Physician Practice Connections –Physician Practice Connections –Patient-Centered Medical HomePatient-Centered Medical Home

(PPC-PCMH)(PPC-PCMH)

NCQA Recognition WorkbookNCQA Recognition Workbook

© Copyright 2011 North Carolina Community Care Networks, Inc.  All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure

NCQA recognition as patient-centered medical homes.  All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with the permission of the respective copyright owners in each case.

Special Thanks to American Academy of Family Physicians (AAFP), Medical Group Management Association (MGMA) and Richard J. Barron, MD for selflessly sharing materials with us.

Special thanks, acknowledgement, and appreciation for their contributions also go to:

The PCMH Team at HealthTeamWorks: http://www.healthteamworks.org/index.aspx Natl Ctr for Medical Home Implementation and the American Academy of Pediatrics: http://www.medicalhomeinfo.org/ Institute for HealthCare Improvement: http://www.ihi.org/ihi Diabetes Initiative: http://www.diabetesinitiative.org/index.html Primary Care Development Corporation: http://www.pcdc.org/ Improving Chronic Illness Care: http://www.improvingchroniccare.org/ Gateway Community Health Center: http://www.gatewaychc.com/ Robert C. Byrd Center for Rural Health at Marshall University: http://crh.marshall.edu/ Mid-State Health – NH: http://www.midstatehealth.org/ NC Academy of Family Physicians: http://www.ncafp.com/ The PCMH Team at CCNC: http://www.communitycarenc.org/

Created by:-Zula Solomon, MBA – PCMH Quality Improvement CoachDeb Barnett, RN, MS, FNP – Family Medicine Residency PCMH Project ManagerR. Scott Hammond, M.D. -- Primary Care Consultants, Inc.

Adapted and expanded by:-R.W. Watkins, MD, MPH, FAAFP – Community Care of North Carolina

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Table of Contents

Organizational Steps 4

Definitions 5

Abbreviations 7

PPC-PCMH STANDARDS AND SCORING 8

PPC 1: Access and Communication ( 9 Points)10

PPC 2: Patient tracking and Registry Functions ( 21 Points) 17

PPC 3: Care Management ( 20 Points ) 28

PPC 4: Patient Self- Management Support ( 6 Points ) 36

PPC 5: Electronic Prescribing ( 8 Points ) 41

PPC 6: Test Tracking ( 13 Points ) 46

PPC 7: Referral Tracking ( 4 Points ) 50

PPC 8: Performance Reporting and Improvement ( 15 Points ) 52

PPC 9: Advanced Electronic Communications ( 4 Points) 60

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Organizational Steps

1. Build your teama. Establish regular meeting timeb. Delegate roles and responsibility (who will be the project manager?)

2. Establish planning timea. Identify practice champion and block non-clinic time for the

provider(s) to do the work3. Understand what it means to be a medical home.

a. What are the joint principles?b. Who is NCQA and what are the standards and guidelines for PPC-

PCMH?c. What is the Chronic Care Model?

4. Establish Aim and milestonesa. Create a time tableb. Identify a project manager who will hold the team accountable to meeting goals and milestones?

5. Read the workbook6. Do the work

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Definitions: Allergies: Adverse reactions to substances. Business associate: A person or organization that on behalf of a covered entity (health plan, health care clearinghouse or health care provider) or organized health care arrangement, which includes a covered entity, performs, or assists in the performance of, but not in the capacity of a workforce member, functions or activities involving the use or disclosure of individually identifiable health information from the covered entity or organized health care arrangement. Clinical visit data: A record of patient activity at the practice. Clinically important condition: A chronic or recurring condition that a practice sees most frequently, such as otitis media, asthma, diabetes or congestive heart failure. The most frequently seen single-episode conditions may also be clinically important conditions such as colds or urinary tract infections.

Contact information: Patient location facts that may include telephone number, e-mail address, payor ID and emergency contact information. Demographic information: Information that includes at least ethnicity, gender, marital status, date of birth, type of work, hours of work and preferred language. Diagnoses: Problem list of conditions, injuries or other health issues.

Documented process: Written statements describing the practice's procedures. The statements may include protocols or other documents that describe actual processes or blank forms the practice uses in work flow such as referral forms, checklists and flow sheets.

Emergency admissions: Any unscheduled medical or behavioral health care event that results in either an emergency room visit or hospital admission.

Evidence-based: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion.

Evidence-based guidelines: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion. See PRACTICE GUIDELINES.

Example: One document, report or prepared material that serves as a model for those used by the practice.

Factor: An item within an element that is scored. For example, an element may require the organization to demonstrate that a specific document includes four items. Each item is a factor.

Materials: Prepared material that the practice provides to patients, including clinical guidelines and self-management and educational resources such as brochures, Web sites, videos and pamphlets.

Multi-Site Group: Multiple practice sites of a larger organization that provide standardized systems across the practice. In this case, NCQA reviews some elements once and applies the results to all practice sites in the Multi-Site Group.

Must Pass elements: Designated elements that a practice must pass at a 50% or greater score to achieve Recognition.

Population management: The assessment of all patients in a practice to identify groups of patients who require specific services.

Practice: [Appears with in Interactive Survey System] One physician or a group of physicians at a single geographic location who practice together. Practicing together means that, for all the physicians in a practice:1) The single site is the location of practice for at least the majority of their clinical time;

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2) The non-physician staff follow the same procedures and protocols;3) Medical records, whether paper or electronic, for all patients treated at the practice site are available to and shared by all physicians as appropriate;4) The same systems--electronic (computers) and paper-based--and procedures support both clinical and administrative functions: scheduling time, treating patients, ordering services, prescribing, keeping medical records and follow-up. Practice guidelines: Systematically developed descriptive tools or standardized specifications for care to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Practice guidelines are typically developed through a formal process and are based on authoritative sources that include clinical literature and expert consensus. Practice guidelines may also be called PRACTICE PARAMETERS, TREATMENT PROTOCOLS or CLINICAL GUIDELINES.

Preventive health data:  A patient's status regarding receipt of preventive screenings, immunizations and counseling appropriate for the patient's age and gender.

Records or files: Actual patient files or registry entries that document an action taken. The files are a source for estimating the extent of performance against an element. There are two ways to measure this performance: 1) a query of electronic files yielding a count, and 2) the sample selection process provided by NCQA--instructions for choosing a sample and a log for reviewing records are in the Record Review Workbook. Registry: A searchable list of patient data that the practice actively uses to assist in patient care.

Reports: Aggregated data showing evidence of action; may include manual and computerized reports.

Risk factors: Behaviors, habits, age, family history or other factors that may increase the likelihood of poor health outcomes.

Sample: A statistically valid representation of the whole. Treatment plan: A written action plan based on assessment data that identifies the individual or patient's clinical needs, the strategy for providing services to meet those needs, the treatment goals and objectives.

Practice is done working on Element

Practice is focusing on this Element

Practice is choosing not to work on this Element

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Abbreviations Acronym AcronymAAFP American Academy of Family Physicians RIA/E Rapid Improvement Activity/EventABFP American Board of Family Physicians RMD Reach My DoctorABIM American Board of Internal Medicine RMHP Rocky Mountain Health PlanABMS American Board of Medical Societies TRIA Tobacco Rapid Improvement ActivityABP American Board of PediatricsACP American College of PhysiciansAHRQ Agency for Healthcare Research and QualityAMA American Medical AssociationAQA Ambulatory Quality AllianceCAFP Colorado Academy of Family PhysiciansCCGC Colorado Clinical Guidelines CollaborativeCCM Chronic Care ModelCCNC Community Care of North CarolinaCMS Colorado Medical SocietyCMS Centers for Medicare and Medicaid ServicesEHR Electronic Health RecordEMR Electronic Medical RecordEPIC Enhancing Practice, Improving CareFPM Family Practice Management HIT Health Information TechnologyICIC Improving Chronic Illness CareIHI Institute for Healthcare ImprovementIOM Institute of MedicineIPIP Improving Performance in PracticeISS Interactive Survey SystemNCAFP North Carolina Academy of Family PhysiciansNCQA National Committee for Quality AssuranceNICHQ National Initiative for Children’s Health Care QualityNIH National Institute of HealthNQF National Quality Forum PBM Pharmacy Benefit Management companyPCM Planned Care ModelPDSA Plan Do Study ActPHR Personal Health RecordPPC Physician Practice ConnectionsPPC-PCMH Physician Practice Connections─Patient-Centered Medical HomeQI Quality Improvement

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PPC-PCMH STANDARDS AND SCORING

Of the 30 elements in PPC-PCMH, 10 are Must Pass, that is, elements that a practice Must Pass at 50% or greater score to achieve Recognition. Practices that achieve less than 5 Must Pass elements receive a Not Recognized status. If there is a difference in Level achieved for the number of points and the Must Pass elements, the practice will be awarded the lesser level. For example, if a practice has 65 points but passes only 7 Must Pass Elements, the practice will achieve Level 1 Recognition.

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PCMH Elements by HIT TypeBasic Intermediate Advanced

PPC 1 A - B PPC 2 B, C, F PPC 6 BPPC 2 A, D, E PPC 5 A - C PPC 8 FPPC 3 A - E PPC 8 EPPC 4 A - B PPC 9 A - CPPC 6 APPC 7 APPC 8 A - DPractice can achieve a passing score on all Must Pass Elements with Basic Health Information Technology

Possible Status Number of Points Must Pass Elements at 50% Scoring Level

Recognized – Level III 75- 100 10 out of 10Recognized – Level II 50-75 10 out of 10Recognized – Level I 25- 50 5 out of 10Not Recognized 0 - 25 0 out of 10

 PPC 1Must Pass Actions for Point Person

Staff responsible

Ready for NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completed Total Points Element A x Yes No Yes No Yes NoElement B x Yes No Yes No Yes No PPC 2Element A Yes No Yes No Yes NoElement B Yes No Yes No Yes NoElement C Yes No Yes No Yes NoElement D x Yes No Yes No Yes NoElement E x Yes No Yes No Yes NoElement F Yes No Yes No Yes No PPC 3Element A x Yes No Yes No Yes NoElement B Yes No Yes No Yes NoElement C Yes No Yes No Yes NoElement D Yes No Yes No Yes NoElement E Yes No Yes No Yes NoPPC 4Element A Yes No Yes No Yes NoElement B x Yes No Yes No Yes NoPPC 5Element A Yes No Yes No Yes NoElement B Yes No Yes No Yes NoElement C Yes No Yes No Yes No PPC 6Element A x Yes No Yes No Yes NoElement B Yes No Yes No Yes No PPC 7Element A x Yes No Yes No Yes No PPC 8Element A x Yes No Yes No Yes NoElement B Yes No Yes No Yes NoElement C x Yes No Yes No Yes NoElement D Yes No Yes No Yes NoElement E Yes No Yes No Yes NoElement F Yes No Yes No Yes No PPC 9Element A Yes No Yes No Yes NoElement B Yes No Yes No Yes NoElement C Yes No Yes No Yes No

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PPC 1: Access and Communication 9 Points

Intent The practice provides patient access during and after regular business hours, and communicates with patients effectively.

Element 1A: What are your written policies for access and communication to your patients? Element 1B: Proof that shows your practice uses polices from 1A for patient access and communication.

Who will manage this standard?NCQA’s Example Sheet:- Standard1 examples from NCQA

PPC 1

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A x

Not started In process Done Not working on this

Yes Yes

B x Not started In process Done Not working on this

Yes Yes

Notes:

Element 1A: Access and Communication Processes Must Pass 4 Points The practice establishes in writing standards for the following processes to support patient access:

Do we have these factors in writing? Tools/ Resources needed Process Owner Due Date

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1. Scheduling each patient with a personal clinician for continuity of care

Yes No

Written policy for scheduling patients with a requested provider.

2. Coordinating visits with multiple clinicians and/or diagnostic tests during one trip

Yes No

Written procedures for staff for making appointments/ scheduling patient visit so that it is one trip to get the services they need.

3. Determining through triage how soon a patient needs to be seen

Yes No

Written policy for triage on what needs to been seen urgently.

4. Maintaining the capacity to schedule patients the same day they call

Yes No

Measuring capacity tool

5. Scheduling same day appointments based on practice's triage of patients' conditions

Yes No

Procedures

6. Scheduling same day appointments based on patient's/family's requests

Yes No

Open Access Article

7. Providing telephone advice on clinical issues during office hours by physician, nurse or other clinician within a specified time

Yes No

8. Providing urgent phone response within a specific time, with clinician support available 24 hours a day, 7 days a week

Yes No

Policy on returning urgent calls

What is your after hour’s coverage? Sending to ER doesn’t meet standard.

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9. Providing secure e-mail consultations with physician or other clinician on clinical issues, answering within a specified time

Yes No Policy on checking e-mail

If using, website for appt, rx refill, test results, etc… what is your policy?

Tool: RMD if your EMR doesn’t have this functionality

10. Providing an interactive practice Web site Yes No

If using, website for appt, rx refill, test results, etc… what is your policy?

Tool: RMD if your EMR doesn’t have this functionality

11. Making language services available for patients with limited English proficiency

Yes No

PPC 4A asks similar communication question.

You don’t have to have policy on this factor. You just have to make a notation in the Support Test/Notes Box.What percent of your practice have limited English proficiency?Do you have bilingual staff? Resources: Language lines (AT&T, Sprint..)

12. Identifying health insurance resources for patients/families without insurance. Yes

No

What is the nearest CHC? Safety net clinic?What the phone number for Medicaid/ Medicare?

Examples Data source: Written procedures for staff for appointments, triage and patient communication; log or schedule to demonstrate capacity (Item 3).

Tools/ Resources

1. Policies and Procedures (chapter 3) MGMA’s - Operating Policies and Procedures: Manual for Medical Practices by Elizabeth Woodcock.

(MGMA Member $135, Joint MGMA-ACMPE member , MGMA affiliate $162.00 , Non-member $211.00) Practice Access Policies (examples) – (click_here)

2. Measuring Demand and Capacity What Works, Effective Tools & Case Studies To Improve Clinical Office Practice by Sue Houck. HealthPress Publishing, 2004, chapters 3 and 7. Same Day Appt Tally Sheet (Word doc) ( click_here)

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Same Day Appt Spreadsheet (Excel doc) (click_here) Open Access (Same Day Appts) Introduction (click_here) Open Access Preparation (click_here) Open Access Implementation (Instructions and Insights) (click_here)

Murray MD, Mark. Same Day Appointment: Exploding the Access Paradigm. FPM 2000 (click here)

IHI’s Demand and Capacity Diagnostic Tool (click here) IHI.org - Shortening Waiting Times: Six Principles for Improved Access (click here)

3. Health Insurance Resources of Patients/ Families without insurance Community Health Centers/ Safety Net Clinics –

i. Community Resources Toolkit (http://www.pediatricmedhome.org/section3/step1/popup_resource_list.aspx )4. Language Resources

NC Professional Interpreters Association - http://ncpiaonline.org/ AT&T’s Language Line (http://www.languageline.com/page/industry_healthcare ) HealthTranslations.com (http://www.healthtranslations.com/ )

5. RMD – Activation of all of the RMD features ( click here )

6. Practice Examples

PCMH 1A1 (PCMH1A1) – Scheduling Policy

PCMH 1A2 (Lakeside FP – One Stop Shop – Referral Policy) – Coordinating Care

PCMH 1A3,5 (Lakeside FP – Triage Policy) – Triage Policy

PCMH 1A4 (PCMH1A4) – Advanced Access

PMCH 1A1,4,6 (Lakeside FP – Open Access Policy) – Open Access

PCMH 1A7 (Lakeside FP – Phone Note Policy) – Phone Policy

PCMH 1A8 (Lakeside FP – On-call Policy) – On-call Policy

PCMH 1A10, 11 (PCMH 1A10, 11) – Language and Web-based Services

PCMH 1A11 (Lakeside FP – Guide to Interpreter Services) – Interpreter Services

PCMH 1A12 (Lakeside FP – Patient Advocacy Policy) – Patient Advocacy Policy

PCMH 1A12 (Lakeside FP – Financial Assistance Policy) – Financial Assistance Policy

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Percentage Min. score to pass Our Score100% Practice has written processes for 9 -12 items75% Practice has written processes for 7 - 8 items50% Practice has written processes for 4 - 6 items X25% Practice has written processes for 2 – 3 items0% Practice has written processes for 0 - 1 items

Further Examples/Notes:

Telephone/Email Response Policy (click here )Scheduling, Same Day Appts, Triage, Care Coordination Policy (click here )Access and communication Policy (click here )Care Coordination between PCP and Specialist Policy (click here )Practice Access and Communication Policies 2 ( click here)Patient Portal Policies (click here ) or (click here)

Element 1B: Access and Communication Results Must Pass 5 Points The practice's data shows that it meets access and communication standards in 1A:

What needs to happen? Tools/ Resources Process Owner

Due Date

1. Visits with assigned personal clinician for each patient

Not started In process Done Linked Patient Feedback Card

2. Appointments scheduled to meet the standards in Items 2-6 in 1A

Not started In process Done Linked Excel Pt. Feedback Tracking sheet

Logs

3. Response times to meet standards for timely response to telephone requests

Not started In process Done Linked Patient Feedback Card

4. Response times to meet its standards for timely response to e-mail and interactive

Not started In process Done Linked can exclude patient that don’t have email

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Web requests 5. Language services

for patients with limited English proficiency.

Not started In process Done Linked can mark NA if language services aren’t required

Examples

Tracking reports, either paper or screen shots, showing records for a period of appointments with personal clinicians, average wait for appointments, average time for returning telephone calls and emails.

Visits with assigned physician Timely response to phone, e-mail and Internet requests Language services if the practice’s population requires it

Tools/ Resources

1. Patient Satisfaction Survey Patient Feedback Card (click here) & Excel Tracking Sheet ( click here) For a more in-depth survey (click here )For making sure patients are being seen in a timely manner use the Patient Cycle Tool (click here )2. Logs

3rd next available appointment, no show, telephone response time, # of same day appointments available, fill rate, ..etc (click here) Also see below for more examples. Open Access information - https://www.aap.org/visit/keymeasures.htm Supply Demand worksheet - click here For an example ( click here)

3. Reports from “How’s your Health” www. howsyourhealth .org 4. Article:- Getting the most of your phone system (click here )5. Panel Size How Many Patients Can a Provider Handle (click here )

Percentage Min. score to pass Our Score100% Practice data meets 5 items75% Practice data meets 4 items50% Practice data meets 3 items X25% Practice data meets 2 items0% Practice data meets 0-1 items

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Practice Examples/Notes:

PCMH 1B1 – Personal Physician (..\Practice Examples\Lakeside FP\PPC1B-1-LO Personal Clinician.pdf ) ( ..\Practice Examples\Elizabeth FP\1B_1_Elizabeth[1].pdf)

PCMH 1B2 – Same Day Log (..\Practice Examples\Lakeside FP\PPC1B-2 Same Day Log LO.pdf ) ( ..\Practice Examples\Lakeside FP\PPC1B-2-LO-Minimized-Trips.pdf) (..\Practice Examples\Lakeside FP\PPC1B-2-LO-Same Day Appointment Scheduled.pdf ) (..\Practice Examples\Elizabeth FP\1B_2_Elizabeth_Family.pdf )

PCMH 1B3 – Language Services (..\Practice Examples\Lakeside FP\PPC1B-5-LO-Language Services.pdf ) (..\Practice Examples\Elizabeth FP\1B_5_Elizabeth[1].pdf ) ( LanguageServicesPolicy)

PCMH 1B5 – Phone Turn-Around Time ( ..\Practice Examples\Lakeside FP\PPC1B-3 LO Phone Note.pdf) (..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log LO.pdf ) (..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log Summary.pdf ) (..\Practice Examples\Elizabeth FP\1B_3_Elizabeth.pdf )

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PPC 2: Patient tracking and Registry Functions 21 Points The practice systematically manages patient information and uses the information for population management to support patient care.

Intent The practice has readily accessible, clinically useful information on patients that enables it to treat patients comprehensively and systematically.

Element 2A: The practice has the ability to query basic patient demographic informationElement 2B: The report from the query in 2AElement 2C: The practice has the ability to query & report patient clinical informationElement 2D: Flowsheet and/ or templates used to organize and document clinical information such as problem lists, medication lists, and risk factorsElement 2E: For patients that have Diabetes, CVD, and Low back pain, can your practice identify: # of patient with condition, # of visits, total fees billed or cost associated with the risk factorElement 2F: Practice uses electronic information to generate lists of patients and remind patients and clinicians of services needed

Who will manage this standard?NCQA’s Example Sheets:- Standard2summaryNCQA , Standard2A2 , Standard2D1 , Standard2D2

PPC 2

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completed Total Points

A

B

C

D X

E X

FNotes:

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Element 2A: Basic System for Managing Patient Data 2 Points The practice uses an electronic data system for patients that includes the following searchable patient information:

Can we search by this field? If no, what needs to happen? Process

Owner Due Date

1. Name Yes No

2. Date of birth Yes No

3. Gender Yes No

4. Marital status Yes No NA

5. Language preference Yes No

6. Voluntarily self-identified race/ethnicity Yes No

7. Address Yes No

8. Telephone (primary contact number)

9. E-mail Address (or “none” for pts) Yes No

10. Internal ID Yes NoYour internal tracking number (ie Chart #)

11. External ID Yes No

12. Emergency contact information Yes No

13. Current and past diagnoses Yes No

14. Dates of previous clinical visits Yes No

15. Billing codes for services Yes No

16. Legal guardian Yes No NA

17. Health insurance coverage Yes No

18. Patient/family preferred method of communication. Yes No

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Examples Reports from electronic systemsTools/ Resources/ Tips

You need to have numerators and denominators for this factor You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document A report of patients seen in the last 3 months that have these fields completed.

o Practices with EMRs it might be helpful to contact your vendor to run this report.o Think of factors that are “required” fields.

Percentage Min. score to pass Our Score100% 12-18 items were entered for 75 -100% of patients75% 8-11 items were entered for 75 -100% of patients50% 6-7 items were entered for 75 -100% of patients X25% 4-5 items were entered for 75 -100% of patients0% 0-3 items were entered for 75 -100% of patients

Practice Examples/Notes:

PCMH 2A – Demographic Data Management ( ..\Practice Examples\Lakeside FP\PPC2A Managing Patient Data Summary.pdf) ( ..\Practice Examples\Lakeside FP\PPC2A-9-Email Capacity.pdf) (..\Practice Examples\Elizabeth FP\2A_Elizabeth_Family.pdf )

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Element 2B: Electronic System for Clinical Data 3 PointsThe practice’s clinical data system or systems to manage care of patients include the following clinical patient information in searchable data fields:

Can we search by this field? If no, what needs to happen? Process

Owner Due Date

1. Status of age-appropriate preventive services (immunizations, screenings, counseling)

Yes No

2. Allergies and adverse reactions Yes No

3. Blood pressure Yes No

4. Height Yes No

5. Weight Yes No

6. Body mass index (BMI) calculated

(Under 18- BMI is percentile plotted on growth chart)

Yes No

7. Laboratory test results Yes No

8. Presence of imaging results Yes No

9. Presence of pathology reports Yes No

10. Presence of advance directives. Yes No

11. Head circumference for patients 2 years or younger Yes No NA

Examples Screen shots or reports showing fields in patient records. Where applicable, these fields may show that the patient has no allergies or lab or imaging tests.

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Tools/ Resources/ Tips

For items 7-10, data may indicate the presence of a written report not in the system Website for head circumference and growth charts from CDC: http://www.cdc.gov/GrowthCharts/ Website for advanced directives for NC residents: http://www.caringinfo.org/files/public/ad/NorthCarolina.pdf

Percentage Min. score to pass Our Score100% System has 9 – 11 data fields75% System has 7 - 8 data fields50% System has 5 - 6 data fields25% System has 3 - 4 data fields X0% System has 0 - 2 data fields

Examples/Notes:

Website for EHR and meaningful use with examples of some of the above data fields: http://boltwebsolutions.com/clients/UniEHR/UniEHRUsersGuidetoMeaningfulUse.pdf (This does not constitute any endorsement of any particular EHR program)

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Element 2C: Use of Electronic Clinical Data 3 PointsThe practice uses the fields listed in 2B consistently in patient records.

Factors from 2BWhat is our percentage of these measures for patients see in the last 3 months?

Tools Process Owner Due

Date

1. Status of age-appropriate preventive services (immunizations, screenings, counseling)

Report from your EMR

orNCQA Excel Spreadsheet

Please note: This is a read-

only example for educational

purposes. Use your RRWB from NCQA Survey Tool.

2. Allergies and adverse reactions 3. Blood pressure 4. Height 5. Weight 6. Body mass index (BMI) calculated 7. Laboratory test results 8. Presence of imaging results 9. Presence of pathology reports 10. Presence of advance directives. 11. Head circumference for patients 2 years or younger

Examples Reports from electronic systemsTools/ Resources You need to have numerators and denominators for this factor.

This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it easier on your practice You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document A report of patients seen in the last 3 months that have these fields completed.

o Practices with EMRs it might be helpful to contact your vendor to run this report. If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.

o 1st have screen shots of where the information is enteredo 2nd use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make

it easier on your practice) For an educational PPT on the use of your RRWB ( click here)Percentage Min. score to pass Our Score

100% 75 -100% of patients seen in last 3 months have at least 7 fields completed75% 50 - 74% of patients seen in last 3 months have at least 7 fields completed50% 25 – 49% of patients seen in last 3 months have at least 7 fields completed25% 10 - 24% of patients seen in last 3 months have at least 7 fields completed X0% Less than 10% of patients seen in last 3 months have at least 7 fields completed

Notes:

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Element 2D: Organizing Clinical Data Must Pass 6 PointsThe practice uses the following electronic or paper-based charting tools to organize and document clinical information in the medical record:

Do you currently have a place in your chart (paper or electronic) for these items? Tools

Process Owner Due Date

1. Problem lists Yes No

Flowsheets, templates or screen shots Yes No

Report from your EMR

or NCQA Excel Spreadsheet

Please note: This is a read-only

example for educational purposes. Use your

RRWB from NCQA

Survey Tool.

2. Lists of over-the-counter medications, supplements and alternative therapies

Yes No

Flowsheets, templates or screen shots Yes No

3. Lists of prescribed medications including both chronic and short-term

Yes No

Flowsheets, templates or screen shots Yes No

4. Structured template for age-appropriate risk factors (at least 3)

Yes No

Risk #1:__________ ___Flowsheets, templates or screen shots Yes NoRisk #2:_____________ Flowsheets, templates or screen shots Yes No Risk #3:_____________ Flowsheets, templates or screen shots Yes No

5. Structured templates for narrative progress notes

Yes No

Flowsheets, templates or screen shots Yes No6. Age appropriate standardized screening tool for developmental testing

Yes No

Flowsheets, templates or screen shots Yes No7. Growth charts plotting height, weight, head circumference and BMI, if less than 18 years.

Yes No

Flowsheets, templates or screen shots Yes No

Examples Medical record review or system report showing percent of patients seen in past 3 months with information documented in at least 3 charting tools

Tools/ Resources

Screen shots of templates/ flowsheets that contain these data fields in your chart or EMR. You need to have numerators and denominators for this factor. This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it easier on your practice You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document A report of patients seen in the last 3 months that have these fields completed.

o Practices with EMRs it might be helpful to contact your vendor to run this report. If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.

o 1st have screen shots of where the information is entered

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o 2nd use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make it easier on your practice) For an educational PPT on the use of your RRWB ( click here)

Percentage Min. score to pass Our Score100% 75 -100% of patients seen in last 3 months have at least 3 tools with information documented.75% 50 - 74% of patients seen in last 3 months have at least 3 tools with information documented.50% 25 – 49% of patients seen in last 3 months have at least 3 tools with information documented. X25% 10 - 24% of patients seen in last 3 months have at least 3 tools with information documented.

0% Less than 10% of patients seen in last 3 months have at least 3 tools with information documented.

Examples/Notes:

Another example of the PCC-PCMH workbook from Elizabeth FP (click here)Another example of the PCC-PCMH workbook from Lakeside FP (click here)

Examples of screen shots: Adult Weight Screening Allergy List Clinical Quality Measures - Vaccinations Problem List Weight/BMI, Blood Pressure charts (less than 21 years old) – (click here)Growth Charts - (click here)Developmental Surveillance and Screening Policy Implementation Project (D-PIP) (click here)Developmental Screening Toolkit (click here)Birth and Development ( click here)Development Screening Algorithm (click here)Early Intervention Referral Form (click here)Medication Reconciliation Form (click here)Patient Meds, Supplements Form (click here)

Element 2E: Identifying Important Conditions Must Pass 4 PointsThe practice uses an electronic or paper-based system to identify the following diagnoses and conditions:

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Can you run a report in your billing system or your EMR to get the following information?

Tools/ Resources

needed

Process Owner

Due Date

1. Practice’s most frequently seen diagnoses

Dx practice sees most often may include single episode conditions (colds, UTI, or chronic conditions).

o # of patients with condition/ problem/ risk factors

o # of visits for the condition or problemso High cost (billed) conditions, problems, or

risk factors

Reports from billing/ Practice management system, or EMR

2. Most important risk factors in the practice’s patient population

Community based demographic characteristics

3. Three conditions that are clinically important in the practice’s patient population.

Chronic or recurring condition practice seeso Most patients, visits, greatest cost,

amendable to care managementExamples Reports from EHR, PM system, billing system or scheduling system to query patients with Diabetes, Hypertension and Hyperlipidemia.

Tools/ Resources

1. Examples might be: Diabetes, Low Back Pain, and Cardiovascular Disease as the 3 clinically important conditions for the practices.

2. In the Support Text/Notes the practice states, the three clinically important conditions. Either in a document or in the Support Text box the practice explains or shows the data used to select the conditions. The clinically important conditions are chronic or recurring conditions that the practice sees such as otitis media, asthma, diabetes or congestive heart failure.

Wording for “Support Text/ Notes” on the PPC-PCMH Interactive Survey System - As part of a National PCMH Demonstration Project and in collaboration with NCQA, the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia as Clinically Important Conditions which represent the best likelihood of being amenable to care management and providing value on costs to the health care system based on regional experience. These conditions have associated required metrics which will be reported by the physician practices as part of the National PCMH Demonstration Project. Some practices may chose to exchange one of the clinically important conditions with a condition that meets the standards established on page 19 of the PPC-PCMH Standards and Guidelines.

Percentage Min. score to pass Our Score100% Practice identifies 3 items75% Practice identifies 2 items50% Practice identifies 1 items X25% No scoring option0% Practice identifies 0 items

Examples/Notes: (Community Based Demographics – Stanly County ) (State of the County Report Stanly County ) – there are usually reports available for all counties in NC

( Top 15 Diagnoses – Elizabeth FP)

(Community Health Risks – Elizabeth FP )

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( 2E3 - 3Top Health Conditions – Elizabeth FP)

(2E2 – BRFSS Report Adult – Elizabeth FP )

Element 2F: Use of System for Population Management 3 PointsThe practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed, as follows:

What is our current status?What needs to happen? Tools/ Resources needed

ProcessOwner Due Date

1. Patients needing pre-visit planning (obtaining tests prior to visit, etc.)

Flowsheets, templates or screen shots Yes No

EMR/RMD Flowsheet & CarePlan screen

2. Patients needing clinician review or action

Flowsheets, templates or screen shots Yes No

EMR/RMD Flowsheet & CarePlan screen

3. Patients on a particular medication Flowsheets, templates or screen shots Yes No

4. Patients needing reminders for preventive care

Flowsheets, templates or screen shots Yes No

EMR/RMD Flowsheet & CarePlan screen

5. Patients needing reminders for specific tests

Flowsheets, templates or screen shots Yes No

RMD Patient handout

6. Patients needing reminders for follow-up visits such as for a chronic condition

Flowsheets, templates or screen shots Yes No

Screen shot of reminder email to patients/ copy of letters to patients

7. Patients who might benefit from care management support.

Flowsheets, templates or screen shots Yes No

Examples The practice provides computerized reports or screen shots and one of the following two options showing use of information in the reports: A written description of the process Examples of use of the reports (see the bulleted list in the details).

Identify all patients who are taking a medication for which the practice received a warning.

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Identify all patients with ischemic vascular disease not taking appropriate medication. Identify all children with developmental delay Identify all children and adolescents with asthma Identify all women over 50 who are due for a mammogram Identify all adult patients with elevated LDL for whom appropriate medication has not been prescribed

Tools/ Resources

1. Lists generated -- reports from EHR, registries, billing systems2. RMD

a. Guideline at Point of Service (Care Plan)b. List of patients (click here)c. Population management reports (RMD Diabetes Summary Report) d. Patient handout e. DM Flowsheet , Prevention Flowsheet

Percentage Min. score to pass Our Score100% Practice used information to take action on 5 – 7 items75% Practice used information to take action on 3 – 4 items50% Practice used information to take action on 1 - 2 items X25% No scoring option0% Practice does not use information to take action

Examples/Notes:

PCMH 2F1 - ( ..\Practice Examples\Lakeside FP\PPC2F-1 Previsit Planning.pdf)PCMH 2F1,2,7 – (..\Practice Examples\Lakeside FP\PPC2F-1,2,7 Heart and Wellness Report.pdf )PCMH 2F2,7 – ( ..\Practice Examples\Lakeside FP\PPC2F-2,7 DSME Report Sentout.pdf)PCMH 2F2,7 ( ..\Practice Examples\Lakeside FP\PPC2F-2,7 Population Mngmt H&W Path.pdf)PCMH 2F2,7 – (..\Practice Examples\Lakeside FP\PPC2F-2,7-DSME Report Inhouse.pdf )PCMH 2F4 – (..\Practice Examples\Lakeside FP\PPC2F-4 Preventive Reminder Report.pdf )PCMH 2F4,5 – (..\Practice Examples\Lakeside FP\PPC2F-4,5 Primary Preventive Care.pdf )PCMH 2F4,5,6 - ( ..\Practice Examples\Lakeside FP\PPC2F-4,5,6 Reminder Call.pdf)PCMH 2F5 – (..\Practice Examples\Lakeside FP\PPC2F-5 HgA1C Reminder Report.pdf )PCMH 2F6 – (..\Practice Examples\Lakeside FP\PPC2F-6 Chronic Condition Reminder Report.pdf )PCMH 2F6 – ( ..\Practice Examples\Lakeside FP\PPC2F-6 Flu Vaccination Reminder Report.pdf)

Example of a Pre-visit Contact form ( Previsit Contact Form)PCMH 2F7 - (ChronicPainManagementFlowsheet )

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PPC 3: Care Management 20 PointsThe practice systematically manages care for individual patients according to their conditions and needs, and coordinates patients' care.

Intent The practice maintains continuous relationships with patients by implementing evidence-based guidelines and applying them to the identified needs of individual patients over time and with the intensity needed by the patients.

• Element 3A: The practice has evidence based clinical guidelines and is used.• Element 3B: Practice uses paper or electronic guideline-based alerts and reminders for providers to write orders and conduct assessments when seeing

patients• Element 3C: Practice uses non-physician staff to manage patient care• Element 3D: Practice has a care management plan for patients with clinically important conditions• Element 3E: Practice coordinates care and follow up for patients who receive care in inpatient and outpatient facilities

Who will manage this standard?

NCQA’s Example Sheet:- Standard3

PPC 3

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completed Total Points

A X

B

C

D

ENotes:

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Element 3A: Guidelines for Important Conditions Must Pass 3 PointsThe practice adopts and implements evidence-based diagnosis and treatment guidelines for:

What is our current status? What needs to happen? Tools/ Resources

needed Process Owner

1. First clinically important condition 2. Second clinically important condition 3. Third clinically important condition.

Examples Workflow organizers, which demonstrate both adoption and implementation of guidelines by the practice. Paper-based organizers–algorithms for developing treatment plans, flow sheets or templates for documenting progress. Electronic system organizers (registry, EHR or other system)–screenshots showing templates for treatment plans and documenting

progress. Tools/ Resources

1. Provide source of guidelines – link takes you to HealthTeamWorks website, then click on guidelines. Other resources are available there as well.

a. Diabetes { CCGC Diabetes Guidelines} b. CVD { CCGC CVD/Stroke Prevention Guidelines} c. Prevention { CCGC Prevention Guidelines} d. Depression { CCGC Depression Guidelines) e. Asthma { CCGC Asthma Guidelines } f. Low Back Pain { ICSI Guidelines for low back pain)

2. The links below take you to AAP’s National Center for Medical Home Implementation for Guidelines, Tools, Registry, and Protocolsa. ADHD (NCMHI ADHD Guidelines)b. Asthma (NCMHI Asthma Guidelines)c. Childhood Obesity (NCMH IChildhood Obesity Guidelines)d. Special Needs Children (NCMHI Special Needs Children Guidelines)e. Gastroenteritis (NCMHI Gastroenteritis Guidelines)f. Safe and Healthy Beginnings/Hyperbilirubinemia (NCMHI Healthy Beginnings Guidelines)

3. Paper flow sheets, templates for documenting progress a. Diabetes { Diabetes flowsheet version 1}, { Diabetes Flowsheet Version 2}b. CVDc. Prevention { CCGC Prevention Flowsheet ) d. Depression {CCGC Depression Flowsheet--Adult}e. Asthma { CCGC Asthma Flowsheet }f. Low Back Pain

4. Screen shots showing templates/ flowsheets for treatment plans and documenting progress.Percentage Min. score to pass Our Score

100% Practice implements guidelines for 3 conditions75% No scoring options50% Practice implements guidelines for 2 conditions X25% Practice implements guidelines for 1 conditions0% Practice does not implements guidelines for any conditions

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Examples/Notes:PCMH 3A,D - (..\Practice Examples\Lakeside FP\PPC3A,D NCQA Slide.pdf )PCMH 3A,D - (..\Practice Examples\Lakeside FP\PPC3A,D NCQA Clinical Outcome Data.pdf )PCMH 3A1 - ( ..\Practice Examples\Lakeside FP\PPC3A-1-DXA Pathway.pdf)PCMH 3A1 – (..\Practice Examples\Elizabeth FP\PPC_3A_1_diab_adult.doc )PCMH 3A2 - ( ..\Practice Examples\Lakeside FP\PPC3A-2-DSME Pathway.pdf)PCMH 3A2 – (..\Practice Examples\Elizabeth FP\PPC_3A_2_Asthma_adult_and_peds.pdf )PCMH 3A3 – ( ..\Practice Examples\Lakeside FP\PPC3A-3-H&W Path.pdf)Asthma Toolkit (Asthma Management Toolkit )Diabetes Toolkit (Diabetes Management Toolkit )Mental Health/Substance Abuse Toolkit (Mental Health/Substance Abuse Toolkit )

Element 3B: Preventive Service Clinician Reminders 4 PointsThe practice uses a paper-based or electronic system with guideline-based reminders for the following services when seeing the patient:

What is our current status? What needs to happen? Tools/ Resources

neededProcess Owner

1. Age-appropriate screening tests

2. Age-appropriate immunizations (e.g., influenza, pediatric) 3. Age-appropriate risk assessments (e.g., smoking, diet, depression) 4. Counseling (e.g., smoking cessation).

Examples Reports, screen shots or paper flow sheets showing how the reminders are available to clinicians during the visit Documentation from an electronic system may include reports or screen shots. Documentation from a paper-based system may include templates, flow sheets, algorithms or reminders. The practice must show that its clinicians have available decision support for interactions with patients including in-person appointments,

telephone calls and e-mail communication.Tools/ Resources/ Tips

1. Paper based practices: Flowsheet/ template that reminds providers to check for risk assessments, immunizations, screening tests.a. Example: Incorporation of flowsheet use detailing prevention activities and when due { CCGC Prevention Flowsheet }

2. Electronic based practices: screen shot of health maintenance screen.

3. Example of a Health Risk-Maintenance Questionnaire ( click here)

Percentage Min. score to pass Our Score100% Practice uses reminders for 4 items75% Practice uses reminders for 3 items50% Practice uses reminders for 2 items X25% Practice uses reminders for 1 items0% Practice uses reminders for no items

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Examples/Notes:

PCMH 3B1,2,3,4 – ( ..\Practice Examples\Lakeside FP\PPC3B-1,2,3,4 LO BS.pdf)PCMH 3B2 – ( ..\Practice Examples\Lakeside FP\PPC3B-2-Vacc Reminders.pdf)For guidelines for immunizations for men (click here) For guidelines for immunizations for women (click here) National Newborn Screening Test Report (click here)Pediatric/Youth Symptom Checklist (click here)Self-Assessment – Tobacco, Activity, Diet (click here)Fitness screening tool – (click here)Fitness screening tool (Spanish) – (click here)Behavioral Health Assessment – Diabetes – (click here )Depression Screening Tool (PHQ-9) in English – (click here )Depression Screening Tool (PHQ-9) in Spanish – (click here )

Element 3C: Practice Organization 3 PointsThe care team manages patient care in the following ways:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

1. Non-physician staff remind patients of appointments and collect information prior to appointments

Peds Ex: ( click here)Adult Ex: ( click here)

2. Non-physician staff execute standing orders for medication refills, order tests and deliver routine preventive services

See below

3. Non-physician staff educate patients/families about managing conditions

See below

4. Non-physician staff coordinates care with external disease management or case management organizations.

Local Agency Referral Form (click here )

Examples Job descriptions, protocols, written standing ordersTools/ Resources/ Tips

1. Team-Based Care: Using Huddlesa. Huddle video (http://www.youtube.com/watch?v=Wttxm7jAnb4)b. Article: Stewart, EE et. al. (2007). Huddles Improve Office Efficiency in Mere Minutes. FPM. { Article } c. Huddle worksheet {click here }d. Article: Bodenheimer, T. et al. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine (5):457- 461. { PDF}

2. Job Descriptions a. Article: Capko. (2007). Get Better Results with Staff Performance Standards. FPM. { PDF }

3. Protocols

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Examples of diabetes clinical protocols addressing glycemic control (medications), cardiovascular risk reduction, and health maintenance/disease prevention. (http://www.med.unc.edu/im/staff/clinic/programs/diabetes/protocols?searchterm=None )4. Standing Orders

a. Example of interactive page to set-up diabetes standing orders {ACP Diabetes Standing Orders}b. Immunization standing orders {Immunization Action Coalition Standing Orders--weblink}c. Article: Escobedo. (2002). Rethinking Refills. FPM {article PDF} Refill Protocol from the Article ( click here) (some Medication(s) on

this list like Salmeterol and Serzone may need to be removed. Please review the list before using this protocol)Percentage Min. score to pass Our Score

100% Staff manages 4 items75% Staff manages 3 items50% Staff manages 2 items X25% No scoring options0% Staff manages 0-1 items

Examples/Notes: PCMH 3C1-4 – (..\Practice Examples\Lakeside FP\PPC3C-1-4 DSME Pathway.pdf )PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Med Refill Standing Order AV, LO, SP.pdf )PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Standing O Flu LO.pdf )PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Standing O Imaging LO.pdf )PCMH 3C2-4 – ( ..\Practice Examples\Lakeside FP\PPC3C-2,3,4 DXA Pathway.pdf)PCMH 3C – ( ..\NCQA\2011-05 (May)\PCMH3CRRWB.pdf)Standing Orders Example – (click here )Standing Orders Example – ( click here)Partnering in Self-Management Support – A Clinician’s Toolkit - (click here )Diabetes Initiative – Tremendous website for all kinds of tools for diabetes management for clinicians and staff – (click here )Diabetes Self-Management Tool – Spanish – (click here )NC Centers for Hospice and End of Life Care (click here)

Element 3D: Care Management for Important Conditions 5 PointsFor the three clinically important conditions, the physician and non-physician staff use the following components of care management support:

What is our current status?What needs to happen?

Tools/ Resources needed

Process Owner Due Date

1. Conducting pre-visit planning with clinician reminders NCQA Excel Spreadsheet

Please note: This is a read-only example

for educational purposes. Use your RRWB from NCQA

Survey Tool.

2. Writing individualized care plans 3. Writing individualized treatment goals 4. Assessing patient progress toward goals 5. Reviewing medication lists with patients 6. Reviewing self-monitoring results and incorporating them into the medical record at each visit 7. Assessing barriers when patients have not met treatment goals 8. Assessing barriers when patients have not filled, refilled or

32

taken prescribed medications 9. Following up when patients have not kept important appointments 10. Reviewing longitudinal representation of patient’s historical or targeted clinical measurements11. Completing after-visit follow-up

Examples Medical record showing the components of care management• Patient record shows Care plans, treatment goals, progress assessments, review of home monitoring results, barriers addressed

Item descriptors:2. Written care plan—addresses respective responsibilities of the medical home and specialists the patient is referred to.7-8. Barriers—include the patients’ lack of understanding, motivation, financial need, insurance issues, or transportation problems.9. Important appointments—those that the practice has requested be made in order to follow standards of care.10. Longitudinal patient data—Graphs or flowsheets showing clinical measures (LDL, BP, wt.) over time. 11. After visit follow-up—Examples may include checking to see if the patients filled a prescription or received care by the referred consultant.

Tools/ Resources

1. NCQA Medical Record Review Worksheet or report from electronic system showing percent of patients seen with at least 4 care management processes documented Screen shots of templates/ flowsheets that contain these data fields in your chart or EMR. You need to have numerators and denominators for this factor. This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it easier on your practice You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document A report of patients seen in the last 3 months that have these fields completed.

o Practices with EMRs it might be helpful to contact your vendor to run this report. If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.

o 1st have screen shots of where the information is entered2nd use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make it easier on your practice) For an educational PPT on the use of your RRWB ( click here)

2. Diabetes sick day management http://www.mayoclinic.com/health/diabetes-management/DA00110 3. Copy of RMD’s Patient handout

4. Patients using RMD’s patient portal - www.reachmydoctor.com , Example Portal Policy (click here ) or (here)

5. Self-Management Task Communication Log {PDF}

6. NC Health and Wellness Trust Fund - http://www.healthwellnc.com/ 7. Develop and refine motivational interviewing skills—

a. NC Practice Improvement Collaborative http://www.ncpic.net/2010/what-is-motivational-interviewing/ b. Motivational Interviewing Roadmap { http://www.healthteamworks.org/guidelines/motivational-interviewing.html }

8. Consider “Teamlet” Model of Care—Health Coaches – see abovePercentage Min. score to pass Our Score

100% 75% of more of patients seen in the past 3 months have at least 4 items documented75% 50 – 74% of more of patients seen in the past 3 months have at least 4 items documented50% 25 – 49 % of more of patients seen in the past 3 months have at least 4 items documented X

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25% 11 – 24 % of more of patients seen in the past 3 months have at least 4 items documented0% Less than 10% of patients seen in the past 3 months have at least 4 items documented

Examples/Notes:

PCMH 3D – (..\NCQA\2011-05 (May)\PCMH3DMedManagement.pdf )Pre-appointment Questionnaire – (click here)Previsit Contact Form ( click here)Action Plan to help patients prioritize problems ( click here)Family Centered Care Coordination Worksheet - (click here )Pediatric Care Plan - ( click here)Post Visit Survey - (click here )Medication List for staff to review with Patients (click here )Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS) (click here )Missed Appt Letter Examples (click here )Goals and Promises Worksheet (click here )Early Intervention Referral Form (click here )Guidelines and Treatment of Pediatric Obesity ( click here)

Element 3E: Continuity of Care 5 PointsThe practice on its own or in conjunction with an external organization engages in the following activities for patients who receive care in inpatient or outpatient facilities or patients who are transitioning to other care:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner Due Date

1. Identifies patients who receive care in facilities 2. Systematically sends clinical information to the facilities with patients as soon as possible 3. Reviews information from facilities (discharge summary or ongoing updates) to determine patients who require proactive contact outside of patient-initiated visits or who are at risk for

34

adverse outcomes 4. Contacts patients after discharge from facilities 5. Provides or coordinates follow-up care to patients/families who have been discharged 6. Coordinates care with external disease management or case management organizations, as appropriate 7. Communicates with patients/families receiving ongoing disease management or high risk case management 8. Communicates with case managers for patients receiving ongoing disease management or high risk case management 9. For patients transitioning to other care, develops a written transition plan in collaboration with the patient and family 10. Aids in identifying a new primary care physician or specialists or consultants and offers ongoing consultation.

Examples May be from the practice itself or from an external case management organization such as a disease management organization with which the practice works. The data sources may include: Policies/protocols that include the practice’s timeframe for patient follow up after an admission or emergency room visit Policies/protocols for using care plans and patient visit flow sheets Printout from registry, EHR, hospital emergency room, admitting department or other computerized reports that include a list of identified patients, emergency room visits and inpatient admissions Paper or electronic communication forms/tools to use with external facility regarding patient clinical information. Manual or electronic patient health/needs assessments Blinded case management or medical record notes. Policies and medical record documentation detailing proactive outreach to patients receiving care at another facility (inpatient or outpatient) to ensure that the patient receives appropriate follow-up care. Follow-up care can include physician counseling and/or referrals to community resources, disease management programs, or self-management support programs.

Tools/ Resources 1. Screen shot of RMD’s CareNotes or CareTeam (click here) or (here)

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2. Example ER follow-up log (click here) or you can adapt the tracking log (click here )3. Care Transitions resources

• an HMO workgroup report on Care Management—excellent background information and resource to operationalize “Care Management” { click here }

• “The Care Transitions Program” affiliated with UCHSC: www.caretransitions.org• Relevant articles

• Sylvester, I. et al. (2008). Transforming your practice—what matters most. Family Practice Management, 15(1). (PDF)• Coleman, E. et al. (2004). Posthospital care transitions: Patterns, complications, and risk identification. Health Services Quality Research, 39(5): 1449-1466. {click here}

Percentage Min. score to pass Our Score100% Activities include 5 – 10 items75% Activities include 3 - 4 items50% Activities include 2 items X25% Activities include No scoring option0% Activities include 1 - 0 items

Examples/Notes: PCMH 3E1,3,4. In-patient List (..\Practice Examples\Lakeside FP\PPC3E-1,3,4 In-pt Patient List.pdf )PCMH 3E1-5 – (..\Practice Examples\Lakeside FP\PPC3E-1-5 Continuity of Care Policy.pdf )PCMH 3E2,10 - (..\Practice Examples\Lakeside FP\PPC3E-2,10 Referral Policy.pdf )PCMH 3E6,7,8 – ( ..\Practice Examples\Lakeside FP\PPC3E-6,7,8 DSME Pathway.pdf)PCMH 3E6,7,8 – (..\Practice Examples\Lakeside FP\PPC3E-6,7,8 DXA Pathway.pdf )PCMH 3E6,7,8 – (..\Practice Examples\Lakeside FP\PPC3E-6,7,8 H&W Pathway.pdf )PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7 DSME Care Plan.pdf )PCMH 3E7 – ( ..\Practice Examples\Lakeside FP\PPC3E-7 DXA Care Plan.pdf)PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7 H&W Care Plan.pdf )PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7_DXA_Care_Plan.pdf )PCMH 3E9 – (..\Practice Examples\Lakeside FP\PPC3E-9 Written Transition Plan.pdf )PCMH 3E1 – (..\Practice Examples\Elizabeth FP\3E_1_Elizabeth_Family.doc )PCMH 3E2 – (..\Practice Examples\Elizabeth FP\3E_2_Elizabeth_Family[1].docx )PCMH 3E2 – (..\Practice Examples\Elizabeth FP\3E_2a_ElizabethAdmissionOrders.pdf )PCMH 3E3 – (..\Practice Examples\Elizabeth FP\3E_3_Elizabeth_Family.doc )PCMH 3E4,5 – ( ..\Practice Examples\Elizabeth FP\3E_4and_5_Elizabeth_FamilyPostDCFollow.pdf)PCMH 3E6 – ( ..\Practice Examples\Elizabeth FP\3E_6_Elizabeth_FamilyReferralHomeHealth.pdf)PCMH 3E6,9 – ( ..\Practice Examples\Elizabeth FP\3E_6a_and_9_ElizabethDirueticProtocolCHF.pdf)PCMH 3E8 – (..\Practice Examples\Elizabeth FP\3E_8_Elizabeth_FamilyAmbulatoryFU.pdf )PCMH 3E – (..\NCQA\2011-05 (May)\PCMH3EDrugDrugInteractions.pdf )PCMH 3E – ( ..\NCQA\2011-05 (May)\PCMH3EGenericAlternatives.pdf)

PPC 4: Patient Self- Management Support 6 PointsThe practice works to improve patients' ability to self-manage health by providing educational resources and ongoing assistance and encouragement.

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Intent The practice collaborates with patients and families to pursue their goals for optimal achievable health.

• Element 4A: Practice assesses patient-specific barriers to communication including language preference and hearing and vision barriers• Element 4B: Practice documents self-management support activities in the patient record

Who will manage this standard?NCQA’s Example Sheet:- Standard 4

PPC 4

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A

B XNotes:

Element 4A: Documenting Communication Needs 2 Points The practice assesses patient/family-specific barriers to communication using a systematic process to:

What is our current status? What needs to happen? Tools/ Resources needed Process Owner

1. Identify and display in the record the language

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preference of the patient and family 2. Assess both hearing and vision barriers to communication.

Examples Documents that show how the practice records language preference (e.g., screen shots, patient assessment forms) and how the practice determines the percentage of its patients that prefer another language (e.g., reports from an electronic system, review of a sample of records).

Tools/ Resources

Address health literacy issues in the practice—see the National Patient Safety Foundation website “Ask Me 3”: www.npsf.org/askme3/ for simple resources.

Office of Health Disparities website: http://www.cdphe.state.co.us/ohd/lep.html NCAFP's Disparities Initiative: http://www.ncafp.com/initiatives/disparity

Percentage Min. score to pass Our score100% Practice assesses 2 items75% No scoring option50% Practice assesses1 item X25% No scoring option0% Practice does not assess any items

Examples/Notes:

PCMH4A - (click here )NC Professional Interpreters Association: http://ncpiaonline.org/ Website for Translation Services: http://www.healthtranslations.com/ NC Services for the Deaf and Hard of Hearing with regional sign language resources available: http://www.ncdhhs.gov/dsdhh/directories.htm

Element 4B: Self-Management Support Must Pass 4 PointsThe practice conducts the following activities to support patient/family self-management, for the three important conditions:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

1. Assesses patient/family preferences, readiness to change and self-management abilities

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NCQA Excel Spreadsheet

Please note: This is a read-only example for educational purposes. Use your RRWB from NCQA Survey Tool.

2. Provides educational resources in the language or medium that the patient/family understands 3. Provides self-monitoring tools or personal health record, or works with patients' self-monitoring tools or health record, for patients/families to record results in the home setting where applicable 4. Provides or connects patients/families to self-management support programs 5. Provides or connects patients/families to classes taught by qualified instructors 6. Provides or connects patients/families to other self-management resources where needed 7. Provides written care plan to the patient/family.

Examples Medical record review includes: Referrals to programs, classes or other self-management resources from the patient record Use of tool for assessing patient preferences, readiness to change and self-management abilities Use of educational brochures, pamphlets and video Self-monitoring tool or personal health record Referrals to community resources.

Tools/ Resources

NCQA Medical Record Review Worksheet For an educational PPT on the use of your RRWB ( click here)

Not all patients with important conditions require self-management support. Physicians may decide that patients already achieving good outcomes do not require self management support; in those cases, a notation that the patient has good outcomes would suffice in place of a record. American College of Physicians patient education materials and video:- http://foundation.acponline.org/hl/diabguide.htm Glasgow, R. et al. (2003). Implementing practical interventions to support chronic illness self-management. Joint Commission Journal on

Quality Review, 29(11), 563-574. { click here for article PDF} Use of PCRS tool to facilitate practice self-analysis and discussion regarding available infrastructure for incorporating self-management

support. {click here } For PDSA worksheet template (click here ) Consider incorporating “How’s Your Health?” { PDF of How’s Your Health Book }; {click here for "How's Your Health website"} Patient version Self-Management Support Communication Log {click here} Paper and electronic versions of a PHR: { click here for an introductory article on the Personal Health Record from FPM} Motivational interviewing training (Merck) Self-Management Support Techniques & Coaching Patients for Successful Self-Management—California Healthcare Foundation; (contact

your coach for a copy of these DVDs) See Health Literacy resource above in 4A.

Percentage Min. score to pass Our score100% 75 – 100% of patients seen in the past 3 months have at least 3 activities documented

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75% 50 – 74% of patients seen in the past 3 months have at least 3 activities documented50% 25 – 49% of patients seen in the past 3 months have at least 3 activities documented X25% 11 – 24% of patients seen in the past 3 months have at least 3 activities documented0% 10% or less patients seen in the past 3 months have at least 3 activities documented

Examples/Notes:

Written Care Plan - Pediatric – (click here )Are You Ready? Brochure – (click here )Adult Asthma Action Plan (click here )Adult Asthma Self-assessment Tool – Spanish ( click here)Adult Asthma Self-assessment Tool – English (click here )Asthma Follow up Visit ( click here)Diabetes Self-assessment Tool (click here )Diabetes Medical Management Plan (click here )Diabetes – checking blood sugar - Spanish ( click here)Diabetes Care and Education Referral Form (click here )Falls Prevention Checklist for the Elderly (click here )Fitness Inventory - English (click here )Fitness Inventory – Spanish (click here )Tobacco Use Assessment (click here )Mental Health/Substance Abuse Resource Guide (click here )Hypertension SMART Goals (click here )Group Visit Starter Kit (click here )Group Visits for Chronically Ill Patients ( click here)Invitation for Group Visit ( click here)Invitation for Cardiac Group Visit (click here )Information Gold Mine for Consumer Health Info ( click here)For Best Information about Healthy Lifestyles (click here)Health Center Migrant Care NC (click here )

40

PPC 5: Electronic Prescribing 8 PointsThe practice employs electronic systems to order prescriptions, to check for safety and to promote efficiency when prescribing.

Intent The practice seeks to reduce medical errors and improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost information when prescribing.

Who will manage this standard?

NCQA’s Example Sheet:- Standard 5

PPC 5

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A

B

CNotes:

41

Element 5A: Electronic Prescription Writing 3 Points The practice uses an electronic system to write prescriptions using either:

Item What is our current status? Tools/ Resources needed

ProcessOwner

Due Date

1. Electronic prescription writer—stand-alone system (general) with either print capability at the office or ability to send fax or electronic message to pharmacy

75-100% of new prescriptions for patients seen in the last 3 months written using this system

Practice has system capable of doing this but does not use it

System does not have capability or less than 75% of prescriptions written using this system

2. Electronic prescription writer that is linked to patient-specific demographic and clinical information.

75-100% of new prescriptions for patients seen in the last 3 months written using this system

Practice has system capable of doing this but does not use it

System does not have capability or less than 75% of prescriptions written using this system

Data source

Reports from system

Tools/ Resources

1. E-prescribing Readiness Assessment .AAFP 2. Consumer Guide to e-prescribing

Percentage Min. score to pass Our score100% 75 – 100% of new prescriptions for patients seen in the last 3 months written with Item 275% 75 – 100% of new prescriptions for patients seen in the last 3 months written with Item 1 X50% No scoring option25% Practice has system capable of either Item 1 or Item 2, but does not use it0% System does not have capability or less than 75% of prescriptions written using this system

Examples/Notes:

PCMH 5A – (..\Practice Examples\Elizabeth FP\5A_Elizabeth_FP_e-prescribing.xlsx )EHR Process from TransforMED ( click here)

42

Element 5B: Prescribing Decision Support—Safety 3 PointsClinicians in the practice write prescriptions using electronic prescription reference information at the point of care, including the following types of alerts and information:

What is our current status?What needs to happen?

Tools/ Resources needed

Process Owner

1. Drug-drug interactions based on general information

Yes No

2. Drug-drug interactions specific to drugs the patient takes

Yes No

3. Drug-disease interactions based on general information

Yes No

4. Drug-disease interactions specific to diseases the patient has

Yes No

5. Drug-allergy alerts based on general information Yes No6. Drug-allergy alerts specific to the patient Yes No7. Drug-patient history alerts based on general information

Yes No

8. Appropriate dosing based on general information Yes No9. Appropriate dosing calculated for the patient Yes No10. Therapeutic monitoring associated with specific drug utilization based on general information (drug-lab alerts)

Yes No

11. Duplication of drugs in a therapeutic class based on general information

Yes No

12. Duplication of drugs in a therapeutic class specific to the patient

Yes No

13. Drugs to be avoided in the elderly based on general information

Yes No

14. Drugs to be avoided in the elderly based on age of the patient

Yes No

15. Patient appropriate medication Yes No

Examples Reports from the system, paper or electronic showing an example of use of each item. Percentage Min. score to pass Our score

100% Practice uses 8 or more kinds of alerts and information75% Practice uses 4 – 7 kinds of alerts and information50% Practice uses 2 – 3 or more kinds of alerts and information X25% System has capability of providing 6 or more kinds of alerts, but practice does not use them0% No system capability, system has capability for fewer than 6 kinds of alerts or practice uses

fewer than 2 kinds of alerts and informationExamples/Notes:PCMH 5B – (click here )

43

PCMH 5B – ( click here)20 Tips to Prevent Medication Errors ( click here)Drugs to be Avoided in the Elderly (click here )Appropriate Dosing of Tylenol in Children (click here )Understanding the Risks of OTC meds (click here )Refill Protocol (click here )

44

Element 5C: Prescribing Decision Support—Efficiency 2 PointsClinicians engage in cost-efficient prescribing through one or more of the following tools

What is our current status? Tools/ Resources needed

Process Owner

1. Electronic prescription writer with general automatic alerts for different choices including generics

We use this tool

System has capability to support both options; practice does not use it

System does not have capability or practice does not use either tool

2. Electronic prescription writer connected to payer-specific formulary that automatically alerts clinician to alternative drugs, including generics.

We use this tool

System has capability to support both options; practice does not use it

System does not have capability or practice does not use either tool

Data source Reports from the system, screen shots, practice protocols.

Tools/ Resources

PCMH5C – Generic Alternatives ( click here)

Percentage Min. score to pass Our Score100% Practice uses 2 tools75% Practice uses 1 tool X50% No scoring option25% System has capability to support both options; but does not use it0% System does not have capability or practice does not use either tool

Notes:

45

PPC 6: Test Tracking 13 PointsThe practice systematically tracks tests ordered and test results, and systematically follows up with patients.

Intent The practice works to improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results.

Who will manage this standard?

NCQA’s Example Sheet:- Standard 6

PPC 6

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A x

BNotes:

46

Element 6A: Test Tracking and Follow-up Must Pass 7 PointsThe practice systematically tracks tests and follows up in the following manner:

What is our current status?What needs to happen? Tools/ Resources needed Process

OwnerDue Date

1. Tracks all laboratory tests ordered or done within the practice, until results are available to the clinician, flagging overdue results 2. Tracks all imaging tests ordered or done within the practice, until results are available to the clinician, flagging overdue results 3. Flags abnormal test results, bringing them to a clinician’s attention 4. Follows up with patients/families for all abnormal test results 5. Follows-up with inpatient facility on hearing screening and metabolic screening to get results 6. Notifies patients/families of all normal test results.

Data source Reports

Examples Reports or logs—may be a paper log or an electronic in-box showing outstanding tests and showing how the practice flags abnormal results.Tools/ Resources

1. Excel workbook for test, newborn screening results and referral tracking 2. Paper test tracking log {click here}3. American College of Medical Genetics ACTsheets (click here )

Percentage Min. score to pass Our score100% Practice does 4 – 6 types of tracking and follow-up75% No scoring option50% Practice does 3 types of tracking and follow-up X25% Practice’s electronic system has the capability to all 4 types of tracking and follow-up but

practice does not use it0% Practice’s system does not have capability to track, or the practice does fewer than 3 types

of tracking and follow-upExamples/Notes:PCMH 6A1,3,4,6 – (..\Practice Examples\Lakeside FP\PPC6A-1,3,4,6 LO Labs.pdf )PCMH 6A1,3,4,6 – (..\Practice Examples\Lakeside FP\PPC6A-1,3,4,6 LO Labs.pdf )PCMH 6A1 – ( ..\Practice Examples\Elizabeth FP\6A_1_Elizabeth_FamilyLabOrderForm.pdf)PCMH 6A2 – (..\Practice Examples\Elizabeth FP\6A_2_ElizabethReferrals.pdf )PCMH 6A3 – (..\Practice Examples\Elizabeth FP\6A_3a_Elizabeth_FamilyAbnormalReport.pdf )PCMH 6A4 – ( ..\Practice Examples\Elizabeth FP\6A_4_Elizabeth_FamilyAbnormalLab.pdf)PCMH 6A6 – (..\Practice Examples\Elizabeth FP\6A_6_Elizabeth_FamilyNormalLab.pdf )

47

PCMH 6A – (..\NCQA\2011-05 (May)\PCMH6AClincalMeasuresChronicCondition.pdf )

Element 6B: Electronic System for Managing Tests 6 PointsThe practice uses an electronic system to::

What is our current status?What needs to happen?

Tools/ Resources needed

Process Owner Due

Date

1. Order lab tests

2. Order imaging tests 3. Retrieve lab results directly from source 4. Retrieve imaging text reports directly from source 5. Retrieve images directly from the source 6. Route and manage current and historical test results to appropriate clinical personnel for review, filtering and comparison 7. Flag duplicate tests ordered 8. Generate alerts for appropriateness of tests ordered.

Data source ReportsExamples Data source: Reports or screen shots from the system showing examples of each of the functions. Tools/ Resources

See NCQA’s example slides

Percentage Min. score to pass Our Score100% Practice uses 5 – 8 functions75% Practice uses 3 – 4 functions50% Practice uses 1 – 2 functions X25% No scoring option0% Practice does not use system

48

Examples/Notes:PCMH 6B1,3,7 – (..\Practice Examples\Lakeside FP\PPC6B 1,3,7 Electronic Lab Test Mgmt LO.pdf )PCMH 6B – ( ..\NCQA\2011-05 (May)\TestTrackingLogEx.pdf)PCMH 6B – (..\NCQA\2011-05 (May)\ElectronicTestTracking.pdf )PCMH 6B – (..\NCQA\2011-05 (May)\LabImagingOrderScreenshot.pdf )PCMH 6B – (..\NCQA\2011-05 (May)\NotifyPtAbnormalResults.pdf )

49

PPC 7: Referral Tracking 4 PointsThe practice systematically documents and tracks referrals and referral results.

Intent The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners. Element 7A:

1. Do we currently provide all of the necessary information about our patients to people we consult with? Such as reasons for the consult/ referral, dx, social and family history, pertinent clinical finding, insurance information, etc?

2. Do we get the consult back from the specialist or consultant?

Who will manage this standard?NCQA’s Example Sheet:- Standard 7

PPC 7

Must Pass

Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completed Total Points

ANotes:

Element 7A: Referral Tracking Must Pass 4 Points Outside of paper medical records and patient visits, the practice uses a paper-based or electronic system to assist in tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice. The practice uses a system that includes the following information for its referrals:

What is our current status? What needs to happen? Tools/ Resources needed Process Owner Due Date

1. Origination Referring provider Contact information Referral form

2. Clinical details ReasonPertinent clinical findings

Referral form

50

Support personFunctional statusFamily historySocial historyPlan of careHealth care providers

3. Tracking status Referral tracking worksheet

4. Administrative details.

Insurance information information about whether the

plan needs approval for services the consultant or specialist will be providing

Referral form

Data sourceExamples Written logs or other paper-based documents if not electronic, reports from the system if electronic.Tools/ Resources

Referral form Audit Paper log or Electronic logSchuldermann, P. (2004). Improving patient care: Using a tracking book for unresolved issues. Family Practice Management, 11(4), 56, 59. Includes tool PDF. { click here }Murray, M (2002). Reducing Waits and Delays in the referral process. Family Practice Management 39-42 (click here )Co-Management Agreement with Specialist (click here )

Percentage Min. score to pass Our Score100% Practice uses system that includes all 4 items75% Practice uses system that includes 2 – 3 items50% Practice uses system that includes 1 item X25% No scoring option0% System does not include any of the items

Examples/Notes:PCMH 7A1-4 – ( ..\Practice Examples\Lakeside FP\PPC7A-1-4 Referral Policy.pdf)PCMH 7A1-4 – ( ..\Practice Examples\Lakeside FP\PPC7A-1-4-Referral Tracking.pdf)PCMH 7A – ( ..\NCQA\2011-05 (May)\ReferralTrackingEx.pdf)PCMH 7A - (..\NCQA\2011-05 (May)\ReferralTrackingLogEx.pdf )A Sample Tracking Book (click here )

51

PPC 8: Performance Reporting and Improvement 15 PointsThe practice regularly measures its performance and takes actions to continuously improve.

Intent The practice seeks to improve effectiveness, efficiency, timeliness and other aspects of quality by measuring and reporting performance, comparing itself to national benchmarks, giving physicians regular feedback and taking actions to improve.

Who will manage this standard?

NCQA’s Example Sheet:- Standard 8

PPC 8

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A X

B

C X

D

E

FNotes:

Element 8A: Measures of Performance Must Pass 3 Points 52

The practice measures or receives data on the following types of performance by physician or across the practice:What needs to happen? Resources needed Process

OwnerDue Date

1. Clinical process (e.g., percentage of women 50+ with mammograms or childhood vaccination rates)

2. Clinical outcomes (e.g., HbA1c levels for diabetics) 3. Service data (e.g., backlogs or wait times) 4. Patient safety issues (e.g., medication errors).

Data source ReportsExamples Manual review of a sample of patient records, patient surveys, practice management system, registry, health plan-provided data, medical group

provided data, electronic database.

Tools/ Resources

1. Practice gets credit for Item 1 and 2 if they have current NCQA recognition for Diabetes or Heart Stroke2. Registry

a. Reach My Doctor Reportsb. CINA Reports. Information at http://www.cina-us.com/pqrifaq.html c. NCIR (NC Immunization Registry) Reports at http://www.immunizenc.com/ncir.htm

3. Custom electronic reports—Query, Crystal, etc.4. Reporting available through EMR5. MGMA’s Physician Practice Patient Safety Assessment Tool {weblink to interactive self-assessment tool}6. Medication Safety

a. Ghandi, T et al. (2003). Adverse drug effects in ambulatory care. NEJM . 348:1556-1564.b. “What Medications Does Your Patient Take: Enhancing Medication Safety in the Outpatient Setting.” IHI website. {click here }c. Examples of outpatient medication reconciliation lists

i. The Med List on Massachusett’s Coalition for Prevention of Medical Errors website {link to Coalition website for resources}ii. Other patient medication reconciliation lists {example medication list PDF} {second example medication list PDF } {third

example medication list PDF}7. Measurement Patient Safety

a. Background IHI Outpatient Adverse Effect Trigger Tool and Toolkit {(click here)}Percentage Min. score to pass Our Score

100% Practice measures at least 2 types of performance75% No scoring option50% Practice measures 1 type of performance X25% No scoring option0% No areas of performance measured

Examples/Notes:

PCMH 8A,C,D,E,F – ( ..\Practice Examples\Lakeside FP\PPC8A,C,D,E,F NCQA Clinical Outcome Data.pdf)PCMH 8A,C,D,E,F - (..\Practice Examples\Lakeside FP\PPC8A,C,D,E,F NCQA Slide.pdf )PCMH 8A1,2 – (..\Practice Examples\Lakeside FP\PPC8A-1-2 NCQA Clinical Outcome Data.pdf )PCMH 8A3 – (..\Practice Examples\Lakeside FP\PPC8A-3 Service Data.pdf )PCMH 8A4 – (..\Practice Examples\Lakeside FP\PPC8A-4 Journey Report.pdf )PCMH 8A3 – Patient Cycle Tool (click here ) Then would need to put the data into a workbook/spreadsheet (click here )

53

54

Element 8B: Patient Experience Data 3 PointsThe practice collects data on patient experience with care in the following areas:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner Due

Date

1. Patient access to care 2. Quality of physician communication 3. Patient/family confidence in self care 4. Patient/family satisfaction with care.

Data source

Reports; may use a phone, paper or electronic survey

Practice may qualify for 50% of points if able to demonstrate that a patient advocacy group or board that meets periodically has been established. The gathering of patient feedback in this context must be documented in order to be eligible.

Tools/ Resources

1. Reportsa. Press Ganey Reportsb. CAHPS Reports. From https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp

2. Patient Satisfaction Survey a. Patient Feedback Card (click here) & Excel Tracking Sheet ( click here ) Patient Survey 2 (click here )

3. Patient Advocacy Boarda. Institute of Family-Centered Care. (2007). Selecting, Preparing and Supporting Patient and Family Advisors in Primary Care.

www.familycenteredcare.org4. Related articles

a. Luallin, M. (2004). Implementing patient satisfaction survey findings into a customer service action plan. Medical Practice Management, 90-94. { PDF }

Percentage Min. score to pass Our Score100% Practice collects data on 3 – 4 areas75% No scoring option50% Practice collects data on 1 – 2 areas X25% No scoring option0% Practice do not collect data in any areas

Examples/Notes:

PCMH 8B1-4 – (..\Practice Examples\Lakeside FP\PPC8B-1-4 Patient Experience Data by Practice.pdf )PCMH 8B1-4 – (..\Practice Examples\Lakeside FP\PPC8B-1-4 Patient Experience Data by Provider.pdf )Family Post Visit Survey (click here)Communication Skills – Breaking Bad News (click here)Latino Focus Group Questions (click here)Family/Caregiver Survey (click here)Measuring Medical Homes PDF – full of surveys/tools for Peds and FM ( click here)EQUIPP - Education in Quality Improvement for Pediatric Practice (click here )Element 8C: Reporting to Physicians Must Pass 3 Points

55

The practice reports on performance on the measures in 8A and 8B:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

1. Across the practice NCQA worksheet2. By individual physician.

Data source ReportsExamples Blinded reports showing summary practice performance or individual physician performance; blinded letters to physicians showing performance. Addnl. information

Reports may come from within or outside of the practice—must reflect entire population and not just a subgroup covered by a single payer Practice to demonstrate how report results are communicated to the whole practice as well as to individual providers

Tools/ Resources

RMD Registry reports EMR Registry reports Customized electronic reports—Crystal, Query, etc. Excel workbooks with audit results

Percentage Min. score to pass Our score100% Practice reports to physicians results both results both across the practice and by

physicians75% No scoring option50% Practice reports to physicians results either across the practice or by physicians X25% No scoring option0% No areas of performance reported to physicians

Examples/Notes:

PCMH 8C1 - (..\NCQA\2011-05 (May)\PCMH6EReportingAcrossPractice.pdf)PCMH 8C2 – (..\NCQA\2011-05 (May)\PCMH6EResultsbyClinician.pdf )PCMH 8C2 – (..\Practice Examples\Lakeside FP\PPC8C-2 Adult Medical Record and Survey Workbook2.pdf )PCMH 8C2 – ( ..\Practice Examples\Lakeside FP\PPC8C-2 Service Data Individual MD.pdf)Diabetes Registry ( click here)CSHCN Registry (click here )

56

Element 8D: Setting Goals and Taking Action 3 PointsThe practice uses performance data to:

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

1. Set goals based on measurement results referenced in Elements 8A and 8B.

NCQA worksheetPlease note: This is a read-only example for educational purposes. Use your RRWB from NCQA Survey Tool.

2. Take action where identified to improve performance of individual physicians or of the practice as a whole.

Data source ReportsExamples Reports or completion of the PPC-PCMH Quality Measurement and Improvement worksheet.Tools/ Resources

1. Consider incorporating use of meeting minutes and/or PDSA Worksheets2. Example templates: {Meeting Agenda template}{Meeting Minutes template}{PDSA worksheet} 3. Example templates for setting goals and aim statement : (click here)4. Article: Schwarz, M. et al. (1999). A team approach to quality improvement. FPM. 6(4):25-30. { article}5. For an educational PPT on the use of your RRWB ( click here)

Percentage Min. score to pass Our score100% Practice does 2 items75% No scoring option50% Practice does 1 item X25% No scoring option0% Practice does no items

Examples/Notes:

Setting Goals and Taking Actions (..\NCQA\2011-06 (Jun)\PPC8D0001.pdf )

57

Element 8E: Reporting Standardized Measures 2 PointsThe practice produces reports on its performance using nationally approved clinical performance measures.

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

How many national measures do you produce as a practice?

Data source

Reports

Examples Reports showing performance measures calculated by practice.

Tools/ Resources

1. See the PCMH Measures Directory for reportable measures associated with DM, CAD, Prevention, Depression, and Low Back Pain2. National Voluntary Consensus Standards for Ambulatory Care endorsed by NQF:

http://www.qualityforum.org/projects/ongoing/ambulatory/index.asp.

Percentage Min. score to pass Our score100% Practice produces reports using 10 or more nationally approved performance measures75% Practice produces reports using 5 - 9 nationally approved performance measures50% Practice produces reports using 3 - 4 nationally approved performance measures X25% No scoring option0% Practice produces reports using 0 - 2 nationally approved performance measures

Examples/Notes:

Example of Satisfaction Survey across a practice ( ..\Practice Examples\Lakeside FP\PPC8E-1 Service Data by Practice.pdf)Practice Level Diabetes Data (..\NCQA\2011-06 (Jun)\PCC8E0001.pdf )You can go to the above website (National Voluntary Consensus Standards for Ambulatory Care endorsed by NQF) and see some of the national standards for Ambulatory Care and Immunizations.

58

Element 8F: Electronic Reporting—External Entities 1 PointThe practice electronically reports results on nationally approved measures to the public sector, health plans or others.

What is our current status? What needs to happen? Tools/ Resources needed

Process Owner

Do you currently participate in report clinical measures to outside organizations?

Yes No

Data source Reports

Examples Report to payer or other user from practice’s electronic system.

Tools/ ResourcesPercentage Min. score to

passOur score

100% Practice transmits 10 or more nationally approved performance measures to an external entity

75% Practice transmits 5 - 9 nationally approved performance measures to an external entity50% Practice transmits 3 – 4 nationally approved performance measures to an external entity X25% Practice transmits 1 – 2 nationally approved performance measures to an external entity0% Practice does not transmit any measures

Examples/Notes:

Reporting results on nationally approved measures to the public sector ( click here)PCMH 8F - ( ..\Practice Examples\Lakeside FP\PPC8F Electronic Reporting-External Entities.pdf)

59

PPC 9: Advanced Electronic Communications 4 Points

The practice systematically manages patient information and uses the information for population management to support patient care.

Intent The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care.

Who will manage this standard?NCQA’s Example Sheet:- Standard 9

PPC 9

Must Pass Actions for Point Person Staff responsible

Ready for

NCQA

The person assigned to do the final review

Standard Complete

NCQA document

linkedPoints

CompletedPoints

PendingUpload

completedTotal

Points

A

B

CNotes:

60

Element 9A: Availability of Interactive Web Site 4 Points The practice provides patients/families with access to an interactive Web site that allows them to:

Does your practice have a website that allows patients to: Tools/ Resources needed Process Owner Due Date

1. Request appointments by reviewing clinicians schedules

Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

2. Request referrals Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

3. Request test results Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

4. Request prescription refills Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

5. See elements of their medical record Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

6. Import elements of their medical record into a personal health record.

Yes No Website with HIPPA complaint communication function

Reach My Doctor – “Basic Patient Communication” function

Examples Screen shots showing presence of web-based functionalityTools/ Resource

If your practice doesn’t have this functionality, sign up for ReachMyDoctor Basic Patient Communication by contacting clicking here .

Percentage Min. score to pass Our Score100% Practice providers 5 – 6 items75% Practice providers 3 – 4 items50% Practice providers 1 – 2 items X25% No scoring option

0% Practice does not any itemsExamples/Notes:

PCMH 9A1 - (..\Practice Examples\Elizabeth FP\9A_1_Elizabeth.doc )PCMH 9A4 – (..\Practice Examples\Elizabeth FP\9A_4_Elizabeth.doc )Practice Brochure (click here )

Element 9B: Electronic Patient Identification 2 PointsThe practice combines use of electronic information and clinical decision-support to contact the following types of patients, once identified, by e-mail:

61

What is our current status? Tools/ Resources neededProcess Owner

Due Date

1. Patients needing clinical review or action Yes

No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function2. Patients on a particular

medication Yes No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function3. Patients needing preventive

care Yes No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function4. Patients needing specific tests

Yes No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function CareSpace

5. Patients needing follow up visits Yes No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function CareSpace

6. Patients who might benefit from disease or case management support.

Yes No

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function. CareNotes and CareTeams

Examples Screen shots showing identification of patients for the above items and an example of e-mail communication with patients based on electronic identification.

Tools/ Resources

If your practice doesn’t have this functionality, sign up for ReachMyDoctor Premium Patient Communication by click here . The practice can add a subscription fee to this service.

Percentage Min. score to pass Our Score100% Practice uses electronic information and communication for 5 – 6 items75% Practice uses electronic information and communication for 3 - 4 items50% Practice uses electronic information and communication for 1 - 2 items X25% No scoring option0% Practice does not use electronic information for any items

Notes:

Element 9C: Electronic Care Management Support 1 PointFor patients with the three clinically important conditions, the practice care management team uses electronic communication for the following:

62

What is our current status? Tools/ Resources needed ProcessOwner

Due Date

1. To communicate with disease or case managers about patient needs

Website with HIPPA complaint communication function Reach My Doctor – “Premium Patient Communication”

function. CareNotes and CareTeams

2. Web-based educational modules for patient self-management.

www.howsyourhealth.com www.mayoclinic.com http://www.newhealthpartnerships.org/

PatientsPuzzlePiecePrint.aspx?id=40&linkidentifier=id&itemid=40

Examples Screen shots showing electronic communication about care management. Screen shots or links to education modules.Tools/ ResourcesPercentage Min. score to pass Our point

100% Practice uses electronic communication for 2 items75% Practice uses electronic communication for 1 items X

50% No scoring option25% No scoring option0% Practice does not use electronic communication for any items

Examples/Notes:

Partnering in Self-management Support – a Toolkit for Clinicians: ( click here) Tremendous Resource from IHI with numerous links to multiple resources for self-management

63