Training Webinar # 4

David Halpern, MD, MPHJanuary 4, 2012

Patient-Centered Medical Home

NCQA’s PCMH 2011 Standards

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Acknowledgements

Let’s Review

• Standard 6 – Measure & Improve Performance– PCMH6A: Measure Performance– PCMH6B: Measure Patient/Family Experience– PCMH6C: Implement Continuous Quality

Improvement – MUST PASS– PCMH6D: Demonstrate Continuous Quality

Improvement– PCMH6E: Report Performance– PCMH6F: Report Data Externally

Today’s Agenda• Standard 1 – Enhance Access &

Continuity– PCMH1A: Access During Office Hours – MUST

PASS (review from Webinar #2)– PCMH1B: After-Hours Access– PCMH1C: Electronic Access– PCMH1D: Continuity– PCMH1E: Medical Home Responsibilities– PCMH1F: Culturally and Linguistically Appropriate

Services– PCMH1G: The Practice Team

PCMH 1A: Access During Office Hours

• Practice has written process/standards and demonstrates that it monitors performance against the standards to:

1. Provide same-day appointments – CRITICAL FACTOR

2. Provide timely advice by telephone

3. Provide timely advice by electronic message

4. Document clinical advice

• MUST PASS• 4 Points:

– 4 factors= 100%– 3 factors (including factor 1) = 75%– 2 factors (including factor 1)= 50% (must-pass threshold)– Factor 1= 25% (not sufficient for passing element)– 0 factors or missing factor 1 = 0%

• Data Sources:– Documented process for scheduling appointments, providing

clinical advice and documenting advice– Report showing same-day access, response times– Screen shots or copies of documented clinical advice

PCMH 1A: Access During Office Hours

PCMH 1A: Example – Factor 1

This is the practice’swritten policy on

same-day scheduling

(Your Practice Name)

PCMH 1A: Example – Factor 1

This is the practice’swritten policy on

same-day scheduling

PCMH 1A: Example – Factor 1

Brown Smith Jones

PCMH 1A: Example – Factor 2Element 1A,

Factor 2

PCMH 1A: Example – Factor 2

Percent of calls returned on the same day

PCMH 1B: After-Hours Access • Practice has written process/standards

and monitors performance:1. Provide access to routine and urgent-care

outside business hours2. Provide continuity of medical record information

for care and advice when office is closed3. Provide timely advice by phone when office is

closed – CRITICAL FACTOR4. Provide timely advice using interactive electronic

system when office is closed5. Document after-hours advice

• 4 Points:– 5 factors= 100% – 4 factors (including factor 3) = 75%– 3 factors (including factor 3)= 50%– 1-2 factors= 25%– 0 factors = 0%

• Data Sources:– Documented process for arranging after hours access, making

medical records available after hours, providing timely advice after hours, documenting advice after hours

– Report showing after hours availability, response times– Materials communicating practice hours– Screen shots or copies of documented clinical advice

PCMH 1B: After-Hours Access

• POLICY - The designated lead physician or manager will prepare and maintain a schedule for members of the medical staff to provide on-call services. The schedule will provide for one physician to be on call for Lakeside Family Physicians and one physician for Lakeside Primary Care. Call will transfer to the designated physician at the end of primary care hours on the day listed on the schedule.

• PROCEDURE - Physician Procedure: The primary care physician assigned to on-call coverage will be available at all times and capable of responding by telephone within fifteen minutes. The on call physician will document on phone note the following information: – Patient name – Person calling if other than the patient – Physician name – Time and date of call – Reason for call – Advice given – Follow up needed

PCMH 1B: Example – Factor C

This is an example of a practice’s policy on after-

hours telephone call.

PCMH 1C: Electronic Access • Practice provides through a secure

electronic system:1. Electronic copy of health information within 3 days to

more than 50% of patients who request it**2. Electronic access to current health information within

4 days to at least 10% of patients**3. Clinical summaries provided for more than 50% of

office visits within 3 days**4. Two-way communication5. Request for appointments or prescription refills6. Request for referrals or test results

** Meaningful Use Requirement

• 2 Points:– 5-6 factors = 100% – 3-4 factors = 75%– 2 factors = 50%– 1 factor = 25%– 0 factors = 0%

• Data Sources:– Report showing percentage of patients who received

electronic copy of health information, access to requested health information, electronic clinical summaries

– Screen shots of its secure web site or portal, web page where patients can make requests and communication capability with patients

PCMH 1C: Electronic Access

PCMH 1C: Example – Factors 4, 5, 6

PCMH 1C:

PCMH 1C: Example – Factors 1, 2

this screenshot demonstrates online lab results

PCMH 1C: Example – Factors 5

this screenshot demonstrates online scheduling system

PCMH 1C: Example – Factor 5

this screenshot demonstrates online refill requests

PCMH 1D: Continuity

• Practice provides continuity by:

1. Expecting patients to select a personal clinician

2. Documenting the choice of clinician

3. Monitoring percent of patient visits with clinician

• 2 Points:– 3 factors = 100% – 2 factors = 50%– 1 factor = 25%– 0 factors = 0%

• Data Sources:– Documented process or materials for clinician selection– Screen shot showing patients choice of clinician– Report showing patient encounters with clinician

PCMH 1D: Continuity

PCMH 1D: Example – Factor 3“Assigned Visits” = patients who are assigned to that PCP

“Unassigned Visits” = patients who are not assigned to that PCP

PCMH 1D: Example – Factor 3

PCMH 1D:

PCMH 1E: Medical Home Responsibilities

• Practice has process and provides materials about role of medical home:

1. Practice responsible for coordinating patient care

2. How to obtain care/advice during/after office hours

3. Patients provide complete medical history and information on care obtained outside practice

4. Care team gives patient access to evidence-based care and self-management support

PCMH 1E: Medical Home Responsibilities

• 2 Points:– 4 factors = 100%– 3 factors = 75%– 2 factors = 50%– 1 factor = 25%– 0 factors = 0%

• Data Sources:– Documented process for providing patient information– Patient materials

PCMH 1E: Example – Factor 1

www.pcpcc.net/content/emmi

Patient Center Medical Home FACT SHEET• What is a patient centered medical home? A patient centered medical home is a care team, led by a

primary care physician that focuses on each patient’s health goals and needs, and coordinates that patient’s care across all settings. The concept of a medical home was initially introduced by the American Academy of Pediatrics in 1967. In March 2007, the AAP, the American College of Physicians , the American Academy of Family Physicians, and the American Osteopathic Association issued the Joint Principles of the Patient Centered Medical Home in response to several large national employers seeking to create a more effective and efficient model of health care delivery. Patient-Centered Medical Home is not an actual building, house or hospital. It’s a team approach to providing comprehensive health care in a high-quality and cost-effective manner.

• A Patient-Centered Medical Home is based on a continuous relationship with a personal physician. The physician leads a team of medical professionals who together take responsibility for a person’s care through all stages of life. The patient has one place to call; they have greater access to services; they get personalized care; that care is safe and scientifically valid; and there is a focus on preventive care which keeps costs down and patients healthier.

• Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

PCMH 1E: Example – Factor 1

PCMH 1E: Example – Factor 2

PCMH 1E: Example – Factor 1 & 4

Examples of information about PCMH model and

self-management tools for patients/families

PCMH 1E: Example – Factor 4

PCMH 1E: Example – Factor 4

• Patient Self management tools are available by clicking on the last tab in Provider Portal or by going to the “Patient Mgmt Tools” tab at the CCNC website: www.communitycarenc.org

• These tools are all non-branded, evidence based, low literacy appropriate and have been vetted by physicians at CCNC

PCMH 1E: Example – Factor 4

PCMH 1E: Example – Factor 4

PCMH 1E: Example – Factor 4

PCMH 1E: Example – Factor 4

PCMH 1F: Culturally & Linguistically Appropriate Services

• Practice meets the cultural and linguistic needs of its patients:

1. Assesses racial/ethnic diversity of patients

2. Assesses language needs of patients

3. Provides interpretation services

4. Provides printed materials in patient language

PCMH 1F: Culturally & Linguistically Appropriate Services

• 2 Points:– 4 factors = 100%– 3 factors = 75%– 2 factors = 50%– 1 factor = 25%– 0 factors = 0%

• Data Sources:– Report showing assessment of racial/ethnic/language of

patients– Documentation showing use of interpretation service– Materials in other languages or website in other languages

PCMH 1F: Example – Factor 2

PCMH 1F: Example – Factor 2

PCMH 1F: Example – Factor 2

PCMH 1F: Example – Factor 3

PCMH 1F:

Use the “Meducation” tab to show non-English speakers how to use an inhaler, glucometer, etc.

For non-English speakers, you also can print these instructions in 13 languages.

CCNC Provider Portal

Reports are specific to NC Medicaid enrollees, but patient materials can be

used/downloaded (for free) for any patients

To sign up, visit:

https://portal.n3cn.org

PCMH 1G: Practice Team

• Practice provides patient care services by:1. Defining roles for clinical/nonclinical team members2. Holding regular team meetings - CRITICAL FACTOR3. Using standing orders4. Training and assigning care team to coordinate care5. Training on self-management, self-efficacy and

behavior change6. Training on patient population management7. Training on communication skills8. Care team involvement in performance evaluation

and QI

PCMH 1G: Practice Team• 4 Points:

– 7-8 factors (including factor 2) = 100% – 5-6 factors (including factor 2) = 75%– 4 factors (including factor 2) = 50%– 2-3 factors = 25%– 0-1 factors = 0%

• Data Sources:– Staff position descriptions– Description of staff communication processes– Written standing orders– Description of training process, schedule, materials– Description of how staff is involved in practice improvements

PCMH 1G: Example – Factor 1, 3

Next Steps (Homework)

• Review the requirements for Standard 1– What does the practice already do?– What does the practice need to

adopt/implement?– Are there elements the practice clearly does

not have in place and does not plan to have in place in time for submission?

Next Steps (Homework)

• Organize Your Documents– Create a place on your computer (server or

hard-drive) for all of your documentation– You should have a folder for each standard– A checklist can help you determine what you

already have created/saved and what you need to prepare from scratch

Next Steps (Homework)• Go to NCQA’s website and take

advantage of the various (free) training presentations they have available:– 2011 Standards– Using the ISS Interactive Survey System– Submitting As a Multi-Site Practice

• http://www.ncqa.org/tabid/109/Default.aspx

Community Care PCMH Team

• David Halpern, MD, MPHCommunity Care of North Carolina (CCNC)

• R.W. “Chip” Watkins, MD, MPH, FAAFPCommunity Care of North Carolina (CCNC)

• Brent Hazelett, MPANorth Carolina Academy of Family Physicians (NCAFP)

• Elizabeth Walker Kasper, MSPHNorth Carolina Healthcare Quality Alliance (NCHQA)

Questions?

Feel free to contact me:

David Halpern, MD, MPH

(215) 498-4648

dhalpern@n3cn.org