1. ~ HIT Investment and Quality Outcomes~ The Patient-Centered Medical Home

2. 2 ~HIT Investment in the PCMH and Quality Outcomes~ National Committee for Quality Assurance NCQA Our Mission To improve the quality of health care Our Methods Measurement We can’t improve what we don’t measure Transparency We show how we measure, so measurement will be accepted Accountability Once we measure, we can expect and track progress

3. 3 ~HIT Investment in the PCMH and Quality Outcomes~ Outcomes and PCMH Some Examples: –$10 PMPM reduction in total costs; total PMPM cost $488 for PCMH patients vs. $498 for control patients (p=.076). –16% reduction in hospital admissions (p<.001); 5.1 admissions per 1,000 patients per month in PCMH patients vs. 5.4 in controls. $14 PMPM reduction in inpatient hospital costs relative to controls. 29% reduction in emergency department use (p<.001); 27 emergency department visits per 1,000 patients per month in PCMH patients vs. 39 in controls. $4 PMPM reduction in emergency department costs relative to controls. –Geisinger has estimated in unpublished reports an ROI of more than 2 to 1 for its investment in its PCMH model, and is spreading the ProvenHealth Navigator PCMH model throughout the Geisenger Health System. Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites. Source: http://www.pcpcc.net/files/evidence_outcomes_in_pcmh_2010.pdfhttp://www.pcpcc.net/files/evidence_outcomes_in_pcmh_2010.pdf

4. 4 ~HIT Investment in the PCMH and Quality Outcomes~ PPC-PCMH & PCMH SITES BY STATE ME VT RI NJ MD MA DE NY WA OR AZ NV WI NM NE MN KS FL CO IA NC MI PA OH VA MO HI OK GA SC TN MT KY WV AR LA AL IN IL SD ND TX ID WY UT AK CA CT NH 61-200 Sites *As of 08/31/12 MS 21-60 Sites 0 Sites 1-20 Sites 201+ Sites 4772 Sites 22565 Clinicians

5. 5 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 2011 Content and Scoring PCMH 1: Enhance Access and Continuity A.Access During Office Hours** B.Access After Hours C.Electronic Access D.Continuity (with provider) E.Medical Home Responsibilities F.Culturally/Linguistically Appropriate Services G.Practice Organization Pts 4 2 4 20 PCMH 2: Identify and Manage Patient Populations A.Patient Information B.Clinical Data C.Comprehensive Health Assessment D.Use Data for Population Management** Pts 3 4 5 16 PCMH 3: Plan and Manage Care A.Implement Evidence-Based Guidelines B.Identify High-Risk Patients C.Care Management** D.Medication Management E.Use Electronic Prescribing Pts 4 3 4 3 17 PCMH 4: Provide Self-Care and Community Resources A.Support Self-Care Process** B.Provide Referrals to Community Resources Pts 6 3 9 PCMH 5: Track and Coordinate Care A.Track Tests and Follow-Up B.Track Referrals and Follow-Up** C.Coordinate with Facilities/Care Transitions Pts 6 18 PCMH 6: Measure and Improve Performance A.Measure Performance B.Measure Patient/Family Experience C.Implement Continuous Quality Improvement** D.Demonstrate Continuous Quality Improvement E.Report Performance F.Report Data Externally G.Use Certified EHR Technology Pts 4 3 2 20 Optional Patient Experiences Survey ** Must Pass Elements

6. 6 ~HIT Investment in the PCMH and Quality Outcomes~ Meaningful Use of Health Information Technology (HIT) NCQA emphasizes HIT because good primary care is information-intensive PCMH 2011 reinforces incentives to use HIT to improve quality Meaningful Use language is embedded, often verbatim, in PCMH 2011 evaluation standards Synergy/virtuous cycle: PCMH 2011 medical practices will be well prepared to qualify for meaningful use, and vice versa

7. 7 ~HIT Investment in the PCMH and Quality Outcomes~ NCQA’s PCMH* and Meaningful Use ~ Powerful Synergy ~ Patient-Centered Medical Homes Build on Meaningful Use Foundation * Based on Stage 1 Meaningful Use Requirements Update to Stage 2 planned

8. 8 ~HIT Investment in the PCMH and Quality Outcomes~ NCQA’s PCMH 2011 and Meaningful Use PCMH closely aligned with Stage 1 MU Electronic prescribing Drug formulary, drug-drug, drug allergy checks Maintaining an up-to date problem list of current and active diagnoses and medications Recording demographics on preferred language gender (sex), race, ethnicity and date of birth Recording and charting changes in vital signs Recording smoking status Reporting ambulatory quality measures Implementing clinical decision support rules… Plan similar alignment with Stage 2 MU

9. 9 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 1: Enhance Access and Continuity Intent of Standard Patient access to routine/urgent care and clinical advice during/after hours that are culturally and linguistically appropriate Electronic access Clinician selected by patient Team-based care; trained staff Meaningful Use Criteria Patients provided electronic: Copy of health information Clinical summary of visit Access to health information

10. 10 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 2: Identify/Manage Patient Populations Intent of Standard Collects demographic and clinical data for population management Assess/document risks Create lists; use for point of care reminders Meaningful Use Criteria Language, gender (sex), race, ethnicity, DOB Problem list Medication list Medication allergy list Vital signs Growth chart (peds.) Smoking status Lists of patients with specific conditions for QI, decrease disparities Follow-up reminders for care

11. 11 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 3: Plan and Manage Care Intent of Standard Identify patients with specific conditions including high-risk or complex, behavioral health Care management – Manage care using point- of-care reminders – Pre-visit planning – Progress toward goals – Barriers to treatment goals Reconcile medications E-prescribing Meaningful Use Criteria Clinical decision support Medication reconciliation with transitions of care E-prescribing Drug-drug, drug-allergy checks Transmit prescriptions using EHR Drug-formulary checks

12. 12 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 4: Provide Self-Care/Community Resources Intent of Standard Assess self-management abilities Document self-care plan Provide educational tools and resources Counsel on healthy behaviors Assess/provide/arrange for mental health/substance abuse treatment Provide community resources Meaningful Use Criteria Patient-specific education materials

13. 13 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 5: Track and Coordinate Care Intent of Standard Tracks, follows-up on and coordinates tests, referrals and patient care in other facilities Orders, retrieves and incorporates into patient records lab and imaging results Establish information exchange with facilities Follows up with discharged patients E-information exchange E-summary of care Meaningful Use Criteria Incorporate lab/test results Exchange patient information with other providers (meds/ allergies, tests) Provide summary care record for transitions and referrals

14. 14 ~HIT Investment in the PCMH and Quality Outcomes~ PCMH 6: Measure and Improve Performance Intent of Standard Practice uses performance and patient experience data to continuously improve Track utilization measures Identifies vulnerable populations Report data to CMS, immunization registries, public health agencies Meaningful Use Criteria Report: Ambulatory clinical quality measures to CMS/state Immunization data to registries Syndromic surveillance data to public health agencies

15. 15 ~HIT Investment in the PCMH and Quality Outcomes~ Alignment: Health IT Meaningful Use & NCQA’s PCMH 2011 Domain MU-only MU-PCMH AlignmentPCMH-only Protecting Privacy Protect EHRs/secure electronic messaging Using Patient Information Family History as structured data (Stage 2) Record and chart vital signs Record smoking status Imaging results/ info accessible through EHR Clinical lab-test results in EHR as structured data Generate lists of patients by conditions Surveillance data to public health agencies Comprehensive Health Assessment (including family history) Use Data for Population Management Plan and Manage Care Identify High-Risk Patients Care Management Measure Patient/Family Experience Patient Education/ Self Care Clinical summaries to patients for each visit Let patients view online, download, transmit health information w/in 4 business days ID patients for preventive/follow-up reminders Use EHR to ID/provide patient-specific education Support self-management/behavior change Care Coordination Summary record for each transition or referral Med reconciliation from other provider/setting Care teams coordinate care Population management Support self-mgmt/behavior change Referrals to Community Resources Referral tracking & follow-up Performance evaluation & QI Medication Management Electronic Rx & CPOE for meds, lab & radiology Decision Support Use clinical decision support to improve performance on high-priority health condition Disparities Record demographics as structured dataAssess patients; racial/ethnic diversity Assess language needs Provide interpretation/bilingual services Printed materials patients’ languages Reporting Report to Registries (Stage 2) Report clinical quality measures to CMS Electronic data to immunization registries Measure and Improve Performance Enhance Access and Continuity Same day appointments Phone/electronic advice After-hours access