patient centered medical home initiative · 2016. 7. 10. · sciences) report crossing the quality...

What does this mean for ourCommunity Health Center?

Patient Centered Medical HomeInitiative

PCMH Background The 2001 Institute of Medicine (National Academy of

Sciences) report Crossing the Quality Chasm: A New HealthSystem for the 21st Century was and continues to be amajor source of inspiration for NCQA’s notion of a PatientCentered Medical Home (PCMH)

The report highlighted "10 Simple Rules for the 21stCentury Health Care System" to guide the redesign of thehealth care system.

These simple rules describe a health system quite differentfrom most of what we see today.

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10 Simple Rules for the21st Century Health Care System

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms,

not just face-to-face visits.

2. Customization based on patient needs and values. The system of care should meet the most common types of needs, but

have the capability to respond to individual patient choices andpreferences.

3. The Patient as the source of control. Patients should be given the necessary information and the opportunity

to exercise the degree of control they choose over health care decisionsthat affect them.

4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information

and to clinical knowledge.3


5. Evidence-based decision making. Patients should receive care based on the best available scientific

knowledge.6. Safety as a system property.

Patients should be safe from injury caused by the care system.7. The need for transparency.

The health care system should make information available topatients and their families that allows them to make informeddecisions when selecting a health plan, hospital, or clinicalpractice, or choosing among alternative treatments.

This should include information describing the system'sperformance on safety, evidence-based practice and patientsatisfaction.

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8. Anticipation of needs. The health system should anticipate patient needs, rather

than simply react to events.

9. Continuous decrease in waste. The health system should not waste resources or patient

time.

10. Cooperation among clinicians. Clinicians and institutions should actively collaborate

and communicate to ensure an appropriate exchange ofinformation and coordination of care.

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PPC-PCMH Joint Principles of Care Early work on the medical home concept was done by pediatricians

and focused on care of children with special needs.

The concepts embedded in the Patient Centered Medical Homewere further developed by a collaboration of the ACP, AAFP, AAPand AOA.

NCQA provided input related to work on the PPC and aCommonwealth Fund grant to define “patient-centeredness.”

Joint principles were created and promulgated by this collective.

Physician Practice Connections®—Patient-Centered Medical Home(PPC-PCMH™) is a modification of the original 2006 PhysicianPractice Connections (PPC).

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PPC-PCMH Joint Principles of Care

Personal Care Provider (PCP)— Each patient has an ongoing relationship with an appropriate PCP

trained to provide first contact, continuous and comprehensivecare.

PCP directed medical practice— An appropriate PCP leads a team of individuals at the practice

level who collectively take responsibility for the ongoing care ofpatients

Whole person orientation— An appropriate PCP is responsible for providing for all the

patient’s health care needs or taking responsibility forappropriately arranging care with other qualified professionals.

For adults, this includes care for all stages of life; acute care;chronic care; preventive services and end of life care.

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Care is coordinated or integrated – Care is across all elements of the complex health care system

(e.g., subspecialty care, hospitals, home health agencies, nursinghomes) and the patient’s community (e.g., family, public andprivate community-based services).

Care is facilitated by registries, information technology, healthinformation exchange and other means to assure that patients getthe indicated care when and where they need and want it.

Care is provided in a culturally and linguistically appropriatemanner.

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Quality and safety are hallmarks of the medicalhome. There is advocacy for our patients’ attainment of optimal, patient-

centered (patient-specific) outcomes that are defined by a careplanning process driven by a compassionate, robust partnershipbetween PCPs, patients and the patient’s family.

Evidence-based medicine and clinical decision-support tools guidedecision making.

PCPs accept accountability for continuous quality improvementthrough voluntary engagement in performance measurement andimprovement.

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Quality and safety are hallmarks of the medicalhome. (cont’d) Patients actively participate in decision making and feedback is

sought to ensure patients’ expectations are being met.

Information technology is utilized appropriately to supportoptimal patient care, performance measurement, patienteducation and enhanced communication.

Patients and families participate in quality improvement activitiesat the practice level.

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Enhanced access to care –

Care is available through system processes such as openscheduling, expanded hours and new (advanced or creative)options for communication between patients, their PCP andclinical team.

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NCQA Recognition Evaluation Process The practice conducts a self-scoring readiness assessment using

NCQA’s Web-based Survey Tool, responding to questions, attachingsupporting documentation to verify responses, and submitting data,if applicable.

NCQA score practice by evaluating all data and documentssubmitted by the practice against the 9 PPC-PCMH Standards andassociated elements.

For at least 5 percent of practices, NCQA conducts an additional,onsite audit during which they review source data, includingmedical records, to validate submitted documentation & responses.

NCQA reports information on the practice, its physicians and itslevel of performance to the NCQA Web site and to data users,including health plans and physician directory publishers.

NCQA does not report information on practices that do not pass atany level.12

The 9 PPC- PCMH Standards Each standard consists of several specific elements. The

standards reflect on our ability to function as a PCMH.PPC 1: Access and CommunicationPPC 2: Patient Tracking and Registry FunctionsPPC 3: Care ManagementPPC 4: Patient Self-Management SupportPPC 5: Electronic PrescribingPPC 6: Test TrackingPPC 7: Referral TrackingPPC 8: Performance Reporting and ImprovementPPC 9: Advanced Electronic Communications

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PPC 1: Access and Communication 9 points

We have standards for access to care and communicationwith patients, and we monitor performance in this regard. Intent: We provide patient access during and after regular

business hours, and communicate with patients effectively.

Brief Details We should have and execute standards for staff to respond to

requests during office hours as well as to urgent concerns afterhours.

Tracking reports should show that we meet our standards foraccess through appointments, telephone calls and e-mail orinteractive Web site where applicable.

The 9 PPC- PCMH Standards

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PPC 2: Patient Tracking and Registry Functions 21 points

We systematically manage patient information and use theinformation for population management to support patientcare. Intent: We have readily accessible, clinically useful information

on patients that enables us to treat patients comprehensivelyand systematically.

Brief Details Our practice management system or registry may enable us to

meet some of the elements of this standard.

Our EHR or supplemental system should include the basic dataneeded to provide these functions.


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PPC 3: Care Management 20 points

We systematically manage care for individual patientsaccording to their conditions and needs, and coordinatepatients' care. Intent: We maintain continuous relationships with patients by

implementing evidence-based guidelines and applying them to theidentified needs of individual patients over time and with theintensity needed by the patients.

Brief Details We use evidence-based guidelines. We use clinical care reminders. We use a team approach in managing patient care. We selectively provide care management support to patients with

designated chronic conditions. We are proactive in ensuring that for patients who receive care at

other facilities their clinical info is transferred and they get f/u care.


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PPC 4: Patient Self-Management Support 6 points

We work to improve patients' ability to self-manage healthby providing educational resources and ongoing assistanceand encouragement. Intent: We collaborate with patients and families to pursue their

goals for optimal achievable health.

Brief Details We document a systematic process for prompting our clinical staff

to assess language preference and hearing and visioncommunication barriers.

We help patients manage their own health.


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PPC 5: Electronic Prescribing 8 points

We employ electronic systems to order prescriptions, tocheck for safety and to promote efficiency when prescribing. Intent: We seek to reduce medical errors and improve efficiency

by eliminating handwritten prescriptions and by using drug safetychecks and cost information when prescribing.

Brief Details

Our electronic system should alert our clinicians to specificprescribing issues for patient safety.

Our electronic system should alert the clinician to the most cost-effective of the choices for the patient, including generic drugs.


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PPC 6: Test Tracking 13 points

We systematically track tests ordered and test results, andsystematically follow up with patients. Intent: We work to improve effectiveness of care, patient safety

and efficiency by using timely information on all tests and result

Brief Details Whether the tracking system is manual or electronic, there must be

evidence that the practice reviews and uses the system’s log before orat the beginning of every patient appointment.

There must be evidence that our practice both follows up andproactively notifies the patient of abnormal results

There is electronic communication between our practice and the laband imaging facilities, as well as electronic alerts generated by or forthe practice.


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PPC 7: Referral Tracking 4 points

We systematically document and track referrals and referralresults. Intent: We seek to improve effectiveness, timeliness and

coordination of care by following through on consultations withother practitioners.

Brief Details Clinical details include the clinical reason for requesting the referral as well

as relevant clinical information .

Administrative details include insurance information, including whether thereferral requires health plan approval.

Tracking status includes whether or not the consultant report has returnedto the practice.

A critical referral is determined by the physician to be important to thetreatment of the patient or indicated by practice guidelines.


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PPC 8: Performance Reporting and Improvement 15 points

We regularly measure our performance and take actions tocontinuously improve. Intent: We seek to improve effectiveness, efficiency, timeliness

and other aspects of quality by measuring and reportingperformance, comparing itself to national benchmarks, givingclinical staff regular feedback and taking actions to improve.

Brief Details We generate and distribute performance reports. We use a survey to assess patient perception of access to care (e.g.,

the ability to make an appointment and see a physician, timelinessand quality of phone calls, office wait time).

Having an established a patient advocacy group or patient advisoryboard that meets periodically garners a lot of points.

We are able to report clinical measures electronically to externalentities.


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PPC 9: Advanced Electronic Communication 4 points

We use electronic communication to communicate withpatients/families and other care providers. Intent: We maximize use of electronic communication to

improve timeliness, effectiveness, efficiency and coordination ofcare.

Brief Details

We provide Web-based functionality that support patient access andpatient-self-management.

We use electronic information to communicate with the patient by e-mail about specific needs.

We use electronic communication to support the care managementprocess. Web-based education modules may be on the practice Website or through an arrangement with, and referral to, others.


NCQA Certificaiton Achievement levels

PPC-PCMH certification entails 3 levels of achievement:

Level 1 25 points–49 points.

Must-pass elements = 5 of 10, with a performance level of atleast 50%.

Level 2 50 points–74 points.


Level 3 75 points or more.


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NCQA Scoring Example

Next Steps

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Division of labor1. Self-evaluation against 9 PPC-PCMH Standards

2. Gap analysis

3. Crosswalk with Joint Commission Standards

4. Corrective action planning that is mindful of ourresource limitations and leverages our IT resources

5. Testing (PDSAs, pilots) and implementation

Pursue NCQA Level 3 Recognition

patient centered medical home initiative · 2016. 7. 10. · sciences) report crossing the quality...

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