NCQA Patient-Centered Medical Home 2011Recognition Program

PCPCC Consumer Engagement

Date

2February 2011

Today• Content and focus of PCMH 2011

standards• Criteria related to consumer

engagement

3February 2011

PCMH 2011 Advisory Committee

Susan Edgman-Levitan - CHAIRMassachusetts General HospitalMelinda Abrams, MSCommonwealth FundBruce Bagley, MDAmerican Academy of Family PhysiciansMichael Barr, MD, MBA, FACPAmerican College of PhysiciansDuane E. Davis, MDGeisinger Health PlanTom Foels, MD, MMMIndependent HealthAlan Glaseroff, MDHumboldt-Del Norte Foundation for Medical Care/IPAFoster Gesten, MD New York State Department of HealthVeronica GoffNational Business Group on HealthPaul Grundy, MD, MPHIBMMarjie Grazi Harbrecht, MDHealthTeam Works

Edward G. Murphy, MDCarilion ClinicMary Naylor, PhD, RNUniversity of PennsylvaniaAnn O’Malley, MD, MPHCenter for Studying Health System ChangeAmanda H Parsons, MD, MBANYC Department of Health and Mental HygieneLee PartridgeNational Partnership for Women and Families Carol Reynolds-Freeman, MDPotomac PhysiciansMarc Rivo, MD, MPHPrestige Health ChoiceHealth Choice Network Xavier Sevilla, MD, FAAPWhole Child PediatricsJeff SchiffMinnesota Department of Human ServicesAnn TorregrossaGovernor's Office, PennsylvaniaEd Wagner, MD, MPHGroup Health Cooperative

4February 2011

What is different about the PCMH 2011 standards?

• Enhances patient-centeredness• Emphasizes language, culturally sensitive aspects• Integrates behaviors affecting health, substance

abuse, mental health and risk factor assessment and management

• Enhances applicability to pediatric practices• Aligns with CMS Meaningful Use requirements• Emphasizes relationship with/expectations of

subspecialists• Enhances evaluation of patient experience• Underscores the importance of system cost-savings• Enhances use of clinical performance measure

results

5February 2011

PCMH 2011 Overview (6 standards/27 elements)

1. Enhance Access and Continuity A. Access During Office HoursB. Access After HoursC. Electronic AccessD. Continuity (with provider)E. Medical Home ResponsibilitiesF. Culturally/Linguistically Appropriate

ServicesG. Practice Organization

2. Identify and Manage Patient PopulationsA. Patient Information B. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population Management

3. Plan and Manage CareA. Implement Evidence-Based Guidelines B. Identify High-Risk PatientsC. Care ManagementD. Medication ManagementE. Use Electronic Prescribing

4. Provide Self-Care Support and Community Resources A. Support Self-Care Process B. Provide Referrals to Community

Resources

5. Track/Coordinate CareA. Track Tests and Follow-UpB. Track Referrals and Follow-UpC. Coordinate with Facilities/Care

Transitions

6. Measure and Improve Performance A. Measure PerformanceB. Measure Patient/Family ExperienceC. Implement Continuous Quality

Improvement D. Demonstrate Continuous Quality

ImprovementE. Report PerformanceF. Report Data Externally

Optional Patient Experiences Survey

6February 2011

PCMH Scoring

Level of Qualifying

PointsMust Pass Elementsat 50% Performance

Level

Level 385 - 100

6 of 6

Level 2 60 - 84 6 of 6

Level 1 35 - 59 6 of 6

Not Recognized 0 - 34 < 6Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.

6 standards = 100 points6 Must Pass elements

NOTE: Must Pass elements require a ≥ 50% performance level to pass

7February 2011

Must Pass ElementsRationale for Must Pass Elements • Identifies critical concepts of PCMH• Helps focus Level 1 practices on most important

aspects of PCMH• Guides practices in PCMH evolution and continuous

quality improvement• Standardizes “Recognition”

Must Pass Elements• 1A: Access During Office Hours• 2D: Use Data for Population Management• 3C: Manage Care• 4A: Self-Care Process• 5B: Referral Tracking and Follow-Up• 6C: Implement Continuous Quality Improvement

8February 2011

PCMH 1: Enhance Access and Continuity

Intent of Standard• Patients have access to

routine/urgent care and clinical advice during/after hours that are culturally and linguistically appropriate

• Electronic access• Clinician selected by patient• Team-based care; trained staff

Elements

A. Access During Office HoursB. After-Hours AccessC. Electronic AccessD. ContinuityE. Medical Home

ResponsibilitiesF. Culturally and Linguistically

Appropriate ServicesG. The Practice Team

Meaningful Use CriteriaPatients provided electronic: • Copy of health information• Clinical summary of visit• Access to health information

9February 2011

PCMH 2: Identify/Manage Patient Populations

Intent of Standard• Collects demographic and

clinical data for population management

• Assess/document risks• Create lists; use for point of

care reminders

ElementsA. Patient InformationB. Clinical DataC. Comprehensive Health

AssessmentD. Use Data for Population

Management

Meaningful Use Criteria• Language, gender, race,

ethnicity, DOB• Problem list• Medication list• Medication allergy list• Vital signs• Growth chart (peds.)• Smoking status• Lists of patients with specific

conditions for QI, decrease disparities

• Follow-up reminders for care

10February 2011

PCMH 3: Plan and Manage Care

Intent of Standard• Identify patients with

specific conditions including high-risk or complex, behavioral health

• Care management – Pre-visit planning – Progress toward goals – Barriers to treatment goals

• Reconcile medications• E-prescribing

ElementsA. Implement Evidence-Based

GuidelinesB. Identify High-Risk PatientsC. Care ManagementD. Medication ManagementE. Electronic Prescribing

Meaningful Use Criteria• Clinical decision support• Medication reconciliation

with transitions of care• E-prescribing• Drug-drug, drug-allergy

checks• Transmit prescriptions using

EHR• Drug-formulary checks

11February 2011

PCMH 4: Provide Self-Care/Community Resources

Intent of Standard• Assess self-management

abilities• Document self-care plan;

provide tools and resources• Counsel on healthy behaviors• Assess/provide/arrange for

mental health/substance abuse treatment

• Provide community resources

ElementsA. Supports Self-Care

ProcessB. Provides Referrals to

Community Resources

Meaningful Use CriteriaPatient-specific education

materials

12February 2011

PCMH 5: Track and Coordinate CareIntent of Standard• Tracks, follows-up on and coordinates tests, referrals

and patient care in other

facilities. • Establish information

exchange with facilities• Follows up with discharged

patients

ElementsA. Track Tests and Follow-

UpB. Track Referrals and

Follow-UpC. Coordinate with Facilities/

Care Transitions

Meaningful Use Criteria• Incorporate lab/test results• Exchange patient information

with other providers (meds/allergies, tests)

• Provide summary care record for transitions and referrals

13February 2011

PCMH 6: Measure and Improve Performance

Intent of Standard• Practice uses performance

and patient experience data to continuously improve

• Track utilization measures• Identifies vulnerable

populations

ElementsA. Measure PerformanceB. Measure Patient/Family

ExperienceC. Implements Continuous

Quality ImprovementD. Demonstrates Continuous

Quality ImprovementE. Report PerformanceF. Report Data Externally

Meaningful Use CriteriaReport:• Ambulatory clinical quality

measures to CMS/ state• Immunization data to

registries• Syndromic surveillance data

to public health agencies

14February 2011

Proposed Plan for Optional Patient Experience Survey

1. PCMH 2011 standards will allow practices to provide reports of patient experience results as documentation for meeting relevant elements

2. Voluntary standardized survey will allow practices to obtain additional distinction for reporting results

15February 2011

Optional Patient Experience Survey• Provide practices with distinction• Require Patient-Centered Medical Home version of

the CAHPS Clinician & Group survey tool on: – Access– Communication– Coordination– Whole person care

• Require standardized sampling approach• Require use of approved data collection

methodologies• Require reporting data to NCQA beginning January

2012• Over time, increase requirements for

standardization to allow results to be scored against benchmarks

16February 2011

Enhance Patient-Centeredness• Goal for PCMH 2011 to Increase patient-centeredness• PCMH 1: Enhance Access and Continuity

– Provide continuity of care with the same provider– Provide information to the patient about medical home– Provide access to care during and after office hours– Provide patient materials and services to meet the language

needs of patients

• PCMH 4: Provide Self-Care and Community Support – Provide resources to support patient/family self-

management

• PCMH 6: Measure and Improve Performance– Involve patients/families in quality improvement– Obtain performance data for key vulnerable populations

17February 2011

Focus on Behavioral Health• Goal for PCMH 2011 to integrate behaviors affecting health,

mental health and substance abuse• PCMH 1: Enhance Access and Continuity

– Comprehensive assessment includes depression screening, behaviors affecting health and patient and family mental health and substance abuse

• PCMH 3: Plan and Manage Care– One of three clinically important conditions identified by the

practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition

– Practice must plan and manage care for the selected condition

• PCMH 4: Provide Self-Care and Community Resources– Self-care support includes educational and community resources

and adopting healthy behaviors

• PCMH 5: Track and Coordinate Care– Tracks referrals and coordinates care with mental health and

substance abuse services

• PCMH 6: Measure and Improve Performance– Preventive measures include depression screening

18February 2011

Questions?

19February 2011

Where to Find PCMH 2011• Standards

– No charge to view or download– Go to www.ncqa.org/view-pcmh2011

• PCMH 2011 Survey Tool – Available March 28– Preorders are accepted now– Go to

http://www.ncqa.org/tabid/629/Default.aspx • NCQA Customer Support

– 1-888-275-7585• Questions

– pcmh@ncqa.org