NCQAPCMH2011DocumentationNCQA PCMH 2011 …

NCQA PCMH 2011 DocumentationNCQA PCMH 2011 DocumentationStandard 1 and Standard 2

Southeast Region WebinargHeather Russo, CCE

May 6, 2014

Advancing Healthcare

CMS FQHC APCP Advancing Healthcare

Improving HealthDemonstration

Learning Objectives

• Discuss tips for documentation formatting• Review documentation requirements and

examples for NCQA PCMH Standards: – 1: “Enhance Access and Continuity”

2 “Id tif d M P ti t P l ti ”– 2: “Identify and Manage Patient Populations”

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General Tips on DocumentationGeneral Tips on Documentation

• Format in a clear and organized manner• Format in a clear and organized manner

• Highlight relevant information for the NCQA surveyor

• Include a ‘narrative description’ as a summary of information presented in the documentation

• Save documentation for a single element into gone document

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General Tips on Documentation p(Cont’d)

R t I l d f th t• Reports: Include name of the report, reporting period, numeric values of the numerator and denominator

• Policies: Include date of most recent update

S h t l ti t d t d id tifi d• Screen shots: use real patient data, de-identified

• Policies, procedures and job descriptions must not be younger than 3 months from date of submission Datayounger than 3-months from date of submission. Data must not be older than 12-months.

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Documentation FormattingDocumentation FormattingHeader with clinic name, NCQA Standard

Information on NCQA Standard, Element and Factor demonstrated in this documentation

N ti d i ti f h li iNarrative description of how clinic meets NCQA factor

Report or other documentation to be shown to NCQA

Footer with NCQA Standard and Element, and page number of total pages

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pages

PCMH 1: Enhance Access and Continuity

The practice has a written process and defined standardsThe practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: Elements:

A. Access During Office Hours (4 points) (Must Pass)B. After-Hours Access (4 points)C. Electronic Access (2 points)D. Continuity (2 points)D. Continuity (2 points)E. Medical Home Responsibilities (2 points)F. Culturally and Linguistically Appropriate Services (2 points)G The Practice Team (4 points)

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G. The Practice Team (4 points)

PCMH 1A: Access During Office Hours g(Must Pass)

The practice has a written process and defined standards,The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:Factors:

1. Providing same-day appointment (Critical Factor)

2. Providing timely clinical advice by telephone during office hours

3. Providing timely clinical advice by secure electronic messaging during office hoursduring office hours

4. Documenting clinical advice in the medical record

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PCMH 1A 1 Documentation ExamplePCMH 1A-1 Documentation Example

Same Day Appointment Availability ReportSame Day Appointment Availability Report

9/24/12 - 9/28/12

Date

Number of Same-Day Appointments Available at Beginning of Day

Compliance with Practice Standard

Monday, 9/24 12 ✔

Tuesday, 9/25 15 ✔

Wednesday, 9/26 8 ✖y,Thursday, 9/27 16 ✔

Friday, 9/28 21 ✔

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PCMH 1A 1 Documentation ExamplePCMH 1A-1 Documentation Example

Scheduling Same-Day Appointments• The Clinic will maintain a specific number of same-day

appointments per day. The remaining available appointments for the day can be scheduled in advance for preventive or follow-up care.

• Same-day appointment types are to be used for acute care visits or other visits deemed necessary to be treated on the same day of service as the request for the appointment. These appointments are only to be scheduled on the same day as the date of service.

f 12 f• A minimum of 12 same-day appointments are to be maintained for availability each day.

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PCMH 1A 2 Documentation ExampleTimely Response Report

PCMH 1A-2 Documentation Exampley p p

9/24/12 - 9/28/12

D tTime of C ll

Time of R

Total Time L d

Compliance with Practice St d dDate Call Response Lapsed Standard

Monday, 9/24 9:35 10:15 0:40 ✔

10:11 10:18 0:07 ✔10:11 10:18 0:07 ✔10:35 11:17 0:42 ✔11:01 11:22 0:21 ✔1:27 2:45 1:18 ✔1:27 2:45 1:18 ✔2:55 3:16 0:21 ✔3:09 3:27 0:18 ✔3:17 3:55 0:38 ✔

10Report would continue to show 5-days worth of data

PCMH 1A-2, 1A-3 ,Documentation Example

R di t Cli i l M P li E tResponding to Clinical Messages – Policy ExcerptUpdated: 1/1/14

• All telephone messages or secure electronic message must be reviewed and responded to within 4 hours of the message being received at the practice.

• Any action taken as a result of the message, such as recommendations provided, or plans/outcomes determined between the care team and the caller, must be documented within the ,patient’s medical record.

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PCMH 1A-4 Documentation Example

R di t Cli i l M P li E tResponding to Clinical Messages – Policy ExcerptUpdated: 1/1/14

• Any action taken as a result of the message, such asAny action taken as a result of the message, such as recommendations provided, or plans/outcomes determined between the care team and the caller, must be documented within the patient’s medical record.p

• The care team member who provides advice to the patient must document within the telephone encounter or secure electronic message encounter within the EHRmessage encounter within the EHR.

• This encounter will automatically be linked to the patient’s medical record.

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PCMH 1A 4 DocumentationPCMH 1A-4 Documentation

3 E l (f di l d)3 Examples (from medical record)

OR

Report of 1-month showing % of times clinical advice was documenteddocumented

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PCMH 1B: After Hours AccessThe practice has a written process and defined standards, and demonstrates that it monitors performance against the

PCMH 1B: After-Hours Access

and demonstrates that it monitors performance against the standards for:Factors:

1. Access to routine and urgent appointments outside regular business hours

2 Continuity of medical record information for care and advice2. Continuity of medical record information for care and advice when the office is not open

3. Timely clinical advice by telephone when the office is not open(Critical Factor)(Critical Factor)

4. Timely clinical advice using a secure, interactive electronic system when the office is not open

5 Documenting after hours clinical advice in patient records

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5. Documenting after-hours clinical advice in patient records

PCMH 1B 1 Documentation ExamplePCMH 1B-1 Documentation Example

ABC Health ClinicABC Health Clinic

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PCMH 1B 2 Documentation ExamplePCMH 1B-2 Documentation ExampleExample Policy Excerpt – Continuity of Medical p y p yRecord Information

Effective 12/01/12

Patients have access at all times to a care provider outside of scheduled office hours. The on call provider will have computer access while on call which will enable that provider to accessaccess while on call, which will enable that provider to access patient records, and also to record after- hours interventions for a patient by logging onto the EHR. The expected response time to patient calls after-hours is 60 minutes and will be documented in thepatient calls after hours is 60 minutes and will be documented in the patient’s EHR within 6 hours of the patient contact.

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PCMH 1B-3, 1B-4 ,Documentation Example

Phone Message AuditPhone Message Audit

Audited dates October 1-31, 2012

Provider Total % GoalProvider Total % Goal26/28 93% 90%

19/19 100% 90%

42/45 93% 90%42/45 93% 90%

20/21 95% 90%

43/48 90% 90%

81%29/36 81% 90%

EVALUATION: The goal is to have all after-hours phone calls addressed within a 4 hour period

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phone calls addressed within a 4 hour period.

PCMH 1B 5 Documentation ExamplePCMH 1B-5 Documentation ExampleExample Policy Excerpt

DOCUMENTATION OF AFTER-HOURS CAREThe on call provider will have computer access while on call, which will enable that provider to access patient records and also to record after-enable that provider to access patient records, and also to record afterhours interventions for a patient by logging onto the EHR. The expected response time to patient calls after-hours is 60 minutes and care provided will be documented in the patient’s EHR within 6 hours of the patient

t tcontact.

Note: In addition to the documented process, you will also need to provide three examples of after-hours clinical advice documented in the record OR a report identifying the percentage of how often clinical advice was documented when provided after-hours (1-month

orth of data)

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worth of data).

PCMH 1C: Electronic AccessPCMH 1C: Electronic AccessThe practice provides the following information and services toThe practice provides the following information and services to patients/families through a secure electronic system:Factors:

1 >50% receive an electronic copy of their health information (including1. >50% receive an electronic copy of their health information (including problem list, diagnosis, diagnostic test results, med lists, allergies) within 3 business days

2. At least 10% have electronic access within 4 business days of2. At least 10% have electronic access within 4 business days of information becoming available to the practice

3. Clinical summaries given to patients for >50% of office visits within 3 business daysy

4. Two-way communication with patients/families 5. Request for appointments or prescription refills6 Request for referrals or test results

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6. Request for referrals or test results

PCMH 1C 1 Documentation ExamplePCMH 1C-1 Documentation Example

MEANINGFUL USE REPORTDate Run: October 10, 2013

Reporting Period: July 1, 2013 – September 30, 2013

ID Measure Name Goal Result Score

CoreProvide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication list, medication allergies) upon request.

50% 62.32% (382/613), , g ) p q

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ID Measure Name Goal Result ScoreID Measure Name Goal Result Score

Menu

Provide patients with timely electronic access to their health information (including lab results, problem list, medication list, and allergies) within 4 business days of 10% 25.29%

(155/613)medication list, and allergies) within 4 business days of the information being available to the EP.

(155/613)

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ID Measure Name Goal Result ScoreID Measure Name Goal Result Score

Core 13Provide clinical summaries for patients for each office visit within three business days. 50% 100.00%

(613/613)visit within three business days. (613/613)

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PCMH 1C-4, 1C-5, 1C-6 , ,Documentation

Screen shot(s) demonstrating se of the• Screen shot(s) demonstrating use of the functionality

• Patient portal OR secure website• Patient portal OR secure website• 1C-4: two-way communication (show the

exchange)exchange)• 1C-5: request medication refills OR

appointmentsappointments• 1C-6: request referrals OR test results

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PCMH 1D: ContinuityPCMH 1D: ContinuityThe practice provides continuity of care for patients/families p p y pby:

Factors:

1. Expecting patients/families to select a personal clinician

2. Documenting the patient’s/family’s choice of clinician3. Monitoring the percentage of patient visits with a g p g p

selected clinician or team

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PCMH 1D 1 Documentation ExamplePCMH 1D-1 Documentation Example

A i t f PCP P dAssignment of PCP Procedure• It is the policy of XXX Clinic to allow each patient to chose

his or her own personal clinicianhis or her own personal clinician. • The patient will be asked for his or her preference and the

preference will be recorded in the practice management systemsystem

• If the patient does not prefer a specific clinician, then the patient will be assigned to the provide with the least dense panel as determined by the panel manager with thispanel, as determined by the panel manager with this selection recorded in the practice management system.

• Patients may request reassignment of clinician at any time.

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PCMH 1D 2 Documentation ExamplePCMH 1D-2 Documentation Example

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PCMH 1D-3 Documentation Example

Continuity Report Continuity Report 11/5/12 - 11/9/12Column A Column B Column C Column D Column E

Number of Patients Rendering

Patients Assigned to % Assigned to a

% of Appointments with Assigned

Seen Provider Provider Provider ProviderTotal by Rendering Provider

55 55 100% 77%6 6 100% 1%67 67 100% 71%42 42 100% 80%

Total for Practice164 164 100% 76%

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164 164 100% 76%

PCMH 1E: Medical Home

The practice has a process and materials that it provides

ResponsibilitiesThe practice has a process and materials that it provides patients/families on the role of the medical home which include the following:Factors:

1. The practice is responsible for coordinating patient care 2. Instructions on obtaining care and clinical advice during and

after hours3. Patients/families should provide a complete medical history

and information about care obtained outside the practice4. The patient/family have access to evidence-based care and

self-management support

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PCMH 1E-1 Documentation Example

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PCMH 1E 1 Documentation ExamplePCMH 1E-1 Documentation Example

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PCMH 1E 2 Documentation ExampleDo You Know? / ¿Usted Sabe?

PCMH 1E-2 Documentation Example

You can get help from us when our office isn’t open.Usted puede recibir ayuda de nosotros cuando nuestra oficina no está abierta:no está abierta:

In the evening / En la nocheDuring the weekend / Durante el fin de semanaOn holidays / En días de fiesta

Call us at 000.000.0000 and press Option #2.Llámenos al 000.000.0000 y presione Opción # 2.

One of our providers is always there for you!Uno de nuestros proveedores siempre está ahí para ti!

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A M di l H T i d hA Medical Home Team is you and your chosen group of trusted health care professionals working together to organize the health care needs of your wholeto organize the health care needs of your whole family using the best available tools, information and technology. Members of your Medical Home Team gy ymay include: doctors, specialists, nurses, dentists, therapists, pharmacists, teachers and care coordinators.

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PCMH 1F: Culturally and Linguistically y g yAppropriate Services

The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by:F tFactors:1. Assessing the racial and ethnic diversity of its population

2 Assessing the language needs of its population2. Assessing the language needs of its population

3. Providing interpretation or bilingual services to meet the language needs of its population

4. Providing printed materials in the languages of its population

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PCMH 1F-1 Documentation Example

Patients By Ethnicity 1/1/2012 – 12/31/2012y y / / / /

Refused to Report

Hispanic/Latino

Non-Hispanic/Latino

Total Unique Patients

# 124 198 523 845% 15% 23% 62% 100%

Patients By Race 1/1/2012 – 12/31/2012Patients By Race 1/1/2012 12/31/2012

Refused African

American Indian or Alaska

Hawaiian or Pacific

Total UniqueRefused

to Report WhiteAfrican American

Alaska Native Asian

or Pacific Islander Other

Unique Patients

# 56 423 267 45 29 2 23 845% 7% 50% 32% 5% 3% 0% 3% 100%

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Patients By Language

English Spanish Other Total

# 667 155 23 845

% 79% 18% 3% 100%

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PCMH 1F-3PCMH 1F 3 Documentation Example

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PCMH 1G: The Practice TeamPCMH 1G: The Practice TeamThe practice uses a team by:F tFactors:

1. Defining roles for clinical and nonclinical team members2. Having regular meetings or a structured communication g g g

process (Critical Factor)3. Using standing orders for services4 Training and assigning teams to coordinate care4. Training and assigning teams to coordinate care 5. …support self-management6. …for population managementp p g7. …in enhanced communication 8. Involving care team staff in the practice’s performance

evaluation and quality improvement activities

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evaluation and quality improvement activities

PCMH 1G-1Documentation Example

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PCMH 1G-2 Documentation Example

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PCMH 1G: The Practice TeamPCMH 1G: The Practice TeamTraining and assigning care teams:PCMH 1G-4: to coordinate care for individual patients

PCMH 1G-5: to support patients and families in self-management and behavior changeand behavior change

PCMH 1G-6: for patient population management

PCMH 1G-7: in communication skills

Documentation: Staff position descriptions describing the role/function AND a description of the practice’s training process and schedule, or materials showing how staff is trained in this area.

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Training Check List Emloyee Name:Training Check List Emloyee Name:

TaskDate

Proficiency Demonstrated

Trainer's Signature

Supervisor's Signature

Training Notes

Care CoordinationReminders to Patients in-between visitsL b t O d T kiLaboratory Order TrackingInforming Patients of Lab ResultsImaging Order TrackingI f i P ti t f I iInforming Patients of Imaging ResultsReferral Order TrackingDischarge Summary Tracking

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Discharge Summary Tracking


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Asthma Care Team TrainingAsthma Care Team TrainingJoint Staff MeetingDecember 18, 2013 11:30 am-12:30pm

Participants: All clinic staff and providers at general monthly clinic meetingAgenda: Utilization of patient registry to manage high-risk asthma patientsSummary: Introduction and education of patient care registry and their value

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St ff M ti Mi tStaff Meeting MinutesJune 2012

The Quality Improvement Committee presented on the latest effortsThe Quality Improvement Committee presented on the latest efforts including improving outcomes patients who currently smoke.

The Tobacco Use assessment is at 85%, which is much lower than the organization’s goal. Staff members were asked for feedback on improving this score.

Many staff members suggested having the Medical Assistants initiateMany staff members suggested having the Medical Assistants initiate this process while the patient is waiting for the provider to arrive in the examination room. The Quality Improvement Committee will take this suggestion and report back on progress next month.

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PCMH 2: Identify & Manage Patient y gPopulations

The practice systematically records patient information and uses it for population management to support patient care.El tElements:

A. Patient Information (3 points)B Clinical Data (4 points)B. Clinical Data (4 points)C. Comprehensive Health Assessment (4 points)D. Use Data for Population Management (5 points) (Must Pass)

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PCMH 2A: Patient Information

The practice uses an electronic system that records the

PCMH 2A: Patient Information

The practice uses an electronic system that records the following as structured (searchable) data for more than 50% of its patients.Factors:1. Date of birth

G d ( lf id tifi d)

8. Dates of previous clinical visits2. Gender (self-identified)

3. Race4. Ethnicity

visits9. Legal guardian/health care

proxy10 Primary caregiver

5. Preferred language6. Telephone numbers7 Email address

10. Primary caregiver11. Presence of advance

directives (N/A for peds)12 Health ins rance

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7. Email address 12. Health insurance information

PCMH 2ADocumentation Example

Demographics Report g p p

Date Range:

Nov. 3, 2013 – Feb. 29, 2014

2A-1 2A-2 2A-3 2A-4 2A-5 2A-6 2A-7 2A-8 2A-9 2A-12

Date of Birth Gender Race Ethnicity Preferred

Language Telephone Numbers

Email Address

Dates of Previous

Visits

Legal Guardian

Health Ins. Info

Patients Seen During Reporting Period

1886 1886 1886 1886 1886 1886 1886 1886 1886 1886

Patients with Data Entered 1886 1886 1885 1884 1884 1886 24 1886 1886 1401

% of Patients with Data Entered 100% 100% 99 95% 99 89% 99 89% 100 % 1 27% 100% 100% 74 28%

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Entered 100% 100% 99.95% 99.89% 99.89% 100 % 1.27% 100% 100% 74.28%

PCMH 2B: Clinical DataThe practice uses an electronic system to record the

PCMH 2B: Clinical Data

following as structured (searchable) data:

Factors:1. An up-to-date problem list with

current and active diagnoses, 80%

2. Allergies, including medication

6. System calculates and displays BMI (N/A for peds)

7. System plots and displays growth allergies and adverse reactions, 80%

3. Blood pressure with the date of update for patients ≥ 2 yrs 50%

charts and BMI percentile (N/A for adults)

8. Status of tobacco use for patients 13 years and older 50%update for patients ≥ 2 yrs, 50%

4. Height for patients ≥ 2 yrs, 50%

5. Weight for patients ≥ 2 yrs, 50%

13 years and older, 50%

9. List of prescription medications with the date of updates, 80%

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Meaningful Use DashboardReporting Period: 3/20/2013 - 6/18/2013

Provider Measure Score Score % Target %

Allergy List 419/453 92%> 80%

Allergy List 522/579 90%> 80%

Allergy List 427/511 84%> 80%

Allergy List 312/367 85%> 80%Allergy List 312/367 85%> 80%

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PCMH 2B-3, 2B-4, 2B-5, ,Documentation Example

Meaningful Use ReportsReporting Period: Reporting Period: 1/1/2012 – 3/31/2012

N t D i t M T tNumerator Denominator Measure Target

Up-to-date Problem List 198 257 77% > 80%

Active Medication List 214 257 83% > 80%

Vital, BMI, Growth Carts 245 257 95% > 50%

Active Medication Allergy List 155 257 60% > 80%

Patient Demographics 233 257 91% > 50%

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PCMH 2B-6 PCMH 2B-7PCMH 2B 6, PCMH 2B 7Documentation

• Screen shots from the electronic system• 2B-6: Calculates and displays BMI• 2B-7: Plots and displays growth charts

– Length/height– Weight– Head circumference

BMI til– BMI percentile– NA for adults

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PCMH 2B-8Documentation Example

Meaningful Use ReportMeaningful Use ReportTime Period: 4/1/2012 - 6/30/2012

Core Measure Numerator Denominator Percent ThresholdCore Measure Numerator Denominator Percent Threshold

Smoking Status 146 216 68% 50%

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PCMH 2B-9Documentation Example

Meaningful Use Reportg pTime Period: 4/1/2012 - 6/30/2012

Core Measure Numerator Denominator Percent ThresholdMaintain Active Medication List 207 244 85% 80%

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PCMH 2C: Comprehensive Health

T d t d th h lth i k d i f ti d f

pAssessment

To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes:pFactors:

1. Documentation of age- and d i t

5. Advance care planninggender-appropriate immunizations and screenings

2. Family/social/cultural h t i ti

6. Behaviors affecting health

7. Patient and family mental health/substance abusecharacteristics

3. Communication needs

4. Medical history of patient and

8. Developmental screening

9. Depression screening for d lt d d l t

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4. Medical history of patient and family adults and adolescents

PCMH 2C DocumentationPCMH 2C Documentation

Completed de identified patient assessmentCompleted, de-identified patient assessmentOR

D t d P f h ll f th i f tiDocumented Process for how all of the information is collected

*Must use the same documentation method for all factors within Element 2C (cannot provide processfactors within Element 2C (cannot provide process

for some and patient assessment for others)

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PCMH 2D: Use Data for Population

Th ti ti t i f ti li i l d t d

pManagement (Must Pass)

The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of p y pservices needed for: Factors:

1. At least three different preventive care services

2. At least three different chronic care services

3. Patients not recently seen by the practice

4. Specific medications

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Documentation RequirementsDocumentation Requirements• Reports/lists for each service must be generated

within the last 12 months (from submission date)within the last 12 months (from submission date) and include:– Report run-date– Criteria for patients represented AND “look back

period” – Example: “Active female patients who have not

received ___ service within ___ period of time”• Demonstration of how the patients are proactively

notified of each service. Examples:notified of each service. Examples:– Letters– Phone scripts

S il/ ti t t l tifi ti62

– Secure email/patient portal notifications

Factors 2D-1 and 2D-2• Three Preventive Care Services (2D-1)Three Preventive Care Services (2D 1)

– Encompass the entire population (not only those with chronic conditions)

– Services or screenings based on age or gender– Practices may only use immunizations as 1 service

(even if for different age groups)( g g p )• Three Chronic Care Services (2D-2)

– May use one chronic condition for three different h i ichronic care services

– May use two or three chronic conditions in reaching out for the same service

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PCMH 2D 1 Documentation ExamplePCMH 2D-1 Documentation ExampleNarrative Description: The report below is run by our care teams on a quarterly basis. Each patient on the list receives a system generated letter asking that they come in to schedule an

Active Female Pts 50+ Who Do Not Have Mammogram in Last 1 Year

p y g g yappointment for their overdue service. Once the letter is sent, a notification is made in the patient’s record to communicate to the care team that the letter has been sent to the patient.

Date of Report: 1/1/14Patient Chart # DOB Date of Last Visit

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PCMH 2D 1 Documentation ExamplePCMH 2D-1 Documentation ExampleNarrative Description: The letter below is generated from our EHR. We have the ability to customize the letter. After the list of patients is run, the letters are generated and sent to all p , gpatients on the list. An indication of the sent letter appears on the patient’s medical record to document the communication that has occurred.

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Factors 2D-3 and 2D-4• Patients not recently seen by the practice (2D-3)Patients not recently seen by the practice (2D 3)

may be defined as:– Established patients without a visit within a certain

ti ftimeframe– Other criteria such as “high-risk” patients without a visit

within a certain timeframe– Patients who have not kept scheduled appointments

• Specific Medications (2D-4) examples may include:– A medication which has had a recall or safety warning– A medication that needs regular monitoring because of

potential side effects

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p

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