applying ncqa ppc-pcmh standards to primary care and behavioral health maria ludwick, mph harold...
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Applying NCQA PPC-PCMH Standards to Primary Care and Behavioral Health
Maria Ludwick, MPH
Harold Pincus, MD
Agenda PCASG Quality Improvement Program
NCQA Patient Centered Medical Home Basics
Adaptation to PC - BH
Gaps in Implementation
Strategies to Fill the Gap
Note: This is a participatory session
Goals for the Primary Care Access and Stabilization Grant
o Increase access to care on a population basis
o Develop sustainable business entities
o Provide evidenced based, quality health care
o Develop an organized system of care
PCASG Quality Improvement Program
Interprets NoA requirement for a quality improvement program at the grantee level
Approved by CMS in June 2008
Outlines a uniform set of quality standards Minimum quality requirements Optional incentive payment program
Encourages maximum participation
Based on National Committee for Quality Assurance (NCQA) Physician Practice Connections – Patient Centered Medical Home
Why NCQA PPC-PCMH? Widely recognized for health care quality standards Received input from a variety of stakeholders e.g. professional
organizations, insurers, and patient advocacy groups
Standards emphasize use of systematic, patient-centered, coordinated care management processes
Reinforces partnerships between individual patients, and their personal physicians, and when appropriate, the family
Uses of registries, care coordination, information technology, and other means to assure patients have the right care when they need it
Standardized survey tool & methodology enables equitable distribution of PCASG funds
Encourages grantees to seek NCQA recognition
5% of PCASG grant funds available for QIP ($3.85M) 3 opportunities (March, June and Dec 09) ~$1.283M each payment Round One Awards Ranged from $67k-$135k
Three Payment Tiers Based on NCQA levels but less stringent Graduated tiers/Graduated payments
Half of an organization’s eligible service delivery sites must pass to obtain a specific tier
Optional Quality Incentive Payment (QIP)
NCQA Scoring PCASG Scoring
Qualifying Level
Points Must Pass
(50%)
Qualifying Tier
Points Must Pass
(50%)
Payment Factor
Level 3 75 10 of 10 Tier 3 50 8 of 10 6x Level 2 50 10 of 10 Tier 2 25 5 of 10 3x Level 1 25 5 of 10 Tier 1 20 4 of 10 1x
PPC-Patient Centered Medical Home Basics Measures evaluate:
Use of systems Effectiveness in prevention Management of chronic illness and patient safety
Measures are “actionable” at practice level Measures are validated by relating them to
performance
Score is based on: Responses in Web-based Survey Tool Supporting documentation attached to Survey Tool Each element specifies type of documentation: Reports;
Documented processes; Records or files
Data Sources & Guidance Data sources and documentation are required
Each element indicate type of HIT required to perform functions
Basic – (HIT) Basic Paper-based or administrative electronic system
Intermediate – (HIT) Intermediate Electronic system for clinical functions
Advanced – (HIT) Advanced Electronic system for connectivity or interoperability
Practices can achieve a passing score on All Must Pass Elements with Basic Health Information Technology
9Physician Practice Connections and Patient-Centered Medical Home
PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and
patient communication**B. Uses data to show it meets its standards for
patient access and communication**
Pts
45
9
Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information
(mostly non-clinical data) B. Has clinical data system with clinical data in
searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting
tools to organize clinical information**E. Uses data to identify important diagnoses
and conditions in practice**F. Generates lists of patients and reminds patients
and clinicians of services needed (population management)
Pts
2
33
64
3
21
Standard 3: Care ManagementA. Adopts and implements evidence-based
guidelines for three conditions **B. Generates reminders about preventive services for
clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,
assessing progress, addressing barriers E. Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pts
3
4
35
5
20
Standard 4: Patient Self-Management Support A. Assesses language preference and other
communication barriersB. Actively supports patient self-management**
Pts
24
6
Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety
checksC. Has electronic prescription writer with cost
checks
Pts33
2
8
Standard 6: Test Tracking A. Tracks tests and identifies abnormal
results systematically** B. Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts7
6
13
Standard 7: Referral Tracking A. Tracks referrals using paper-based or
electronic system**
PT4
4
Standard 8: Performance Reporting and Improvement
A. Measures clinical and/or service performance by physician or across the practice**
B. Survey of patients’ care experience C. Reports performance across the practice
or by physician **D. Sets goals and takes action to improve
performance E. Produces reports using standardized
measures F. Transmits reports with standardized measures
electronically to external entities
Pts
3
33
3
21
15
Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support
Pts121
4
**Must Pass Elements
NCQA PPC – PCMH Requirements: Must pass criteria 1A – Written standards for patient access 1B – Data to show it meets access standards 2D – Use charting tools to organize clinical info 2E – Data to identify 3 important conditions 3A – EBG for 3 conditions – 2 to pass 4B – Supports patient self management 6A – Test tracking 7A – Referral tracking 8A – Measure performance 8C – Report performance
Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective
Prepared, ProactivePractice Team
Informed, Empowered Patient and Family
Productive InteractionsPatient-Centered Coordinated
Timely and Evidence- Efficient Based and Safe
Improved Outcomes
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management
Support
Health SystemCommunity
Health Care OrganizationResources and Policies
Chronic Disease Clinical Models
Hypertension Congestive heart failure (CHF)/Coronary
artery disease (CAD) Stroke COPD (Chronic Obstructive Pulmonary
Disease) DM (Disease Management) Asthma Multiple comorbidities Transitional care management
Depression Clinical Models
• Chronic (planned) care model – Wagner• Collaborative care – Katon• Partners in Care (AHRQ) – Wells• PROSPECT – Alexopoulous, Katz, Reynolds• Telephone care management – Simon, Hunkeler• IMPACT (Hartford) – Unutzer• RESPECT (MacArthur) – Dietrich• Quality Improvement for Depression (NIMH) – Rost,
Ford, Rubenstein• Child models – Campo, Asarnow, GLAD-PC• Other models for anxiety/PTSD
Clinical Model: Major ComponentsLeadership Accountability
Vision Resources
Practice design Patient registryProtocolsCare manager
Clinical information systems
Red flagsFeedback to provider on clinical progressSupport care manager
Decision support GuidelinesProvider trainingExpert/specialist consultationReferral pathways
Self management support
Patient preferences, cultural competencyInformation on depression, medications, skills
Community resources
Information on and for consumer groups and other servicesAccess to non-provider sources of care
Leadership
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Component Key Principles Description
Leadership There must be a leadership team composed of organizational partners with overall program accountability for implementation across partnering organizations
A team of primary care, mental health, and senior administrative personnel that:
• Garners resources (personnel, space, financial)
• Incorporates and coordinates stakeholder interests
• Promotes adherence to treatment guidelines and protocols
• Sets target goals for key process measures and outcomes
• Encourages efforts at continuous quality improvement
Delivery System Design
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Component Key Principles Description
Delivery System Design
The delivery system is available to implement all aspects of decision support. It consists of:•Access to guidelines and protocols•A depression patient registry•A care manager responsible for implementing coordinated care in conjunction with primary care providers and, when necessary, mental health specialists•A systematized approach to obtaining access to mental health specialists for referral, consultation, and feedback
1) Care manager, either on or off site, implements protocols for:
• Systematically identification of patients at elevated risk for depression
• Screening of patients at elevated risk for major depression using a structured assessment tool
• Stratification of treatment intensity by episode severity and patient preference
• Monitoring and promotion of adherence to guideline-based treatment(s) for depression
• Routing follow-up at intervals specific to a patient’s phase of depression treatment (acute, continuation, or maintenance)
2) Structure is in place to ensure facilitated access to mental health specialists
Clinical Information System
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Component Key Principles Description
Clinical Information System
The clinical information system consists of tools to facilitate the roles of the primary care providers and care managers
Note: The clinical information system does not necessarily need to be interactive with other computer systems
• Enables the primary care physician and care manager to establish a registry to identify, manage, and track depressed patients
• Tracks key process and program measures (e.g. percent of patients who received a structured assessment for depression, percent of patients continuing pharmacotherapy after 3 months, percent of patients who achieved a 50% decrease in depression scores)
Decision Support
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Component Key Principles Description
Decision Support Evidence-based depression treatment guidelines and care protocols are available to improve recognition and treatment of depression
1) There are evidence-based treatment guidelines and care protocols for:
• Systematically identifying patients at elevated risk for depression
• Case identification using a structured assessment tool
• Stratification of treatment intensity by severity
• Treatment by provider and care manager• Mental health specialist referral2) Staff are trained in using decision
support tools3) Materials receive periodic review and
updating4) Mental health specialists are readily
available for decision support and patient referral
Self-Management Support
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Component Key Principles Description
Self-Management Support
Materials, tools, and processes are available to promote patient activation and self-care for depression
Self-management support consists of:•Shared decision making between patient and provider(s), taking into account patient preferences for treatment and family involvement•Culturally appropriate patient information available in a variety of formats (e.g. print, audio, and videotape)•Self-study materials including such self-care techniques as goal setting and problem solving, as well as promotion of adherence to pharmacotherapy•CM follow-up on a patient’s progress with advice and acquisition of skills described in self-study materials
Community ResourcesComponent Key Principles Description
Community Resources
Patient information and education about depression are available from organizations that are independent of providers and health plan
Patients and families are informed of nonprogram information and other resources designed to assist in their understanding of depression and the various treatments available from such entities as:•Local/national organizations•Clergy, employee assistance programs, and support groups
Functions of Care ManagersPatient-Focused Support •Develop and maintain rapport
•Help access psychosocial treatment (e.g. interpersonal therapy or problem-solving therapy)
Education/Self Management •Educate about illness, treatments, side effects•Communicate, customize, and maintain self-action plan for patient
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Functions of Care ManagersFollow-up •Encourage adherence to medications and
education on their side effects •Facilitate and remind patient about telephone or personal visits•Facilitate communication and linkages with mental health specialist and primary care provider•Intervene in crisis
Clinical •Systematically monitor depressive symptoms, comorbidities, adherence •May provide psychosocial therapy or counseling (e.g. interpersonal therapy or problem-solving therapy)
A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002
Phases of Depression Treatment
Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.
Treatment Phases
RelapseRecurrence
Recovery
Acute Continuation Maintenance
Syndrome
Symptoms
Remission
Response
No Depression
Top Ten IssuesGeneral Health/Mental Health Relationships
1. Partnerships2. Formalize3. Accountability4. Referral5. Consultation/Evaluation6. Information Flow7. Money8. Quid Pro Quo9. Maintenance10. Generalize
Gaps (1) Participant comments
NCQA Reports
RESULTS FROM Round One NCQA Surveyed Sites
36 Sites Total 34 Primary Care 2 Behavioral Health
Where QIP Participants Did Well PPC1A: Access & Communication Processes e.g. Written Standards*
MUST PASS 4 POINTS
PPC2A: Patient Data e.g. Practice Management System or Registry*
Not MUST PASS
2 POINTS
PPC2E: Identify Important Conditions* MUST PASS 4 POINTS
PPC3A: Implement EBG* MUST PASS 3 POINTS
PPC3B: Guideline-based Reminders When Seeing Patient
Not MUST PASS
4 POINTS
PPC8A: Measures clinical and service performance*
MUST PASS 3 POINTS
TOTAL 20 POINTS
* PCASG Quality Minimum Requirement
Where QIP Participants Didn’t Do WellPPC2F: System for Population Management
Generates lists of patients needing appts or follow-up, reminders for follow, on particular meds, chronic condition
Not MUST PASS
3 POINTS
PPC3E: Continuity of Care Identifies patients receiving care in facilities; routinely sends
info to facilities; contacts patients after discharge
Not MUST PASS
5 POINTS
PPC4B: Actively Supports Self-Management: Readiness for change, language appropriate educational resources,
self-monitoring tools, support programs, written care plan
MUST PASS 4 POINTS
Where They Didn’t Do Well (cont)PPC6A: Test Tracking and Follow-up: Track lab and imaging tests until results return; flags overdue and
abnormal results; notify patients of abnormal results; paper based or electronic
MUST PASS 7 POINTS
PPC7A: Referral Tracking and Follow-upFor referral to specialist or consultant: origination: referring
clinician; reason for referral; status; insurance/preapproval
MUST PASS 4 POINTS
Where Results Were VariablePPC1B: Report on Access & Communication Visits with assigned physician; Response times; Same day
appointment access; Language services available
MUST PASS
5 POINTS
PPC2B & C: Has and Uses Clinical Data System (SEARCHABLE)
Age appropriate preventive services (immunizations, screening, counseling); Allergies; Vitals (BP, weight, BMI); Labs, imaging and path results
Not MUST PASS
3 POINTSeach
PPC2D: Charting Tools Problem lists, medications, structured templates
MUST PASS
6 POINTS
PPC3C: Care TeamNon-clinician provides reminders, standing orders, education, coordination
Not MUST PASS
3 POINTS
PPC3D: Care Management Care plans, treatment goals, assess progress
Not MUST PASS
5 POINTS
Behavioral Health Organizations Challenges & Successes
Successes Reporting on
Access & Communication
Charting Tools Care
Management
Challenges Clinical Data System for Population Management Self Management Support Test Tracking
Primary Care Organizations Challenges & Successes
Successes Processes for Access &
Communications Charting Tools
Challenges Reporting on Access & Communication Clinical Data Systems System for Population Management Care Management Continuity of Care Self Management Support Test Tracking
Gaps (2) Organizing care management
Tasks/Roles/People Incorporating self management Disease registries Referral tracking Communication/HIPAA Test tracking Guideline-based reminders Using data for QI Continuity of care Anticipation of needs
Care Management Functions Patient engagement/rapport Screening/Assessment Education/Planning Self management support Clinical monitoring/Tracking Reminders (patient/provider) Accessing resources/referrals Coordination/Continuity Problem solving/counseling/therapy
Top Ten IssuesGeneral Health/Mental Health Relationships
1. Partnerships2. Formalize3. Accountability4. Referral5. Consultation/Evaluation6. Information Flow7. Money8. Quid Pro Quo9. Maintenance10. Generalize