© 2015 the verden group delving into pcmh standards (working with elements 3, 4 & 6) your...

© 2015 The Verden Group

Delving Into PCMH Standards(Working with Elements 3, 4 & 6)

Your Partner in Practice

OP User’s ConferenceApril 23-25, 2015


Agenda

Connect the dots in Elements 3 & 4 to understand the requirements

Selecting patients for ‘care reminders’ (3D) Selecting patients for ‘clinical decision support’ (3E) A look at Comprehensive Health Assessments (3C) Determining patients for ‘care management’ and managing

that care (Element 4A & B) Utilizing the Workbook (3C, 4B, 4C) Setting up performance measurement and quality

improvement processes (Element 6)


Connecting the Dots


3C reads as if you must implement ‘comprehensive health assessments’ (CHAs) for ALL your patients. You can, but realistically you will use the CHAs for data mining for 3D and 3E, and 4A and 4B. So we start at 3D & 3E and then implement 3C for those ‘conditions’ selected.

Connect the dots this way:• 3.C (comprehensive health assessments)

are used on the patients selected in 3.D and 3.E• 3.D (care reminders)

• 2 different preventive care services• 2 different immunizations• 3 chronic / acute conditions

• 3.E (clinical support / evidenced based medicine)• 1 mental health• 1 chronic condition• 1 acute condition• 1 unhealthy behavior condition• 1 well child care

Connecting the Dots


For 4A you use the same patients identified in 3D/E and 4B utilizes the patients ‘discovered’ in 4A. You can also use 3E6 (overuse) and 4A for improvement measures in 6B.

Connect the dots this way:

• 4.A (identifying patients needing care management)• Behavioral health• High cost / utilization• Poorly controlled / complex conditions• Outside referrals

• 4B (care planning & self support)

Data mining the patients in 4A, you must utilize the CHAs (3C) to ensure that care planning and self-care support is addressed

Connecting the Dots


Choosing & Working With Preventive & Acute Care,

Immunizations and Overdue Patients for

Point of Care Reminders


PCMH 3D: Use Data for Population Management

At least annually practice proactively identifiespopulations of patients and reminds them, or theirfamilies/caregivers, of needed care based on patientinformation, clinical data, health assessments andevidenced-based guidelines including:1. At least two different preventive care services.+2. At least two different immunizations.+3. At least three different chronic or acute care services.+4. Patients not recently seen by the practice.5. Medication monitoring or alert.

+ Stage 2 Core Meaningful Use Requirement


PCMH 3D: Scoring

MUST-PASS

5 Points

Scoring• 4-5 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factor = 25%• 0 factors = 0%


PCMH 3D: DocumentationDocumentation

• F1-5:1) Reports or lists of patients needing services generatedwithin the past 12 months (Health plan data okay if 75% ofpatient population)

AND2) Materials showing how patients were notified for eachservice (e.g., template letter, phone call script, screenshot of e-notice).

• Practice must perform these functions at least annually.


Keep it simple and use what’s readily available. OP recommends using:

PCMH/OP Reports: Demographic Analysis/Recall Event Chronology PCMH CQMs

Choosing Preventive Measures


Choosing Preventive Measures


3 services must be targeted and can be related to only one condition.

Chronic care management services consider a practice’s entire population. Practices may focus on three chronic care services related to one condition.

Examples in Pediatrics include services related to chronic conditions such as asthma, ADHD, ADD, obesity and depression.

Example: One condition, three services could be Asthma -• Flu shot reminder• Medication follow up• 6-month visit follow up (newly diagnosed patient)

Choosing Chronic / Acute Services


Choosing & Working With

Conditions and Behaviors for

Evidence-Based Decision Support(3E)


PCMH 3E: Implement Evidence-Based Decision Support

The practice implements clinical decisionsupport+ (e.g., point of care reminders) followingevidence-based guidelines for:

1. A mental health or substance use disorder. (CRITICALFACTOR)

2. A chronic medical condition.

3. An acute condition.4. A condition related to unhealthy behaviors.

5. Well child or adult care.

6. Overuse/appropriateness issues.


PCMH 3E: Scoring and Documentation

4 Points

Scoring• 5-6 factors (including factor 1) = 100%• 4 factors (including factor 1) = 75%• 3 factors = 50%• 1-2 factors = 25%• 0 factors = 0%

Documentation• Factors 1-6: Provide

Conditions identified by the practice for each factor and Source of guidelines and Examples of guideline implementation


• Mental / substance abuse in Peds

ADHD Depression Substance abuse (tobacco, alcohol, drugs)

• Condition related to unhealthy behaviors

Pediatric Obesity

Great resource for information and guidelines:Section on Developmental and Behavioral Pediatrics

http://www2.aap.org/sections/dbpeds/screening.asp

Developmental and Behavioral:




Focus on chronic or recurring conditions such as asthma, eczema, allergic rhinitis, pharyngitis, bronchiolitis, sinusitis, otitis media and urinary tract infection

Some examples OP recommends using:• Asthma• Pharyngitis• ADD/ADHD• Depression

Acute and Chronic Conditions:

Tie them back to your MU measures if you are already making clinical decision support rules


Any age well child visit can be used for this measure.

• Utilize Bright Futures as the clinical decision support guidelines.• Protocol templates are included in the OP EMR and based

on Bright Futures

• Update orders on templates• Adjust Care Plan to meet your practice’s needs

Well Child Measure:


May include

ER visits Redundant imaging or lab tests Prescribing generic medications vs. brand name

medications Number of specialist referrals.

Overuse / Appropriateness


Comprehensive Health Assessments (3C)


PCMH 3C: Comprehensive Health Assessment

To understand the health risks and information needsof patients/families, the practice collects andregularly updates a comprehensive healthassessment that includes:1. Age- and gender appropriate immunizations and

screenings.2. Family/social/cultural characteristics.3. Communication needs.4. Medical history of patient and family.5. Advance care planning (NA for pediatric practices).6. Behaviors affecting health.


PCMH 3C: Comprehensive Health Assessment (cont.)

7. Mental health/substance use history of patient and family.8. Developmental screening using a standardized tool (NA for

practices with no pediatric patients).9. Depression screening for adults and adolescents using a

standardized tool.10. Assessment of health literacy.


PCMH 3C: Scoring4 Points

Scoring• 8-10 factors = 100%• 6-7 factors = 75%• 4-5 factors = 50%• 2-3 factor = 25%• 0-2 factors = 0%

NOTE• Factor 5 (NA for pediatric practices)• Written explanation needed for NA responses.


PCMH 3C: Documentation

Documentation• F1-10: Report with numerator and denominator based on

all unique patients in a recent three month periodindicating how many patients were assessed for eachfactor.

OR

• F1-10: Review of patient records selected for the recordreview required in elements 4B and 4C, documentingpresence or absence of information in Record ReviewWorkbook.

NOTE: USE THE WORKBOOK!


Working With Care Management & Support

(4A & B)


PCMH 4: Care Management and Support

IntentThe practice systematicallyidentifies individual patientsand plans, manages andcoordinates care, based onneed.

Meaningful Use Alignment• Practice implements

evidence-basedguidelines

• Practice reviews andreconciles medicationswith patients

• Practice uses e-prescribing system

• Patient-specificeducation materials


20 Points

Elements• Element A: Identify Patients for Care Management

• Element B: Care Planning and Self-Care Support- MUST PASS

• Element C: Medication Management

• Element D: Use Electronic Prescribing

• Element E: Support Self-Care and Shared Decision-Making

PCMH 4: Care Management and Support


PCMH 4A: Identify Patients for Care Management

The practice establishes a systematic process andcriteria for identifying patients who may benefit from caremanagement. The process includes consideration of thefollowing:1. Behavioral health conditions.

2. High cost/high utilization.3. Poorly controlled or complex conditions.

4. Social determinants of health.

5. Referrals by outside organizations (e.g. insurers, health system,ACO), practice staff or patient/family/caregiver.

6. The practice monitors the percentage of the total patientpopulation identified through its process and criteria. (CRITICALFACTOR)


Identifying Patients for Care Management

• Identify all patients in practice with conditionsreferenced in 4A, Factors 1-5.

• Patients may “fit” more than one criterion (Factor).

• Patients may be identified through electronic systems(registries, billing, EHR), staff referrals and/or health plandata.

• Review comprehensive health assessment (Element 3C)as a possible method for identifying patients.

• Factor 6 is critical - NO points if no monitoring

The concept is to use 3C: CHAs, to help identify these patients.


PCMH 4A: Scoring and Documentation4 PointsScoring

• 5-6 factors (including factor 6) = 100%• 4 factors (including factor 6) = 75%• 3 factors (including factor 6) = 50%• 2 factor (including factor 6) = 25%• 0-1 factors (or does not meet factor 6) = 0%

Documentation• F1-5: Documented process describing criteria for identifying

patients for each factor• F6: Report with

- Denominator = total number of patients in the practice- Numerator = number of unique patients identified in

denominator as likely to benefit from care management.


4A1: Behavioral Health

Pediatric populations

Practices may identify children and adolescents with special health care needs, defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.”

(Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)


PCMH 4B: Care Planning and Self-Care Support

Care team and patient/family/caregiver collaborate (atrelevant visits) to develop and update an individual careplan that includes the following features for at least 75percent of the patients identified in 4A.1. Incorporates patient preferences and functional/

lifestyle goals.

2. Identifies treatment goals.3. Assesses and addresses potential barriers to meeting

goals.

4. Includes a self-management plan.

5. Is provided in writing to patient/family/caregiver.

10


PCMH 4B: Scoring and Documentation

4 PointsScoring

• 5 factors = 100%• 4 factors = 75%• 3 factors = 50%• 1-2 factors = 25%• 0 factors = 0%

Documentation• F1-5:

Submission of Record Review Workbook and Examples of how each factor is met (e.g. copy of a care plan)


Using the Record Review Workbook


Workbook


Determining What & How to ‘Measure & Improve’


PCMH 6: Measure and Improve

Use all the same measures from

Element 3D!


PCMH 6A4: Vulnerable Populations

4. Performance data stratified for vulnerable populations (to assess disparities in care).

• The data collected by the practice for one or more measures from factors 1–3 is stratified by race and ethnicity or by other indicators of vulnerable groups that reflect the practice’s population demographics, such as age, gender, language needs, education, income, type of insurance (i.e., Medicare, Medicaid, commercial), disability or health status.

• Vulnerable populations are “those who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability,” (AHRQ) and include people with multiple co-morbid conditions or who are at high risk for frequent hospitalization or ER visits.


Also look back to 4A to help determine ‘vulnerable’ patients. They may include:

• High level of resource use e.g. visits, medication, calls• Frequent visits for urgent or emergent care (2 or more visits in the

last 6 months)• Frequent hospitalizations (2 or more in the last year)• Multiple co-morbidities, including mental health• Non-compliance with treatment or medications• Terminal illness• Multiple risk factors• Psychosocial status, lack of social or financial support that impedes

ability for care

6A – Identifying Vulnerable Populations


PCMH6B: Resource Use

Look back to 4A2 for utilization measures affecting costs.


PCMH 6D: Implement Continuous QI MUST PASS!

Utilize previous measures: 3D, 3E tracked to 6A and 4A2 to 6B – reuse and recycle! 6D flows to 6E


PCMH6C: Continuous Improvement

The practice sets goals and acts to improve performance, based on clinical quality measures (Element A), resource measures (Element B) and patient experience measures (Element C). The goal is for the practice to reach a desired level of achievement based on its self-identified standard of care.

• 6A ties to 3D and 3E• 6B ties to 4A2

USE the ‘Quality Measurement and Improvement Worksheet’


PCMH 6C: NCQA Quality Measurement and Improvement Worksheet


Contact Information

The Verden Group, IncYour Partner in Practice

www.TheVerdenGroup.com

Susanne Madden, MBA, NCQA [email protected]

Julie Wood, MSc, NCQA [email protected]

Q & A

© 2015 the verden group delving into pcmh standards (working with elements 3, 4 & 6) your...

Documents

d care reminders

care element

verden group pcmh

d selecting patients

child care

needed care

overdue patients

identifying patients