0. Quality Improvement Program Patient-Centered Medical Home 2010
TITLE
Quality Improvement Team
Primary Care Information Project
NYC Department of Health & Mental Hygiene
Primary Care Information Project

1. What is a Patient Centered Medical Home and Who is NCQA?
Specialist
Patient Centered Home
VNS
PCP/ Patient
Hospital
Pharmacy
COORDINATION OF CARE
“There is a clear consensus that primary care needs to be at the center of a reformed US health care system. The Patient-centered Medical Home (PCMH) has emerged as the key strategy for the redesign of primary care. The PCMH model builds upon the core concepts of primary care that include accessible, accountable, coordinated, comprehensive, and continuous care in a healing physician-patient relationship over time. Added to these basic primary care concepts are features that improve quality of care, improve patient centeredness, organize care across teams, and reform the payment system to support this enhanced model of primary care.”
doi: /af
m.1087 
Annals of Family Medicine 8:88-89 (2010)
© 2010 Annals of Family Medicine, Inc. 1 1

2. NCQA PCMH Nine Focus Areas
The American Academy of Pediatrics (AAP)
introduced the term “medical home” in 1967 and
within a decade it was AAP policy.(18-20) Initially it
was used to describe a single source of medical
information about a patient but gradually grew
to include a partnership approach with families
to provide primary health care that is accessible,
family-centered, coordinated, comprehensive,
continuous, compassionate, and culturally effective.
In 2002, AAP added an operational definition
that lists 37 specific activities that should occur
within a medical home.
PPC1: Access and Communication
PPC2: Patient Tracking and Registry Functions
PPC3: Care Management
PPC4: Patient Self-Management Support
PPC5: Electronic Prescribing
PPC6: Test Tracking
PPC7: Referral Tracking
PPC8: Performance Reporting and Improvement
PPC9: Advanced Electronic Communication 2 2

3. THERE ARE 10 MUST-PASS ELEMENTS IN PCMH SCORING
Points
Elements
Points
1: Access & Communication (9 pts)
1A: Access & communication processes
1B: Access & communication results 4 5
5: Electronic prescribing (8 pts)
5A: Electronic prescription writing
5B: Prescribing decision support-safety
5C: Prescribing decision support-efficiency 3 2 2 3 6 4
2: Patient Tracking & Registry Functions (21 pts)
2A: Basic system for managing patient data
2B: Electronic system for clinical data
2C: Use of electronic clinical data
2D: Organizing clinical data
2E: Identifying important conditions
2F: Use of system for population management
6: Test tracking (13 pts)
6A: Test-tracking and follow-up
6B: Electronic system for managing tests 7 6
7: Referral tracking (4 pts)
7A: Referral tracking 4
3: Care Management (20 pts)
3A: Guidelines for important conditions
3B: Preventive service clinician reminders
3C: Practice organization
3D: Care management of important conditions
3E: Continuity of care
8: Performance Reporting & Improvement (15 pts)
8A: Measures of performance
8B: Patient experience data
8C: Reporting to physicians
8D: Setting goals and taking action
8E: Reporting standardized measures
8F: Electronic reporting- external entities 3 4 5 3 2 1
9: Advanced Electronic Communications (4 pts)
9A: Availability of interactive website
9B: Electronic patient identification
9C: Electronic care management support
4: Patient Self-Management Support (6 pts)
4A: Documentation of communication needs
4B: Self-management support 1 2 2 4
TOTAL POINTS 100 3
Source: NCQA Overview Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH) 3

4. PPC-PCMH STRUCTURE DETAIL
Description
NCQA offers a 20 percent discount from the Full Survey to applicants sponsored by health plans, employers
and other programs. PPC-PCMH applicants receive the discount when the:
• Practice has 15 or fewer physicians and
• Sponsor has ten or more applications in a market area within a twelve-month period.
Achievement levels
Level 1
25-49 points; Must-pass elements = 5 of 10, with performance of at least 50%
Level 2
50-74 points; Must-pass elements = 10 of 10, with performance of at least 50%
Level 3
75 points or more; Must-pass elements = 10 of 10, with performance of at least 50%
IT requirements
Basic: Requires electronic practice management
Intermediate: Requires EHR or e-prescribing
Advanced: Requires interoperable IT capabilities
Practice conducts self-scoring assessment
Practice completes on-line Survey Tool
NCQA evaluates all data and documents & provides score
At least 5% of practices receive additional, onsite audit by NCQA
NCQA provides final information to the practice
NCQA reports information on the practice, the providers and level of performance to NCQA & data users (health plans & physician directories) for practices that pass a level
Steps for evaluation
Pricing charged by NCQA
Initial fee Survey Tool license -$80
Initial Application fee
-$450-$2700 for 1-6 non-sponsored provider
-$360-$2700 for 1-6 sponsored providers
Add-on Survey Application fee to advance to next level
-Ranges from $225-$1350 for 1-6 providers
PCIP RATE- HALF OF THE RATE NOTED ABOVE- $225/PHYSICIAN – benefit of participating with PCIP 4 4

5. PCIP QUALITY IMPROVEMENT ACTIVITIES – WHAT DO WE DO?
Provide technical assistance to physicians to help them improve the health outcomes of patients,
Focus on 4 priority TCNY areas (ABCS)
Help providers get to meaningful use
Provide CME/CNE credits for participating with QI
Provide support for office redesign (e.g., workflows, documentation, standard processes) to improve office efficiency
if desired, prepare for NCQA Patient Centered Medical Home (PCMH)
Provide additional coaching on preventive-health features & how to use them for QI
Provide a forum for discussing performance feedback and sharing best practices for QI efforts
Provide feedback to the teams at PCIP on what we observe during site visits (development, IS, Billing, EMR) 5 5

6. Standard 1- Access and Communication
INTENT OF THE STANDARD
Practice removes barriers to care by providing improved access for appointments and on-going patient communication
Patients have a personal physician, coordinating care and diagnostics during one visit
Obtain patient feedback about potential access and communication issues to reduce barriers to care
Concepts Addressed
Supporting Evidence
Scheduling
Methods to contact MD
Identifying health insurance
Patient feedback
Written telephone triage process
Written policy – helping patients identify insurance options
Job descriptions for each staff member

7. PPC 1 – Access and Communication
Practical Examples:
Incorporate feedback from patients and staff into office process
Develop policies, procedures, and job descriptions to ensure that staff understand responsibilities.
Consider holding monthly staff meetings to discuss staff ideas and provide training
Conduct a patient survey and incorporate feedback into the practice
Post information in your office or website about how to obtain
insurance for those patients who do not have coverage 7 7

8. Standard 2- Patient Tracking and Registry Function
INTENT OF THE STANDARD
Capturing and using data for population management and data driven decision making to improve outcomes for chronic conditions
Proactively outreach to patients --identify needed treatment outside of the normal office visit
Capture important information for continuity of care if patient sees another provider
Promote consistency of patient care
Concepts Addressed
Supporting Evidence
Registry
Capturing patient data
Charting tools/documentation
Conduct a 36 chart review, MRR spreadsheet
Chose three disease focus areas, prove they are clinically important for the practice
Written description- how often the registry is used, examples of preventive outreach efforts

9. PPC 2 Patient Tracking and Registry Functions
Practical Examples:
Identify three chronic clinical conditions to focus on at your practice
Run a billing report of top 10 billed ICD 9 codes
Identify health conditions prevalent in your zip code through DOH report
Run registry query to determine percentage of patients with condition at your practice
Select chart sample (36 patients) for medical record review
Use the registry to identify potential gaps in care for patients, i.e., overdue Hgb A1C, HTN patients without an office visit in 12 months
Use letters function, telephone encounters, and s to document outreach efforts 9 9

10. Standard 3 – Care Management
INTENT OF THE STANDARD
Patients receive coordinated care at the practice according to evidence - based guidelines
Provide a physician directed, team based approach to managing and coordinating the patient care – non-physician staff are an important part of the care team
Avoid patient safety errors or duplicative, unnecessary care through coordination with patient, family and external organizations (hospital, health plan, nursing home)
Concepts Addressed
Supporting Evidence
Care management
Clinical focus areas
Team approach-non-physician staff
PCIP Multi-site
Job Descriptions
Policy and Procedures
Create Standing Orders
MRR to assess use of care plans, review of medication list, self-monitoring etc

11. PPC 3 – Care Management Practical Examples:
Maximize the features of system and delegate to non-physician team members
Clear CDSS alerts
Have each staff member practice to the fullest capacity of their license and use standing orders
Create a program for patient self management
Order FREE educational material from the DOH and distribute to patients
Refer patients to local classes or programs (i.e.: Weight Watchers, HTN, Diabetes)
Document all of the coordination work
Create a policy and workflow on how to communicate with external agencies (documenting phone calls using t-encounters in the patient chart)
Document referral follow-up
Customize Preventive medicine section. The doctor can then easily document (1) Individualized treatment goals; (2) assess patient treatment goals; and (3) Assess barriers when patient have not met their goals
Use flowsheets and incorporate self-monitoring results into flowsheet. 11 11

12. Standard 4 – Patient Self-Management
INTENT OF THE STANDARD
Engaged patients will participate in their care and take responsibility improving outcomes through self monitoring, community programs, and group classes
Patients become part of the care team and collaborate with the practice by setting their own goals and being accountable
Physicians consider hearing and vision barriers to learning and self management
Concepts Addressed
Supporting Evidence
4A – PCIP multi-site 1 point
NYCDOH free educational materials
Hite site website link
Document referral to community resources
Smart forms
Patient home monitoring
Documentation of patient education
Patient goal setting

13. PPC 4 – Patient Self-Management
Practical Examples:
Encourage patients to manage their chronic conditions
Provide educational materials
Provide patients with a printed visit summary
Assess readiness to change
Use smart forms to screen
Assess barriers to achieving clinical and personal goals
Create and use alerts at the front desk for assessing hearing and vision barriers
Customize Preventive medicine section. This allows for easier documentation of goal assessments 13 13

14. Standard 5- Electronic Prescribing
INTENT OF THE STANDARD
Electronic prescribing reduces errors through using drug safety checks and eliminating transcription errors
Recording medications in the EHR helps coordinate care among providers and in the event of an emergency
Concepts Addressed
Supporting Evidence
Prescribing workflows
Potential incentives and rewards for eRx
Meaningful use
Screen shots of the practice’s schedule (last 5 days)
Screen shots of eRx’s (printing, faxing or automating success)
Indicate what % of eRx’s the practice does on a daily or weekly basis

15. PPC 5 – Electronic Prescribing
Practical Examples:
Encourage coordination of pharmacy care and e-prescribing
Routinely document patient’s preferred pharmacy and document in EHR
Compare 5 days of practice schedule with reports of eRx to determine percentage of patients using service 15 15

16. Standard 6- Test Tracking
INTENT OF THE STANDARD
Timely follow up/tracking of lab tests will assist providers in medical decision making
Patients and families can engage in care by understanding the test results and adhering to treatment plans that improve outcomes
Concepts Addressed
Supporting Evidence
Developing Strong Workflows
Using Lab interfaces
Closing the loop and coordinating care
Written process for lab workflow
Screenshots of letters or telephone encounters that notify patients of lab results

17. **Remember to document all telephone calls!
PPC 6- Test Tracking
Practical Examples:
Use a lab interface
Develop a strong workflow
Create written policy for test tracking and follow-up
Track all tests and document all actions in the telephone encounter section
Notify patients of lab results by either sending letters or calling the patient
**Remember to document all telephone calls! 17 17

18. Standard 7-Referral Tracking
INTENT OF THE STANDARD
Coordination of complex care requires the systematic tracking of referrals and treatment plan from other providers
Concepts Addressed
Supporting Evidence
Written description of the referral
process
Screen shots of completed
referral and tracking process
Referral workflows
Delegating follow-up items to staff

19. PPC 7- Referral Tracking
Practical Examples:
Develop a strong workflow
Create policies for tracking outgoing referral
Use eCW to document all outgoing referrals
Continuously track referrals until consult notes are received 19 19

20. Standard 8- Performance Reporting and Improvement
INTENT OF THE STANDARD
Practice uses all available data to improve all aspects of care and includes patient feedback into the process
Data is shared within the practice to target improvement and with external agencies (I.e., health plans, PQRI, DOH)
Practices utilize data-driven decision making
Concepts Addressed
Supporting Evidence
Using the practice’s data to change health outcomes
Patient surveys and score sheet
Written process for survey distribution
Written plan for performance assessment and improvement

21. PPC 8-Performance Reporting and Improvement
Practical Examples:
Develop a strong workflow and delegate items to non physician staff
Determine which reports will be run, by whom, and how often
Hold monthly staff meetings to discuss results, set goals, and take action
Review quality measures monthly and identify areas that need improvement
Periodically assess the practice’s performance by distributing patient surveys
Use data from registry and patient feedback to drive discussions
Report to CMS through PQRI Measures to satisfy external reporting requirements 21 21

22. Standard 9-Advanced Electronic Communication
INTENT OF THE STANDARD
Patients can communicate with providers in a variety of ways that is convenient and maximizes coordination of care
- Website, , patient portal
- Communicate with disease/case mgmt
- Patient web-based education
Concepts Addressed
Supporting Evidence
Using website education as a tool
Must be interactive
communication management
Written processes of electronic communication
Screenshots of direct communication between patients and physicians
must be secure communication- not regular

23. PPC9- Advanced Electronic Communication
Practical Examples:
Create policies for electronic communication
Implement the patient portal
Educate patients about how/when to use the portal to communicate
Develop an interactive website 23 23

24. PPC9- Advanced Electronic Communication

25. PPC9- Advanced Electronic Communication

26. GETTING STARTED AT YOUR PRACTICE – WHAT DO WE DO FIRST?
Visit and download the standards
Read the requirements and determine where you would like to make changes at your practice to optimize workflows and patient care
Arrange a visit from QI / EMR / Billing teams to optimize workflows and documentation
Organize a plan and timeline for making changes
Delegate tasks to your staff
Involve your entire team in the process
Get feedback from staff and patients
1) Start by defining policies, procedures and job descriptions
Use PCIP templates to create these documents
2) Administer a patient satisfaction survey
3) Hold your first staff meeting 26 26

27. PCMH Project Plan – PDCA CYCLE
DCO-ON njPP1
PCMH Project Plan – PDCA CYCLE
PLAN: A QI Specialist performs an onsite assessment with the physician and other key staff members at the practice. Following the visit, the practice receives a project plan and timeline along with recommendations for workflow redesign and toolkit items to help achieve goals.
DO: QI project plan begins; practice purchases NCQA online tool, defines policies and procedures, job descriptions, distributes /scores patient surveys, improves EHR documentation, identifies 3 clinically important conditions to focus PCMH efforts, practice considers advanced communication techniques ie: portal/website options
CHECK: QI assesses workflow changes at practice and suggests additional changes as needed, practice analyzes data (including patient survey data and chart audit results)
ACT: QI Specialist reviews all documentation and provides feedback---Practice submits application to NCQA 27 27