or provider level performance publically Report practice or provider level performance to patients (which includes letting them know that reports are available publically) Need to include at least one clinical measure, one resource measure, and one patient experience measure In PCMH 6F, the practice produces performance data reports using measures from Elements A, B, and C. Reports must reflect data from all 3 elements or it will not meet the intent for that factor. For factor 1, practices report individual clinician performance results with the PRACTICE. For factor 2, Practice-level performance results are shared with the practice. For factor 3, Individual clinician OR practice-level performance results are shared publicly. Venues for reporting for factor 3 can be via a web site, a health plan, or other entity. For factor 4, Individual clinician OR practice-level performance results are shared with patients. Examples of reporting to the patients can be via the patient portal, a poster on the wall, a newsletter, , or mass mailing.

6G Use Certified EHR Technology
PCMH 6G: Use Certified EHR Technology 6G Use Certified EHR Technology NCQA is interested in collecting data on practice’s use of certified EHR technology NCQA is interested in collecting data on practice’s use of certified EHR technology. There are no available points for this element.

http://www.uvm.edu/medicine/vchip/ http://www.ncqa.org
Conclusion Greg Dana Patti Lutton Rachael McLaughlin Ellen Talbert Julianne Krulewitz This concludes our review of the 2014 Standards. Please feel free to contact any of us at any time with questions about the standards. Please ask us. We would rather work with you as you prepare for recognition than have you experience difficulty at the last minute. Use your facilitator. That is what they are there for. The facilitator can and will get input from all other facilitators as well as VCHIP evaluators. Remember, this is a collaborative process. We all function as a team to be sure that patients get the best, most comprehensive care possible. For those of you who are interested or know of colleagues who could not attend this evening, we will be offering this presentation on Wednesday, June 10, 2015 at 12:00 p.m. This presentation will be posted on VCHIP’s website.

Vermont Blueprint for Health ANNOUNCEMENT
You are invited to join the next joint meeting of the Blueprint Executive Committee and the Blueprint Planning and Evaluation Committee. The agenda will focus on proposed modifications to the Blueprint payment model and the development of a plan to best use the new $2,446,075 State appropriation. Your input on the impact of Community Health Teams and payment models is invited. Contact your Blueprint Project Manager for more information about this meeting. Date: Thursday, June 18, 2015 Time: 8:00 – 10:00 am Location is 10 East Allen St (VSAC Building), Winooski, VT (Community Room) Dial in number for those who are unable to attend in person: Dial in ; Participant # We have one final announcement to share. The Blueprint for Health would like to invite you to join the next joint meeting of the Blueprint Executive Committee and the Blueprint Planning and Evaluation Committee. The agenda will focus on proposed modifications to the Blueprint payment model and the development of a plan to best use the new $2,446,075 State appropriation. Your input on the impact of Community Health Teams and payment models is invited. Contact your Blueprint Project Manager for more information about this meeting. The meeting will be held on Thursday, June 18, 2015 from 8 to 10 a.m. at 10 East Allen Street, The VSAC Building, in Winooski Vermont. The meeting will be held in the community room. If you are unable to attend in person, you may dial in. Please call and use participant #

PCMH 2014 NCQA Standards and Guidelines

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