1. Regional Care Collaborative March 26, 2015

2. 2011/2014 Crosswalk
(Standards 1-6)
Maia Bhirud

3. Standard 1 Crosswalk PCMH 1: Enhance Access and Continuity
2011
Access during office hours
After-hours access
Electronic access
Continuity
Medical home responsibilities
Culturally and linguistically appropriate services
The Practice Team
PCMH 1: Patient- Centered Access
2014
Patient-centered appointment access
24/7 Access to clinical advice
Electronic access
PCMH 1: Enhance Access and Continuity
2011
Access during office hours
After-hours access
Electronic access
Continuity
Medical home responsibilities
Culturally and linguistically appropriate services
The Practice Team
2011 standard split in half to become 2014 standards 1 and 2

4. 2014 Standard 1: Must Pass
PCMH 1A: Patient-Centered Appointment Access
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 appointments outside of regular business hours
Providing alternative types of clinical encounters
Availability of appointments
Monitoring no-show rates
Acting on identified opportunities to improve access
Very similar to 2011; combination 1A & 1B
1) providing same day apts…the same as before. Documentation: 5 days apts fr routine and urgent care apts
2) outside regular business hours…proof extended hours evenings and weekends (formerly 1B1)
3) [New} Alternative type of clinical encounter using real time mode of communication (telephone, video chat, secure instant messaging)
Documentation: report showing the frequency of scheduled alternative encounters over a 30 day period
4) [New} apt availability
Documentation: 5 day report showing appointment wait times (third next available – measures length of time from when a pt contact the practice to request an apt to the third next available apt on the clinician’s schedule)
5) [New} No Show Rates
Documentation: 30 day calendar period # pts not show to pre scheduled apts/ # pts w pre scheduled apts that came
6) Identify opportunities to improve factors 1-5….suggest PDSA cycle format
(critically evaluation your activities and institute real quality improvement)

5. Standard 1C: Electronic Access
Standard 1B: 24/7 Access
Basically the same as Telephone access during and after hours has been combined into one factor
Standard 1C: Electronic Access
Also basically the same as 2011 – MU reports but MU stage 2

6. Standard 2 PCMH 1: Enhance Access and Continuity 2011 D. Continuity
Medical Home
Responsibilities
Culturally and linguistically
Appropriate Services
G. The Practice Team
PCMH 2: Team-Based Care
2014
Continuity
Medical Home Responsibilities
Culturally and Linguistically Appropriate Services
The Practice Team
PCMH 1: Enhance Access and Continuity
2011
D. Continuity
Medical Home
Responsibilities
Culturally and linguistically
Appropriate Services
G. The Practice Team

7. Standard 2A: Continuity
Mapped to D Continuity
Factor 3: process to orient pts to staff and they really are looking for a process
Factor 4: transition plan for pts transitioning from pediatric to adult care (formerly 5B)
Documentation: written transition plan
Standard 2B: Medical Home Responsibilities
Same idea with added criteria to add into your brochure or website
Standard 2C: Culturally and Linguistically Appropriate Services
Unchanged

8. 2014 Standard 2: Must Pass PCMH 2D: The Practice Team (10 factors)
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 standing orders for services.

9. 2014 Standard 2: Must Pass
Training and assigning members of the care team to coordinate care for individual patients.
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 schedule 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.
2D: The Practice Team [Must Pass}
Factor 2: [New] delineates responsibilities for sustaining team based care
Documentation: Overview of team-base care structure (org chart)
Factor 3: Critical factor – process for structured communication of care team – want to know the frequency of communication and at least 3 samples of meeting summaries, checklists, apt notes or chart notes as evidence
Factor 8: scheduled team meetings to routinely improve care for all patients (general care of patients as different from factor 3 which is individual care of specific patients)
Documentation: description of team meetings and at least one example of meeting minutes, agenda, staff memos-- discussion about staff roles and responsibilities, performance measurement data, team member training and areas for improvement
Factor 9: [New] formal quality improvement initiatives – documented process for quality improvement
Factor 10:
Process and examples of patient participation

10. Standard 3 Crosswalk PMCH 2: Identify and Manage Patient Populations
PCMH 3: Population Health Management
2014
Patient Information
Clinical Data
Comprehensive Health Assessment
Use of Data for Population Management
Implement Evidence-Based Decision Support
PMCH 2: Identify and Manage Patient Populations
2011
Patient Information
Clinical Data
Comprehensive Health Assessment
Use of Data for Population Management
PMCH 2: Identify and Manage Patient Populations
2011
Patient Information
Clinical Data
Comprehensive Health Assessment
Use of Data for Population Management
Patients have access by same day request
Patients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and after office hours
The practice provides electronic access
Patients select their PCP
The focus is on team-based care with trained staff

11. 3A: Patient Information (2011 2A)
3B: Clinical Data (2011 2B)
(remember now aligned with MU Stage 2)
3C: Comprehensive Health Assessment (2011 2C)
Review of completeness
Report clearly showing how many patients had incomplete or complete assessments for all factors
Or Review of patient records (using record review workbook)

12. 2014 Standard 3: Must Pass PCMH 3D: Use Data for Population Management
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
The practice collects demographic and clinical data for population management
The practice assesses and documents patient risk factors
The practice identifies patients for proactive and point-of-care reminders

13. 3E: Implement Evidence Based Decision Support
Different from proactive pop mngt activities that are reminding pts to come in to receive specific services - Point of care reminders related to your clinical decision support. – Pick conditions and show templates of the tools or electronic system organizer

14. Standard 4 PCMH 4: Care Management and Support PCMH 3: Plan and Manage
2011
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Care Management (Must Pass)
Medication Management
Use Electronic Prescribing
PCMH 4: Provide Self-Care Support and Community Resources
Support Self-Care Process (Must Pass)
Provide Referrals to Community Resources
2014
Identify Patients for Care Management
Care Planning and Self-Care Support
Medication Management
Use Electronic Prescribing
Support Self-Care and Shared Decision Making

15. 4A: Care Management and Support (2011 3A)
New from 2011 is designation of specifically high cost/utilization population as well as a population specifically made vulnerable by a social determinant of health (such as exposure to crime, access to education, housing status, etc.
Documentation: process and criteria for identifying populations; percentage of the total patient population to benefit from care management based on the number/type of conditions selected for factors 1-5

16. Standard 4: Must Pass PCMH 4B: Care Planning and Self-Care Support
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% of the patients identified in Element A:
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.

17. 4C: Medication Management (2011 3D)
Just like 3D although now aligned w Meaningful Use Stage 2
4D: Use Electronic Prescribing (2011 3E)
Just like 3E in 2011
4E: Support Self-Care and Shared Decision Making
Adapted from A and 4B, emphasis on providing educational resources to patients for their use in self management, including referrals to available community resources.

18. Standard 5 2011 Test Tracking and Follow-Up
PCMH 5: Track and Coordinate Care
PCMH 5: Care Coordination and Care Transitions
2011
Test Tracking and Follow-Up
Referral Tracking and Follow-Up (Must-Pass)
Coordination with Facilities and Care Transitions
2014
Test Tracking and Follow-Up
Referral Tracking and Follow-Up (Must-Pass)
Coordinate Care Transitions

19. 5A: Test Tracking and Follow Up
Very closely aligned with 5A from Larger thresholds for the percent of lab and radiology orders that are electronically recorded in the pt record.

20. Standard 5: Must Pass The practice:
PCMH 5B: Referral Tracking and Follow-Up
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 specialists pertinent demographic and clinical data, including test results and the current care plan.

21. Standard 5: Must Pass The practice:
PCMH 5B: (continued)
The practice:
Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan.
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% 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.

22. 5C: Coordinate Care Transitions
very similar to 2011

23. Standard 6 PCMH 6: Measure and Improve Performance 2011
PCMH 6: Performance Measurement and Quality Improvement
2011
Measure Performance
Measure Patient/Family Experience
Implement Continuous Quality Improvement (Must Pass)
Demonstrate Continuous Quality Improvement
Report Performance
Report Data Externally
2014
Measure Clinical Quality Performance
Measure Resource Use and Care Coordination
Measure Patient/Family Experience
Implement Continuous Quality Improvement (Must Pass)
Demonstrate Continuous Quality Improvement
Report Performance
Use Certified EHR Technology

24. 6A: Measure Clinical Quality Performance
Like Population management, separated measurement of immunization measures from other preventative care measures
6B: Measure resource use and care coordination
Added two measures related to care coordination. Examples include: biopsy follow up, patient follow up after ER visit (see pg. 82 in standards for more examples)
6C: Measure Patient/Family Experience
Exactly aligned 2011 standards for measuring patient experience(2011 6B)

25. Standard 6: Must Pass
PCMH 6D: Implement Continuous Quality Improvement
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.

26. 6E: Demonstrate Continuous Quality Improvement
Closely aligned with D…credit for achieving improvement on measures from elements A through C
6F: Report Performance
Report performance data internally and publicly by individual clinician and at the practice-level
6G: Use Certified EHR Technology
Not scored so no impact on points but they want you to report whether or not you use an EHR to perform a number of capabilities