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TRANSCRIPT
Advancing HealthcareImproving Health
2017 NCQA PCMH Standards Workshop Day 1
June 12, 2018Susan Crocetti, RN, NCQA PCMH CCE
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Polling Questions
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Objectives for today:• Review the re-designed process for gaining and
maintaining NCQA PCMH recognition • Discuss strategies for managing the work• Review the intent and evidence requirements of
the NCQA 2017 PCMH Standards• Highlight what’s new, what’s the same, discuss challenges
and strategies to overcome these3
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What Hasn’t Changed
• Foundation of Medical Home Model
• Eligibility criteria• 2014 Must Pass
Elements are embedded in Core Concepts
• Record Review Workbook and QMIW
• Types of documentation (data sources)
• Multisite requirement• Pre-validation credits• Reconsideration still
an option
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2017 High-Level Changes• Focus on
– understanding your patient population– using data to customize your practice – demonstrating outcomes
• Flexible path to recognition• Personalized service • Single sign-on• Less documentation burden• Ownership of recognition process
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New Terminology: The Three C’s
Concept =Foundational premise for
PCMH
Criteria =Individual structure, function, activity
Competency =Categorized to organize the details
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Team-Based Care and Practice Organization (TC)
Knowing and Managing Your Patients (KM)
Patient-Centered Access and Continuity (AC)
Care Management and Support (CM)
Care Coordination and Care Transitions (CC)
Performance Measurement and Quality Improvement (QI)
The Six Concepts
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New Format for StandardsConcept
Description Core or Elective
Documentation requirements
Additional information NCQA
wants to see
Criteria
Competency and Description of Performance Expectation
Shareable across practice sites
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Recognition and Distinction• No levels = No add-on surveys• Pass or Fail• Options for distinction
– Patient Experience Reporting– Behavioral Health Integration– Electronic Measure Reporting (eCQM)
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PCMH 2017 Scoring
• Meet all core criteria in the program = 40 credits• Earn 25 credits in elective criteria across 5 of 6
concepts– There are 60 elective criteria for a total of 83 elective
credits available = criteria may be worth 1, 2, or 3 credits
Minimum passing score is 65 credits
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Pathways to 2017 Recognition
2017 PCMH
Recognition
Never Recognized:
Full Redesign Process
PCMH 2011 or 2014 Level 1 or 2
Recognized:Accelerated
Renewal ProcessPCMH 2014 Level
3 Recognized:Direct to
Sustaining Process
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• “Think you’re ready? Take our assessment.”• NCQA representative helps with evaluation plan and
schedule• At least three virtual reviews• Must submit evidence as outlined in the 2017
Standards within 1 year of enroll & fees
Initial
• PCMH 2011 – any level• PCMH 2014 – Level 1 or 2• Attest to certain criteria – submit evidence for others• At least three virtual reviews
Accelerated
• PCMH 2014 Level 3• 30 days before anniversary date – complete all
“Succeed” steps• Attest to previous performance• Provide evidence (at any point within the year) of
demonstrating continuing PCMH activities
Annual
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New Recognition ProcessCommit, Transform, Succeed
NCQA PCMH 2014 Level 3’s start at “Succeed”!
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Commit• Find or create Q-PASS
account• Complete an online
guided assessment to ensure eligibility
• Complete Q-Pass enrollment information
• Sign documents within Q-PASS and pay fee
• Have planning call with assigned NCQA Representative
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Q-PASS Enrollment Checklist
• Organization and Individual Practice– legal name and
address– primary and secondary
contact names and email addresses
– Representative with legal authority to sign BAA with NCQA
– Method of payment or sponsor code
• Individual Practice– List of specialties– Practice tax ID number
and NPI (if available)– Clinician names, DOB,
specialty, board certification type and numbers, NPI numbers
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Transform• Schedule 1-3 virtual
check-in calls over a 12 month period with NCQA Evaluator
• Follow your plan– Prior to each check in call,
submit agreed upon documents
– Get feedback on what you submitted and share additional information “live” at each check in call
– Earn recognition– Reconcile clinician #’s and
adjust fees
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Succeed and Sustain
• Annual data submission and attestation
• Done through Q-PASS and will not require a virtual check-in unless selected for audit
• Annual fees due at this time
• Multisite practices submit annual data at same time
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Practices Not Previously Recognized
• Recognition Process Steps– Create or locate your Q-PASS Account– Complete Eligibility / Readiness Survey– Enroll Site(s)– Meet with NCQA Representative and plan for up to 3
virtual check-ins and what to cover at each one– Discover Educational Resources– Provide Evidence Prior To and During Review– Modify based on feedback
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“Transform” Phase Virtual Check-In Process
Determine Criteria to Address
Focus on Core & Documented
Processes First
Identify Criteria for 25 Elective Credits
Provide Documents For Offsite Review
Submission
P&P’s, website links, public information
Attestation in Q-Pass
Provide Evidence During Virtual
Review
Discussion and Demonstration
with NCQA Evaluator
Substitute or Provide Additional
Information if Needed
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Let Your Innovation Shine
• Flexibility and Creativity are Encouraged!
• Guidance and Suggested Evidence are Not Exhaustive
• Prepare your rationale with evidence and enthusiasm
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After a Virtual Check-In• Evaluator marks criteria
“met”• Can see your current
score under “Evaluation” in Q-PASS
• Practice can continue to work on criteria “not met”
• NCQA will review questions remaining
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After the Final Virtual Check-In
If all Core and at least 25 Elective credits earned, results are forwarded to NCQA Review Oversight Committee (ROC) for final decision
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Virtual Check-Ins
• Must be completed within 12 months of date payment was made to NCQA
• If additional check in’s or time extension needed can be arranged for additional fee
• Allow 2 hours per session• Who needs to be there?• How can you prepare?
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Accelerated Renewal For Practices Recognized under 2011
or 2014 Level 1 or 2• May attest to identified criteria (18 of the 40 core criteria, 34 of the
60 elective criteria)• “Commit” six months prior to expiration date• Submit required evidence in Q-PASS.• For attestation eligible criteria enter the statement below for the first
criteria, then type “Accelerated Renewal” into the text box for additional attestable criteria
“Our practice achieved PCMH [201X] Level [X] recognition as a patient-centered medical home. We attest that our responses reflect our practice’s current operations. Documentation to support these responses will be provided upon request.”
• Will have virtual review / check-in(s) option with NCQA to demonstrate eligible evidence
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Accelerated Renewal Table
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Succeed / Sustain Annual Reporting Process
• PCMH 2014 level 3 practices or 2017 practices only• Submit at least 30 days prior to recognition expiration
date but can get started any time within the year.• Enroll / set up Q-PASS (confirm practice information and
make any clinician changes, pay fee, sign documents)• Complete Self Assessment verifying that core features of
the medical home have been sustained • Upload or attest to specific requirements listed in Annual
Reporting Requirements Table into Q-PASS
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Annual Reporting Requirements: Overview and Table
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Succeed / Sustain
• No virtual meeting with NCQA required• NCQA will audit a random sample of practice
submissions to verify that PCMH requirements and guidelines are being met over time– Focus will be on areas addressed through practice
attestation in the annual reporting requirements– Will involve a virtual meeting
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Multisite• Three or more practice sites sharing an EHR
and standardized policies and procedures• Multisite “Enrollment” in Q-PASS• Add site information in Q-PASS
– Option to access an Excel template within Q-PASS, complete it and upload
• Use same Q-PASS account platform for proving eligibility of shared and site specific criteria
• 68 of 100 criteria can be shared across sites (42 fully, 26 partially / documented process only)
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Multisite (con’t)• Identify primary site
– Full review only for this site– Shared criteria auto-populate in subsequent sites
• Use the Accelerated Renewal Table as a quick reference for criteria that are shareable
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Staying Current
• Standards for documentation and reporting will likely change annually and will be available 6 months prior to when they are due to take effect.
• If you miss your annual check-in or don’t meet the requirements– Recognition is suspended– Have 90 days to make corrections
• If not, still have 9 months to make corrections, submit reports and participate in a limited review process with an evaluator
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Eligibility Evaluation
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Questions?
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Preparing for Survey - Where to Begin? • PCMH 2017 Standards and Guidelines (free)
• Conduct Preliminary Self-Assessment • Updates / revisions
• NCQA Training On-line (free)• Webinars• Presentation Slides • FAQ’s
• NCQA On-line Application via Q-PASS (**new process - pay fees up front) http://qpass.ncqa.org/
• Account Information (demographics, contact info, etc.)• Legal Documents (program agreement, BAA)• Multisite Eligibility Request• Clinician names and numbers
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Select a Project Team• Develop the multidisciplinary project team:
clinician, nursing, admin, IT/analytics, QI
• Project team characteristics:– Champions/leaders to bring about change and lead
decision making– Organizational and departmental knowledge– Detail-oriented– Policy knowledge – Reporting skills – Ability to obtain screen shots
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Establish a Timeline
Self Assessment, GAP Analysis, Action Plan with priorities and assignments
1 year prior to current expiration date
All Processes Implemented and dated documented processes completed
4 months prior to current expiration date
Submit in QPASS
1 month prior to current expiration date
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Conduct a Self-Assessment• Evaluate what processes are in place
• Address core criteria first, then elective criteria using “speed dating” method
• Implement new processes or revise existing processes as needed• Consider 90 day track record and revise timeline
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Self Assessment Using the Qualis Health 2017 Assessment and Action
Plan Tool
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Prepare Evidence• Ensure evidence to support compliance exists
• Store these in an organized folder system• Reports must not be older than 1 year, documented
processes dated and in place at least 3 months– Annotate with call outs/highlighting/text boxes, etc. to
identify sections that meet specific criteria– Redact any PHI
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Where Can I Learn More?
http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh
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Questions?
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THE STANDARDSLet’s Dig In!
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Concept: Team-Based Care and Practice Organization (TC)
• The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.
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TC Competency A:Practice Organization,
Team Roles and Training• The practice is committed to transforming into
a sustainable medical home. • Members of the care team serve specific roles
as defined by the practice's organizational structure and are equipped with the knowledge and training to perform those functions.
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Competency A - TC 01 (Core) PCMH Transformation Leads
NEW• Identifies the clinician lead and the
transformation manager (the person leading the PCMH transformation). This may be the same person.
• Evidence = details about the clinician lead and the PCMH manager; the practice provides details including the person’s name, credentials, roles &responsibilities.
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Competency A -TC 02 (Core) Organizational Structure and Staff Responsibilities
• Provide an overview of practice staff; an outline of duties the staff are expected to execute as part of the medical home; and how the practice will support and train staff to complete these duties.
• Evidence = Staff structure overview and description of staff roles, skills and responsibilities. Care team staff training program.
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Competency A -TC 03 (1 Credit) Involvement in External PCMH
Collaborations - NEW• Demonstrates involvement in at least one
state or federal initiative or participates in a health information exchange.
• Evidence = Description of involvement in external collaborative activity (e.g., CPC+, care management learning collaborative led by the state, two-way data exchange with a local health information exchange; population-based care or learning collaborative).
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Competency A -TC 04 (2 Credits) Patient/Family/Caregiver Involved in
Governance • Patients/families/caregivers have
a role in the practice’s governance structure or Board of Directors.
• Organizing a patient and family advisory council (i.e., stakeholder committee).
• Evidence = Documented process and evidence of implementation
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Competency A -TC 04 Documented Process
• Clarifies role, selection criteria, frequency of meetings
Source: Turner House Children’s Clinic, 2015, used with permission.
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Competency A -TC 05 (2 Credits)Certified EHR System
• The practice enters the name of the electronic system(s) implemented in the practice.
• Only systems the practice is actively using should be entered
• Evidence = Certified EHR name
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TC Competency B:Care Team Communication
and Functioning• Communication among staff is organized to
ensure patient care is coordinated, safe, and effective.
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Competency B -TC 06 (Core)Individual Patient Care Meetings /
Communication• The practice maintains a structured
communication process, sharing information about patients, care needs, concerns for the day and other information that encourages efficient patient care and practice flow.
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Competency B -TC 06 (Core)Individual Patient Care
Meetings/Communication• The process may include tasks or messages
in the medical record, regular e-mail exchanges, or notes on the schedule about a patient and the roles of the clinician or team leader and others in the communication process.
• Evidence = Documented process and evidence of implementation.
Aligns with PCMH 2014 2D3
58Source: Turner House Children’s Clinic, 2015, used with permission.
Competency B -TC 06 (CORE)Individual Patient Care
Meetings/CommunicationEvidence
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Competency B -TC 07 (Core)Staff Involvement in Quality Improvement
• The documented process for quality improvement activities includes a description of staff roles and staff involvement in the performance evaluation and improvement process.
• Evidence = Documented process and evidence of implementation.
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Competency B -TC 08 (2 Credits)Behavioral Health Care Manager
The practice identifies the behavioral healthcare manager and provides their qualifications. The care manager has the training to support behavioral healthcare needs in the primary careOffice and coordinates referrals to specialty behavioral health services outside the practice.
• Evidence = Identified behavioral health manager and their qualifications
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TC Competency C:Patient/Family/Caregiver Orientation
• The practice communicates and engages patients on expectations and their role in the medical home model of care.
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Competency C - TC 09 (Core) Medical Home Information
• The documented process includes providing patients/families/caregiver with information about the role and responsibilities of the medical home.
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TC 09 – At a Minimum Includes Information On:
• After-hours access• Scope of services • Evidence-based care• Availability of
education and self-management support
• Practice points of contact
• Evidence = Documented process and evidence of implementation
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Competency C TC 09 Medical Home Information-Evidence
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Questions?
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Break10:30 –10:40 am
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Polling Questions
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Concept: Knowing and Managing Your Patients (KM)
• The practice captures and analyzes information about the patients and community it serves and uses the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.
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Competency A
• The practice routinely collects comprehensive data on patients to understand background and health risks of patients. The practice uses information on the population to implement needed interventions, tools, and supports for the practice as a whole and for specific individuals.
KM Competency A: Comprehensive
Patient/Population Knowledge: The practice routinely collects
comprehensive data on patients to understand background and health risks of patients. The practice uses
information on the population to implement needed interventions,
tools, and supports for the practice as a whole and for specific
individuals.
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Competency A - KM 01 (Core) Documents an Up-To-Date Problem List
• Up-to-date means that the most recent diagnoses are added to the problem list.
• Evidence = Report showing patients with updated problem list at least annually or KM06 list of top priority conditions and concerns
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KM 01 Up-To-Date Problem List
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Competency A - KM 02 (Core) Comprehensive Health Assessment - NEW
• A comprehensive patient assessment includes an examination of the patient’s social and behavioral influences in addition to a physical health assessment.
• The practice uses evidence-based guidelines to determine how frequently the health assessments are completed and updated.
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Competency A - KM 02 (Core) Comprehensive Health Assessment - All
A. Medical history of patient and family.
B. Mental health/substance use history of patient and
family.
C. Family/social/cultural
characteristics.
D. Communication needs.
E. Behaviors affecting health.
F. Social functioning. (NEW)
G. Social determinants of
health. https://www.healthypeopl
e.gov/
H. Developmental screening using a
standardized tool. (NA for practices with no pediatric population
under 30 months of age.)
I. Advance care planning. (NA for pediatric
practices.)
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Competency A - KM 02 (Core) Comprehensive Health Assessment - NEW
• All items required• Evidence = Documented process AND
evidence of implementation
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KM 02-Comprehensive Health AssessmentCreate a Flowsheet for a Comprehensive Health Assessment so all of
the documentation is easily seen in one place
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Competency A – KM 03 (Core) Conducts Depression Screenings for Adults and
Adolescents Using a Standardized Tool
• Screening for adults: Screening adults for depression with systems in place to ensure accurate diagnosis, effective treatment and follow-up.
• Screening for adolescents (12–18 years): Screening adolescents for depression with systems in place to ensure accurate diagnosis, effective treatment and follow-up.
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Competency A – KM 03 (Core) Conducts Depression Screenings for Adults and
Adolescents Using a Standardized Tool
• Evidence = Documented process or report –and evidence of implementation which includes identifying the tool. The documented process includes the practice’s screening process and approach to follow-up for positive screens.
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Competency A - KM 04 (1 Credit) Conducts Behavioral Health Screenings Using a
Standardized Tool - NEWImplement two or more:
A. Anxiety.
B. Alcohol use disorder.
C. Substance use disorder.
D. Pediatric behavioral health screening.
E. Post-traumatic stress disorder.
F. Attention deficit/hyperactivity disorder.
G. Postpartum depression.
Evidence = Documented process AND evidence of implementation
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KM 04 ResourcesLinks to Screening Tools
• https://www.drugabuse.gov/nidamed-medical-evidence-based-screening-tools-adults
• http://www.sbirttraining.com/• CAGE AID• DAST-10• http://www.integration.samhsa.gov/clinical-
practice/screening-tools• AAP Mental Health Tools for Primary Care
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Competency A - KM 05 (1 Credit)Assess Oral Health & Provide Necessary
Services - NEW
• Conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer.
• Evidence = Documented process and evidence of implementation.
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Competency A - KM 06 (1 Credit)Identifies Predominant Conditions and
Health Concerns of Patient Populations
• The practice identifies its patients’ most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.
• Evidence = List of top priority conditions and concerns
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Competency A - KM 07 (2 Credits)Understands Social Determinants of Health
Within the Population - NEW
• Collects information on social determinants of health, demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources, or other tools to serve the on-going needs of its population.
• Evidence = Report and evidence of implementation
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KM 07 Social Determinants of Health• Examples of social determinants include:
– Availability of resources to meet daily needs– Access to educational, economic & job opportunities– Public safety, social support– Social norms and attitudes– Food and housing insecurities– Household/environmental risk factors– Exposure to crime, violence and social disorder– Socioeconomic conditions– Residential segregation
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Competency A - KM 08 (1 Credit) Patient Materials - NEW
• Evaluates patient population demographics, communication preferences, health literacy to tailor development and distribution of patient materials– Demonstrates an understanding of the patients’
communication needs by utilizing materials and media that are easy for their patient population to understand and use.
– Considers patient demographics such as age, language needs, ethnicity, and education when creating materials for its population.
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Competency A - KM 08 (1 Credit)Patient Materials - NEW
• May consider how patients like to receive information (i.e., paper brochure, phone app, text message, e-mail), in addition to the readability of materials (e.g., general literacy and health literacy).
• Evidence = Report and evidence of implementation
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KM Competency B: Cultural Competency
• The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs. The practice uses this information to ensure linguistic and other patient needs are met.
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Competency B - KM 09 (Core)Assesses Race, Ethnicity and One More
Measure of Diversity
• Collects information on how patients identify in at least three areas that include:
1. Race2. Ethnicity3. One other aspect of diversity, which may include, but is not limited to, gender identity, sexual orientation, religion, occupation, geographic residence.
• Evidence = Report
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KM09
Use Patient Demographics to collect race,
ethnicity, gender.
Use UDS reports Tables 3
& 4
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Competency B - KM 10 (Core)Assesses Language Needs of the
Population
• Documents in its records whether the patient declined to provide language information, that the primary language is English or that the patient does not need language services.
• A blank field does not mean the patient’s preferred language is English.
• Evidence = Report
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Competency B - KM 11 (1 Credit) Identifies and Addresses Population-Level
Needs Based on Diversity - NEW
• Recognizes the varied needs of its population and the community it serves, and uses that information to take proactive, health literate, culturally competent approaches to address those needs.
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Competency B - KM 11 Population Needs Consider at least 2 items below and show
evidence of implementation A. Targets population health management on disparities in care
• Identifies disparities in care and implements actions to reduce the disparity, providing care equally to their vulnerable populations and general population
• Can also show QI 05 and QI 13 –assess disparities and act to improve as evidence
B. Educates practice staff on health literacy
• Builds a health literate organization (e.g., apply universal precautions, health literacy training to staff, system redesign to serve patients at all levels, utilize health literacy toolkits
C. Educates practice staff in cultural competence
• Builds a culturally competent organization that educates staff on how to interact effectively with people of different cultures. Supports staff to be respectful and responsive to health beliefs and cultural/linguistic needs of patients
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Competency B - KM 11 (1 Credit) Resources
• IOM Ten Attributes of Health Literate Organizations
• AHRQ Health Literacy Toolkit.pdf• Alliance for Health Reform Toolkit
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KM Competency C:Proactive Population Management• The practice proactively addresses the care
needs of the patient population to ensure needs are met.
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Competency C - KM 12 (Core) Proactively and Routinely Reminds Patients
of Needed Services• Must report at least 3 categories:
A. Preventive care services.B. Immunizations.C. Chronic or acute care services.D. Patients not recently seen by the practice.
• Evidence =– Report/list and outreach materials– May use KM 13 to meet item C
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KM 12 Examples
Patient Centered Medical Home (PCMH 2014) Standards Training material is reproduced with permission from the National Committee for Quality Assurance (NCQA) website. Source: http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PCMH2014Standards.aspx. Last accessed: October 2015.
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KM 12 Examples
Source: Turner House Children’s Clinic, 2015, used with permission.
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Competency C - KM 13 (2 Credits) Excellence in Performance - NEW
• At least 75% of eligible clinicians have earned NCQA HSRP or DRP recognition or
• The practice demonstrates that it is participating in a program that uses a common set of measures to benchmark participant results, has a process to validate measure integrity and publicly reports results. Shows (with reports) that clinical performance is above national or regional averages.
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Evidence = Report or proof that at least 75% of eligible clinicians have earned NCQA HSRP or DRP recognition. Examples of other programs include: MN Community Measures, Bridges to Excellence, IHA or other performance-based recognition programs.
Competency C - KM 13 (2 Credits) Excellence in Performance - NEW
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KM Competency D:Medication Management
• The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation, and assessment of barriers.
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Competency D - KM 14 and 15 (Core) Reviews and Reconciles Medications and
Maintains Medication Lists• Medication review and
reconciliation occurs at transitions of care, or at least annually
• Maintains an up-to-date medication list
• Evidence = Report > 80%
101
Competency D - KM 16 -17 (1 Credit Each) Assesses Understanding of New
Medications, Patient Response, and Barriers
• Uses patient-centered methods, such as open-ended questions (i.e., teach-back collaborative method), to assess medication understanding.
• Asks patients if they are having difficulty taking a medication, are experiencing side effects and are taking the medication as prescribed. If not, determines why.
• Evidence = Report > 50% and evidence of implementation
102
Competency D - KM 18 (1 Credit) Reviews Controlled Substance Database - NEW
• Consults a state controlled-substance database - also known as a Prescription Drug Monitoring Program (PDMP) or Prescription Monitoring Program (PMP) -before dispensing Schedule II, III, IV, and V controlled substances.
• Follows established guidelines or state requirements to determine frequency of review
103
KM 18 Controlled Substance Database Review
• Evidence = Evidence of implementation
• https://app.mt.gov/pdr
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Competency D - KM 19 (2 Credits) Obtains Prescription Claims Data to Assess and Address Medication Adherence - NEW
• Systematically obtains prescription claims data or other medication transaction history. This may include systems such as SureScripts e-prescribing network, regional health information exchanges, insurers, or prescription benefit management companies.
• Evidence = Evidence of implementation
105
KM Competency E:Evidence-Based Decision Support
106
Competency E: KM 20 (Core)Clinical Decision Support
• Implements clinical decision support following evidence-based guidelines for care of various conditions
• Utilizes systems in day-to-day operations that integrate EBG/CDS, such as:– Computerized alerts– Condition specific order sets– Focused patient data reports and summaries– Documentation templates– Diagnostic support– Contextually relevant reference information
107
Competency E - KM 20 (Core)
A. Mental health condition
B. Substance use disorder
C. A chronic medical condition
D. An acute condition
E. A condition related to unhealthy
behaviorsF. Well child or
adult care
G. Overuse or appropriateness
issues
108
Competency E - KM 20 (Core) Incorporates Evidence-Based Clinical
Decision Support • Must demonstrate at least 4 of the 7 criteria• Evidence = Identifies condition, source of
guidelines, AND evidence of implementation• The American Board of Internal Medicine
Foundation’s Choosing Wisely campaign provides information about implementing evidence-based guidelines as clinical decision support:
• http://www.choosingwisely.org/
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Competency E KM 20 Clinical Decision SupportThe measure Configuration is in set up and the CDSS Alerts can be seen for each patient
Other ideas:Create an Order Set or Flowsheet
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KM Competency F:Community Resources
Identifies, considers and establishes connections to community resources to collaborate and direct patients to needed support.
111
Competency F - KM 21 (Core) Uses Information to Prioritize Needed
Community Resources - NEW
• Identifies needed resources by assessing collected population information.
• May assess social determinants, predominant conditions, emergency department usage, and other health concerns to prioritize community resources.
• Evidence = List of key patient needs and concerns
112
Competency F - KM 22 (1 Credit) Access to Educational Resources
• Provide access to educational materials, peer support sessions, group classes, and other resources.
• Evidence = Evidence of implementation, plus 3 examples
113
Competency F KM 22 Patient MaterialsPublish Patient Education to the PortalNOTE: For Stage 3 MU must send Patient Education electronically from a third party vendor (Healthwise, Krames, etc)
114
Competency F - KM 23 (1 Credit) Provides Oral Health Education and
Resources to Patients - NEW
• The practice provides an example of how it provides patients with educational and other resources that pertain to oral health and hygiene.
• Evidence = Evidence of implementation, one example
115
Competency F - KM 24 (1 Credit) Adopts Shared Decision-Making Aids for
Preference Sensitive Conditions
• The care team has, and demonstrates use of, at least three shared decision-making aids that provide detailed information without advising patients to choose one option over another.
• Evidence = Evidence of implementation
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Shared Decision-Making Tools Examples
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Shared Decision-Making Tools Examples
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Shared Decision-Making Tools Resources
• “Helping Patients Make Better Treatment Choices with Decision Aids” by the Commonwealth Fund: http://www.commonwealthfund.org/publications/newsletters/quality-matters/2012/october-november/in-focus
• International Patient Decision Aid Standards Collaboration
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Competency F - KM 25 (1 Credit) Engages with Schools or Intervention Agencies in the Community - NEW
• Develops supportive partnerships with social services organizations or schools in the community.
• The practice demonstrates this through formal or informal agreements or identifies practice activities in which community entities are engaged to support better health.
• Evidence = Documented process AND evidence of implementation
120
Competency F - KM 26 (1 Credit) Maintains a List of Community Resources
• Based on the needs identified in KM 21, the practice maintains a community resource list by selecting five topics or community service areas of importance to the patient population.
• Evidence = List of resources, with date of recent update. The list includes services offered outside the practice and its affiliates.
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Competency F - KM 27 (1 Credit) Assesses the Usefulness of Identified
Community Resources• Assesses the usefulness of
resources by requesting and reviewing feedback from patients/families/caregivers about community referrals. Community referrals differ from clinical referrals, but may be tracked using the same system.
• Evidence = Evidence of implementation
122
Competency F - KM 28 (2 Credits) Case Conferences Involving Parties Outside
the Practice Team - NEW• Uses “case conferences” to share information
and discuss care plans for high-risk patients with clinicians and others outside its usual care team.
• Case conferences are planned, multidisciplinary meetings with community organizations, or specialists to plan treatment for complex patients.
• Evidence = Documented process ANDevidence of implementation
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Questions?
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Time for Lunch!