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Transforming Practices Through
Patient-Centered Medical Home (PCMH)
Overview of the NCQA PCMH 2017 Standards
June 27, 2018
AgendaTime Topic Lead
8:00 - 8:25 AM Welcome, Introductions and Icebreaker Karen & Christina
8:25 - 9:25 AM Overview & Highlights of PCMH 2017- What’s New w/PCMH 2017- Concepts & Scoring- Accelerated Renewal Process- Annual Reporting- Prevalidation- QPASS- Recommended Timelines for Recognition
Karen & Christina
9:25 - 10:10 AM PCMH 2017 Clinical Content & Reports Review- FAQ Document – Demonstration of Centricity Forms- Reports Spreadsheet –Available PCMH reports Review
Christina
10:10-10:20 AM BREAK
10:20-11:15 AM Group Activity- Group activities to introduce attendees to a few of the new criteria
Christina
11:15-11:45 AM Panel Discussion- Best practices/lessons learned from PCMH recognized Health
Centers
Your Fellow Colleagues!
11:45-12:00 PM Q&A- Any further questions?- Available PCMH resources- Future steps as a PCMH cohort
Karen & Christina
Continuing Education Disclosures
Commercial Support – None
Speaker or planner conflicts of interest – None
For CME and CNE credit or an Attendance Certificate -
Full session attendance and
completion of an on-line evaluation is required.
Link to the evaluation is on the AllianceChicago Conference App
Thank you!
Welcome & Introductions
Welcome & Introductions
• Name
• Health Center
• PCMH Recognition Status
Getting to Know You...
1) Find one person with the same color chip and share one PCMH challenge your organization faces (3 minutes).
2) Find one person with the same color chip and share one PCMH success story from your organization (3 minutes).
3) Find one person with the same color chip and share a story about a favorite journey you've taken in your life (3 minutes).
Overview & Highlights of PCMH 2017
Why Patient-Centered Medical Home?
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
• Helps to drive important reforms in healthcare delivery
• PCMHs save money
• Mitigates health disparities
• Improves patient outcomes
And......
Click to add text
HRSA Grant Awards
PCMH 2017 Highlights
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
PCMH 2017 Standards Format
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
PCMH 2017 Standards
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
PCMH 2017 Standards
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
PCMH 2017 Standards
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Recognition: No More Levels
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Scoring
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Redesign: Why?
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Standards: 2014 v 2017
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Standards Redesign: 3 Parts
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Sustaining Recognition
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
2017 Distinction Modules
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
Prevalidation
• NCQA prevalidated Health IT solutions have successfully demonstrated that their technology solution has functionality that supports or meets one or more criteria in the PCMH standards
• GE Centricity is a prevalidated HIT vendor!
• Evaluation can result in approved fully met criteria and partially met criteria that are transferable to eligible client practices submitting for recognition and acknowledgment of practice support functionality
Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance
PrevalidationHow to obtain prevalidation:
• Contact the AllianceChicago (Karen or Christina) to obtain:
• Letter of Product Implementation from GE/your vendor, indicating which prevalidated tool(s)/modules approved for transfer credit have been implemented at the practice
• Vendor’s Prevalidation Letter of Credit Approval
• Upload the Letter of Product Implementation to QPASS and submit for review/approval from NCQA
Accelerated Renewal Process
• Practices will be able to attest to meeting certain criteria without providing the full evidence required (no demonstration of documentation and/or evidence)
• Qualifications
• PCMH 2011 Level 1, 2, or 3 recognized practices
• PCMH 2014 Level 1 or 2 recognized practices
Annual Reporting
• Practices will attest that they have continued to adopt the PCMH principles and maintained recognition using the PCMH Annual Questionnaire
• Qualifications
• PCMH 2014 Level 3 recognized practices
• PCMH 2017 recognized practices
Q-PASS
• ISS Survey Tool > Quality Performance Assessment Support System (Q-PASS)
• Web-based platform to submit required evidence and documentation to NCQA during the Transformation Phase & Succeed Phase (annual reporting)
• Q-PASS lets you manage multiple organizations, practices, clinicians and recognitions through a SINGLE portal.
Q-PASS
Quick demo:
https://qpass.ncqa.org/
- How to set up an account
- How to access the organization dashboard
- Where/how to submit evidence
- How to link evidence
QPASS – How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- How/where to submit evidence
QPASS - How/where to submit evidence
QPASS- How/where to submit evidence
QPASS- Accelerated Renewal: How to attest for a criteria
QPASS- How to submit for a virtual check-in
QPASS- How to submit for a virtual check-in
Recommended Timelines – No Prior Recognition
Modify any
evidence that did
not pass & continue
preparation for 3rd
virtual review
Modify any
evidence that did
not pass & continue
preparation for 2nd
virtual review
Schedule &
complete 1st virtual
check-in call
Schedule &
complete 2nd virtual
check-in callSecond& complete
3rd/final check-in
call
Review the 2017
S&G and the
PCMH Progress
Log
Submit NOI to
HRSA if needed
QPASS – Set up
account and enroll
site(s)
Initial intro call with
NCQA Rep
Qrt 1 Qrt 2 Qrt 3 Qrt 4
Recommended Timelines – Accelerated Renewal Process
Modify any
evidence that did
not pass & continue
preparation for 3rd
virtual review
Modify any
evidence that did
not pass & continue
preparation for 2nd
virtual review
Schedule &
complete 1st virtual
check-in 2-3
months after the
initial intro callSchedule &
complete 2nd virtual
check-in call 2-3
months after the
2nd check-in call
Schedule &
complete 3rd/final
check-in call 2-3
months after the 3rd
check-in call
Review the 2017
S&G, Accelerated
Renewal Process,
& PCMH Progress
Log
Submit NOI to
HRSA if needed
QPASS – Set up
account and enroll
site(s)
Initial intro call with
NCQA Rep
Qrt 1 Qrt 2 Qrt 3 Qrt 4
Recommended Timelines – Annual ReportingComplete Annual Survey Questionnaire in QPASS-
Note: Reporting date, or the date the evaluation must be
submitted is 30 days before the end of the practice’s
current recognition
Review the 2017
S&G, Annual
Reporting PDF, &
PCMH Progress
Log
Submit NOI to HRSA
if needed
QPASS – Create
organizations and
enroll site(s) at the
minimum 90 days
before the end of the
practice’s current
recognition
Initial intro call with
NCQA Rep
Month 1 Month 2 Month 3 End of current recognition
PCMH 2017 Clinical Content & Reports Review
Helpful Documentation
• The following can help you start or maintain PCMH Recognition:
▪ Alliance NCQA PCMH 2017 Progress Log
▪ Alliance FAQ: PCMH 2017 Content
▪ Alliance High, Medium, Low Priority Reports Log
Helpful Documentation• Alliance Progress Log
• Located on Loop.alliancechicago.org > Resources > PCMH
• Useful for PCMH teams to review the type of documentation required, location in the content, NCQA 2014 alignment, and responsible party
PCMH 2017 Clinical Content
• Alliance FAQ: PCMH Content
• Located on loop.alliancechicago.org > Resources > PCMH
• Helps to inform you of new and revised content for PMCH
• Can be a good training document for staff
PCMH 2017 Clinical Content• Alliance PCMH 2017 Flowsheet
• Initial Intake
• Adult Chief Complaint / History of Present Illness
• Care Management Plan
• Care Team
• Self-Management Goals
• Quality of Care Checklist
• Pre-Visit Preparation
• Team Huddle
• Phone Note
• PC-PTSD
• Adult ADHD
• Referral Order
• Pre-visit Prep
• Assessment and Plan
• PRAPARE
• Patient History
• Well Child Care
• Adult HM & Ed
• Preventative Care
• GAD
• AUDIT
• DAST
• HEEADSSS
PCMH 2017 Clinical Content – Let's take a closer look
• PCMH 2017 Flowsheet
• Initial Intake
• Care Management Plan
• PRAPARE
PCMH 2017 Reporting
• Alliance PCMH Reporting Log and Status
• Located on loop.alliancechicago.org > Resources > PCMH
• Lists High, Medium, Low Priority Reports & Status / Delivery Schedule
10 Minute Break
Group Activities: Let's get familiar with the 2017 standards and guidelines!
Group Activities
• Find a table with other folks outside your organization
• You're going to review challenging criteria and discuss how you would meet it
• What documented process, evidence of implementation, or patient examples would we need?
Group Activities
Team Based Care
• TC 06 (Core) Individual Patient Care Meetings/Communication: Has regular patient care team meetings or a structured communication process focused on individual patient care. (10 minutes, 5 minutes report-out)
Knowing & Managing Your Patients
• KM 02 (Core) Comprehensive Health Assessment: Comprehensive health assessment includes (all items required): (10 minutes, 5 minutes report-out)
• Medical history of patient and family.• Family/social/cultural characteristics.• Communication needs.• Behaviors affecting health.• Social functioning.• Social determinants of health.• Developmental screening using a standardized tool (NA for practices with no pediatric population under 30 months of age)• Advance care planning (NA for pediatric practices).
Group Activities Continued
Care Coordination and Care Transitions
• CC 14 (Core): Identifying Unplanned Hospital and ED Visits: Systematically identifies patients with unplanned hospital admissions and emergency department visits.
• CC 15 (Core): Sharing Clinical Information: Shares clinical information with admitting hospitals and emergency departments.
• CC 16 (Core): Post-Hospital / ED Visit Follow-up: Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit. (10 minutes, 5 minutes report-out)
Hear from the Experts!
Best Practices/Lessons Learned
• Developing your PCMH Team
• How to overcome challenges/barriers during the PCMH transformation journey
• How to successfully engage providers and staff to transform into a PCMH
Next Steps & Attendee Feedback
• How can the AllianceChicago best support you in your future PCMH transformation?
• PCMH Workshops/Webinars – Deep dive of the PCMH 2017 Standards & Guidelines
• Monthly/Quarterly Committee Calls
Q & A
Thank you!
Karen Iversen, MPH, PCMH-CCEkiversen@alliancechicago.org
Christina Kim, MPH, PCMH-CCEckim@alliancechicago.org
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