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Patient-Centered Specialty Practice
(PCSP) Recognition Program
Standards Workshop Part 2 2013
All materials © 2013, National Committee for Quality Assurance
2 Patient-Centered Specialty Practice Recognition Program
Agenda Part 1 • Content of PCSP Standards and Guidelines
– Standards 1 – 3
– Documentation Examples*
Agenda Part 2 • Content of PCSP Standards and Guidelines
– Standards 4 – 6
– Documentation Examples*
*Examples in the presentation only illustrate the element intent. They
are NOT definitive nor the only methods of documenting how the
requirements may be met.
3 Patient-Centered Specialty Practice Recognition Program
NCQA Resources Available
Free training each month http://www.ncqa.org/rptraining.aspx
• Getting On Board • Includes How to Submit as a Multi-site
• Standards (2 part program)
• Software Training • Using the ISS System for PCMH 2011 and PCSP
• The Online Application
4 Patient-Centered Specialty Practice Recognition Program
PCSP 4: Plan and Manage Care
Intent
• Collaborate with
patient/family/caregiver
and PCP to develop and
implement care plan
• Review and reconcile
medications
• E-prescribe
Meaningful Use
• Use EHR to identify patient
education resources
• Review and reconcile
medications
• Use an e-prescribing
system to write and
transmit prescriptions
• Compare meds. With
formularies, check for
generics, drug-drug and
drug-allergy interactions
5 Patient-Centered Specialty Practice Recognition Program
PCSP 4: Plan and Manage Care
• Elements
PCSP 4A: Care Planning
and Self-Care Support
PCSP 4B: Medication
Management - MUST PASS
PCSP 4C: Use of Electronic Prescribing
6 Patient-Centered Specialty Practice Recognition Program
PCSP 4A: Care Planning and Self-Support
The practice provides the following care management
and self-care support for practice-specific conditions:
1. Conduct pre-visit preparations
2. Assess patient risk status to identify patients needing
additional support and services
3. Collaborate with the patient/family/caregiver to
develop a specialist’s plan of care that includes
patient’s goals, potential barriers/self-care ability
-CRITICAL FACTOR
4. Share specialist’s plan of care including
recommendations for self-care support with the PCP
and referring clinician -CRITICAL FACTOR
(con’t)
7 Patient-Centered Specialty Practice Recognition Program
PCSP 4A: Care Planning and Self-Support
The practice provides the following care management
and self-care support for practice-specific conditions:
5. Give the patient/family/caregiver a written specialist’s
plan of care including self-care recommendations.
6. Provide educational resources or refer
patients/families/caregivers to assist in self-
management
7. Assess/address barriers when patient has not met
treatment goals
8. Use an EHR to identify patient-specific education
resources and provide to more than 10 percent of
patients++/+
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
8 Patient-Centered Specialty Practice Recognition Program
PCSP 4A: Care Planning and Self-Support
• 11 Points
• Scoring
– 100% - 6-8 factors, including Factors 3 and 4
– 75% - 4-5 factors, including Factors 3 and 4
– 50% - 2-3 factors, including Factors 3 and 4
– 25% - 1 factor
– 0% - 0 factor
• Documentation
– Factors 1-7: Written process and examples
– Factor 8: Report with numerator, denominator and
percentage
9 Patient-Centered Specialty Practice Recognition Program
PCSP 4A: Example Pre-visit Form
Patients complete form pre-visit:
Focus of today’s visit
Medications
Allergies
Pain assessment
Flu vaccine
Depression assessment
Recent ER visit
10 Patient-Centered Specialty Practice Recognition Program
PCSP 4A: Example Patient Education
Prenatal Care: Steps Toward a Healthy Pregnancy
Prenatal Session #1
PROGRAM: Comprehensive Perinatal Services Program TIME: 1-1 ½ Hours
OBJECTIVES
By the end of the session, the participant will be able to:
1. Identify basic anatomy of human reproductive system
2. Identify common discomforts of pregnancy including aspects of fetal growth and
development
3. Identify danger signs during pregnancy and action to take
during complications
4. Identify lab tests including the importance of ultrasound
5. Understand the importance of Oral health during pregnancy
Practice must also attach a complete set of education materials that could be
provided to the patient.
11 Patient-Centered Specialty Practice Recognition Program
PCSP 4B: Medication Management
The practice has a process and demonstrates that it
systematically manages medications prescribed by the practice in the following ways:
1. Reviews and reconciles medications for more than
50 percent of patients received from another care setting or a relevant visit++/+
2. Provides information about new prescriptions from
specialty practice to patients/families/caregivers.
3. Coordinates medication management and
reconciliation with the PCP, referring clinician and
patient/family/caregiver
(con’t)
12 Patient-Centered Specialty Practice Recognition Program
PCSP 4B: Medication Management
The practice has a process and demonstrates that it
systematically manages medications prescribed by the practice in the following ways:
4. Assesses patient/family/caregiver understanding
of medications from specialty practice
5. Assesses patient response to medications from
specialty practice and barriers to adherence
6. Documents over-the-counter medications, herbal
therapies and supplements
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
13 Patient-Centered Specialty Practice Recognition Program
PCSP 4B: Medication Management
• Must Pass
• 5 Points
• Scoring
– 100% - 5-6 factors
– 75% - 4 factors
– 50% - 3 factors
– 25% - 2 factors
– 0% - 0-1 factors
• Documentation:
– Factors 1-6: Documented process and three
examples for each factor
14 Patient-Centered Specialty Practice Recognition Program
PCSP 4B: Example Medication Reconciliation
Reconcile meds. at each visit for patient
safety and effectiveness of medications 1. Pts. bring list or meds. to each visit; reminded
when appt. scheduled; signs in pt. rooms
2. Med. asst. reviews meds. at each visit
3. MD reviews current meds.; discusses pt.
concerns
4. Motivational interviewing/shared decision-
making to help with risks/benefits of meds.
5. MD/staff teach pt. about med. administration
6. Follow-up call to pt. when major change to
meds.
7. Check with pt. if refill requests are conflicting
15 Patient-Centered Specialty Practice Recognition Program
PCSP 4B: Patient Role in Med. Management
Posted in office to
encourage patients to
help managing their
medications
16 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Use of Electronic Prescribing
The practice uses an electronic prescription system with the following:
1. Writes at least 75 percent of eligible prescriptions electronically.
2. More than 40/50 percent of eligible prescriptions written by the
practice are compared to drug formularies and electronically
sent to pharmacies++/+
3. Enters electronic medication orders into the medical record for
more than 30/60 percent of patients with at least one medication
in their medication list+
4. Performs patient-specific checks for drug-drug and drug-allergy interactions+
5. Alerts prescriber to generic alternatives
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
17 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Use of Electronic Prescribing
• 2 Points
• Scoring
– 100% - 3-5 factors
– 75% - 2 factors
– 50% - 1 factor
– 25% - No scoring option
– 0% - 0 factors
• Documentation
– Factors 1, 2 and 3: Report with a numerator, denominator
and percentage
– Factors 4 and 5: Report or screen shot demonstrating
capability
18 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Example Electronic Prescription
Writing
Prescription Writing Activity
Electronic 57% 2563 Rx
Printed, given to patient 31% 1419 Rx
Print, fax to pharmacy 1% 89 Rx
_______________________________________
TOTAL
Rx 4474 Rx
% E-RX 89%
19 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Example
Drug-Drug Interactions
Drug-Drug
Interactions
20 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Example Prescription Allergy
21 Patient-Centered Specialty Practice Recognition Program
PCSP 4C: Example Generic Alternatives
22 Patient-Centered Specialty Practice Recognition Program
PCSP 5: Track and Coordinate Care
Intent
• Track/follow-up on lab
and imaging results
• Exchange test results
with primary care
• Track/follow-up on
referrals
• Coordinate with
hospitals/ ERs; transition
patients back to
primary care
Meaningful Use
• Incorporate clinical lab test
results into the medical
record
• Electronically exchange
clinical information with
other clinicians and
facilities
• Provide electronic
summary of care record for
referrals and care
transitions
CMS EHR Incentive Programs: http://www.cms.gov/Regulations-
and-Guidance/Legislation/EHRIncentivePrograms/index.html
23 Patient-Centered Specialty Practice Recognition Program
PCSP 5: Track and Coordinate Care
Elements
PCSP 5A: Test Tracking and Follow-Up
PCSP 5B: Referral Tracking and Follow-Up
PCSP 5C: Coordinate Care Transitions
24 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Test Tracking and Follow-Up
The practice has a documented process for and
demonstrates that it:
1. Requests and tracks receipt of test results from PCP and
referring clinician
2. Provides PCP and referring clinician with results of
relevant tests ordered by the specialist - CRITICAL
FACTOR
3. Tracks lab tests until results are available, flagging and
following up on overdue results
4. Tracks imaging tests until results are available, flagging
and following up on overdue results
5. Flags abnormal lab results, bringing them to the
attention of the clinician
(con’t)
25 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Test Tracking and Follow-Up (cont.)
The practice has a documented process for and
demonstrates that it:
6. Flags abnormal imaging results, bringing them
to the attention of the clinician
7. Patients/families/caregivers are notified about
normal and abnormal lab and imaging test
results
8. More than 30 percent of laboratory orders are
electronically recorded in the patient record+
(con’t)
26 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Test Tracking and Follow-Up (cont.)
The practice has a documented process for and
demonstrates that it:
9. More than 30 percent of radiology orders are
electronically recorded in the patient record+
10.Electronically incorporates more than 40/55
percent of all clinical lab test results into structured
fields in medical record++
11.More than 10 percent of scans and tests that result
in an image are accessible electronically+++
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
+++ Stage 2 Menu Meaningful Use Requirement
NOTE: Factor s 8, 9 and 11 will not be scored until 1/1/2015
27 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Test Tracking and Follow-Up
• 5 Points
• Scoring
– 100% - 6-11 factors, including factor 2
– 75% - 4-5 factors, including factor 2
– 50% - 3 factors, including factor 2
– 25% - 1-2 factors, including factor 2
– 0% - 0 factors or does not meet factor 2
• Documentation
– Factors 1-7: Documented process and report with 5 days of data or three examples of meeting the process for each factor
(demonstrate the implemented process)
– Factors 8, 9, 10, 11: Report with a numerator, denominator and
percentages
28 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example, Lab Process
Missing Flagging
Overdue labs and FU
29 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example Policy for
Abnormal Test Results
Policy: Definitions for
Abnormal Test Result
Categories and Reporting
Requirements for Each
• Abnormal
• Abnormal (Priority)
• Abnormal (Critical)
30 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example Test Tracking Log
DATA COLLECTED
Patient name
DOB
Provider
Order date
Test ordered
Urgency
Date results received
Results normal/abnormal
Date results to provider
Date results to patient
31 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example Electronic Test Tracking
All lab and imaging tests are
tracked until results are
available
Overdue results are flagged
Abnormal results are
flagged
Practice tracks:
Date ordered
Overdue
Abnormal
Priority
Patient name
Provider
Order description
Last appointment
Next appointment
32 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example Tracking Imaging
33 Patient-Centered Specialty Practice Recognition Program
PCSP 5A: Example Letter for Patient
Notification of Abnormal Imaging Results
Patient/family was notified by
provider of abnormal test results
and given follow-up instructions
34 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Referral Tracking and Follow-Up
The practice coordinates referrals to other
(secondary) specialists by:
1. Consulting with PCP and referring clinician and
patient/family/ caregiver regarding secondary
referrals
2. Giving the consultant or specialist the clinical
reason for the referral and pertinent clinical
information - CRITICAL FACTOR
3. Tracking the status of the referral, including
required timing for receiving a specialist’s report
4. Following up to obtain specialist’s report
(con’t)
35 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Referral Tracking and Follow-Up
The practice coordinates referrals to other
(secondary) specialists by:
5. Establishing and documenting agreements with
specialists in the medical record if co-
management is needed
6. Asking patients/families/caregivers about self-
referrals and requesting reports from clinicians
7. Assuring the PCP and original referring clinician are notified of the secondary referral results.
8. Providing an electronic summary of care record to
another provider for more than 50 percent of referrals++/+
36 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Referral Tracking and Follow-Up
The practice coordinates referrals to other
(secondary) specialists by:
9. Electronically transmitting a summary of care record to another care provider for more than 10
percent of care referrals+
10. Conducting one or more successful electronic exchanges with a recipient who has technology
developed by a different EHR developer or
successfully tests with the CMS designated test EHR.+ + Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
NOTE: Factors 9 and 10 will not be scored until 1/1/2015
37 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Referral Tracking and Follow-Up
• 6 Points
• Scoring
– 100% - 8-10 factors, including Factor 2
– 75% - 6-7 factors, including Factor 2
– 50% - 4-5 factors, including Factor 2
– 25% - 1-3 factors, including Factor 2
– 0% - 0 factors
• Documentation
– Factors 1-7: Documented process
– Factors 1-7: Reports or logs showing data collection in a tracking
system
– Factors 8 and 9: Report with numerator , denominator and
percentages
– Factor 10: Screen shot showing capability
38 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Example Referral Tracking
Referral Tracking Data - 5 days
• Date ordered
• Referring provider
• Diagnosis
• Referred to
• Supporting clinical information
• Urgency
• Type of referral
• Appointment date
• Date results received
• Date of follow-up for missing report
39 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Example Co-Management Policy
40 Patient-Centered Specialty Practice Recognition Program
PCSP 5B: Example Follow-Up to
Get Referral Report
41 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Coordinate Care Transitions
For conditions managed by the specialist, the
practice systematically:
1. Demonstrates its process for identifying
patients with a hospital admission and patients
with an emergency department visit
2. Demonstrates its process for sharing clinical
information with admitting hospitals or
emergency departments
3. Demonstrates its process for consistently
obtaining patient discharge summaries from
the hospital and other facilities
42 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Coordinate Care Transitions
For conditions managed by the specialist, the practice
systematically:
4. Demonstrates its process for transitioning patients back
to the primary care practice
5. Provides an electronic summary-of-care record to
another care facility for more than 50 percent of
transitions of care++/+
6. Electronically transmits a summary of care record to
another care setting for more than 10 percent of care
transitions+
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
NOTE: Factor 6 will not be scored until 1/1/2015
43 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Coordinate Care Transitions
• 5 Points
• Scoring
– 100% - 4-6 factors
– 75% - 3 factors
– 50% - 2 factors
– 25% - 1 factor
– 0% - 0 factors
• Documentation
– Factors 1-4: Documented process and three examples
– Factors 5 and 6: Report with a numerator, denominator
and percentages
44 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Example Identifying
Patients in Facilities
Practice receives admission
reports electronically from
hospital
45 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Example ER
Visit Follow-Up Log
46 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Pediatric to Adult Transition
Diabetes Care Self-Assessment
Self-assessment of worries,
concerns, burdens related to
diabetes and preparation for
transitioning
I would like to talk about:
• Challenged by diabetes
burdens
• Social/emotional/cognitive
issues
• Transition preparation/
readiness to move on
47 Patient-Centered Specialty Practice Recognition Program
PCSP 5C: Clinical Summary for New Health
Care Team
48 Patient-Centered Specialty Practice Recognition Program
PCSP 6: Measure and Improve Performance
Intent
• Measure clinical
performance,
coordination of care,
utilization affecting
costs, access to care,
patient experience and
report performance
• Use and monitor
effectiveness of quality
improvement process
Meaningful Use
Report:
• Ambulatory quality
measures to CMS
• Immunization data to
registries
• Syndromic surveillance data to public health
agencies
• Cancer cases to registry
49 Patient-Centered Specialty Practice Recognition Program
PCSP 6: Measure and
Improve Performance
Elements
• PCSP 6A: Measure Performance
• PCSP 6B: Measure Patient/Family Experience
• PCSP 6C: Implement & Demonstrate
Continuous Quality Improvement - MUST
PASS
• PCSP 6D: Report Performance
• PCSP 6E: Use Certified EHR Technology
50 Patient-Centered Specialty Practice Recognition Program
PCSP 6A: Measure Performance
The practice measures or receives data on:
1. At least three clinical measures related to the
practice specialty
2. Coordination of care results
3. At least two utilization measures affecting
health care costs
4. Performance data stratified for vulnerable
populations (to assess disparities in care).
5. Timely access to appointments
based on established criteria
51 Patient-Centered Specialty Practice Recognition Program
PCSP 6A: Measure Performance
• 5 Points
• Scoring
– 100% - 4-5 factors
– 75% - 3 factors
– 50% - 1-2 factors
– 25% - No scoring option
– 0% - 0 factors
• Documentation
– Factors 1-5: Reports showing performance
52 Patient-Centered Specialty Practice Recognition Program
Vulnerable Populations Defined
“Those who are made vulnerable by their
financial circumstances or place of
residence, health, age, personal
characteristics, functional or
developmental status, ability to
communicate effectively, and presence
of chronic illness or disability.”
Source: AHRQ
53 Patient-Centered Specialty Practice Recognition Program
Vulnerable vs. High Risk
54 Patient-Centered Specialty Practice Recognition Program
PCSP 6A: Example Chronic
Care Clinical Measures
55 Patient-Centered Specialty Practice Recognition Program
NCQA Clinical Program Recognition Where Can it Be Used to Meet Elements?
• NCQA Clinical Recognition Programs
– Diabetes Recognition Program (DRP)
– Heart/Stroke Recognition Program (HSRP)
• Credit for Clinical Program Recognition may be used for meeting some requirements if 75% of clinicians are Recognized:
– PCSP 6A Factor 1
– PCSP 6C Factors 1 and 7 (if renewed), for Element A portion
– PCSP 6 D Factor 1, 2 and 3 for Element A portion
56 Patient-Centered Specialty Practice Recognition Program
NCQA Clinical Program Recognition
Where Can it Be Documented to Meet Elements?
57 Patient-Centered Specialty Practice Recognition Program
PCMH 6 ELEMENT A: Factor 3
Care Managers receive referrals from PCP'S, Hospitalists, Social Workers or family members
requesting evaluation for patients to be treated at an alternative level of care (home, SNF) or in the
office. The team has had a 22% success rate in saving hospital admissions since Nov 2007.
CARE MANAGEMENT ACTIVITIES
2011 JANUARY - MAY
TOTAL CM REFERRALS / SAVED ADMISSIONS
2011 2011 2011 2011 2011
TOTAL TO
DATE
JAN FEB MARCH APRIL MAY 2011
TOTAL CM REFERRALS 220 202 299 221 219 1161 TOTAL CM REFERRALS
SAVED ADMISSIONS 57 53 55 49 57 271 SAVED ADMISSIONS
FAILED ATTEMPTS 5 7 2 3 3 20 FAILED ATTEMPTS
PCSP 6A: Example
Measures Affecting Health Care Costs
PCSP
58 Patient-Centered Specialty Practice Recognition Program
PCSP 6A: Example Data for
Vulnerable Populations
59 Patient-Centered Specialty Practice Recognition Program
PCSP 6B: Measure Patient/Family Experience
The practice obtains feedback from patients/families on
their experiences with the practice and their care.
1. The practice conducts a survey (using any instrument) to evaluate
patient/family experiences on at least three of the following
categories:
– Access
– Communication
– Coordination
– Self-management support
2. The practice uses CAHPS** Clinician & Group (CG) Survey Tool
3. The practice obtains feedback on experiences of vulnerable patient groups
4. The practice obtains feedback from patients/families through
qualitative means
**Consumer Assessment of Healthcare Providers and Systems (CAHPS)
https://www.cahps.ahrq.gov/clinician_group/
60 Patient-Centered Specialty Practice Recognition Program
PCSP 6B: Measure Patient/Family Experience
• 6 Points
• Scoring
– 100% - 3-4 factors
– 75% - No scoring option
– 50% - 2 factors
– 25% - 1 factor
– 0% - 0 factors
• Documentation
– Factors 1-4: Reports showing performance
61 Patient-Centered Specialty Practice Recognition Program
PCSP 6B: Example of Reported CAHPS
Questions for Patient Experience
62 Patient-Centered Specialty Practice Recognition Program
PCSP6B: Example Patient Experience Data
63 Patient-Centered Specialty Practice Recognition Program
PCSP6B: Example Patient Experience Survey Results
Survey questions include:
Access
Communication
NEEDS A THIRD CATEGORY
64 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Implement & Demonstrate
Continuous Quality Improvement
The practice demonstrates ongoing monitoring of
the effectiveness of its improvement process by:
1. Setting goals/acting to improve on at least
three clinical quality or utilization measures
2. Setting goals/acting to improve quality on at
least one patient experience measure
3. Setting goals/acting to improve timeliness of
patient access
4. Setting goals/acting to improve coordination
with primary care
65 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Implement & Demonstrate
Continuous Quality Improvement
The practice demonstrates ongoing monitoring of the
effectiveness of its improvement process by:
5. Tracking results over time
6. Assessing the effect of its actions
7. Achieving improved performance on one
measure
8. Achieving improved performance on a second measure
9. Setting goals and addressing at least one
identified disparity in care/service for vulnerable populations
66 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Implement & Demonstrate
Continuous Quality Improvement
• MUST PASS
• 4 Points
• Scoring
– 100% - 6-9 factors
– 75% - 4-5 factors
– 50% - 3-4 factors
– 25% - 2 factors
– 0% - 0-1 factor
• Documentation
– Factors 1-8: Reports or completed PCSP Quality Measurement
and Improvement Worksheet
– Factor 9: Written process and three examples demonstrating the process
67 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Quality Measurement and
Improvement Instructions
68 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Quality Measurement and
Improvement Worksheet
Performance Measures (A)
Disparities in Care (A)
Patient/Family Experience (B)
Measure (C)
Opportunity Identified (C)
Initial Performance/
Measurement Period (A/B)
Performance Goal (C)
Action Taken and Date (C)
Re-measurement Performance (C)
Demonstrate Improvement (C)
69 Patient-Centered Specialty Practice Recognition Program
PCSP 6C Example of Goals for
Vulnerable Populations 1. EQUITABLE
• …whoever you are.
• No inequality
• Aim Statement:
• Eliminate differences in clinical care & health status between racial, ethnic and
socioeconomic groups
Measure
• “0” disparity by race for all effectiveness measures
2. ACCESSIBLE
• We promote access to comprehensive health services to all in our service area,
regardless of ability to pay.
• No barriers to health care services for all who seek it
• Aim Statement:
• Serve 50% of our target populations
Measure
• Health center penetration rate for underserved/special populations in specified
service areas
70 Patient-Centered Specialty Practice Recognition Program
PCSP 6C: Example Tracking
Data Over Time
71 Patient-Centered Specialty Practice Recognition Program
PCSP 6D: Report Performance
The practice shares performance
data from Element A and Element B:
1. Within the practice, results by
individual clinician
2. Within the practice, results across
the practice
3. Outside the practice to patients or
publicly, results across the practice
or by clinician
72 Patient-Centered Specialty Practice Recognition Program
PCSP 6D: Report Performance
• 2 Points
• Scoring
– 100% - 3 factors
– 75% - 2 factors
– 50% - 1 factor
– 25% - no scoring option
– 0% - 0 factors
• Documentation
– Factors 1-2: Reports to practice or clinicians and practice
staff; explains how results are provided
– Factor 3: Example of report to patients or the public
73 Patient-Centered Specialty Practice Recognition Program
PCSP 6D: Example Reporting by Clinician
1 2 3 4 5 6
Blinded 6 Clinicians
74 Patient-Centered Specialty Practice Recognition Program
PCSP 6D: Example Practice Level
Diabetes Data
75 Patient-Centered Specialty Practice Recognition Program
PCSP 6D: Example of External Reporting
76 Patient-Centered Specialty Practice Recognition Program
PCSP 6E: Use Certified EHR Technology
1. The practice uses an EHR system (or modules) that
has been certified and issued a Certified HIT
Products List (CHPL) Number(s) under the ONC (Office of the National Coordinator for Health
Information Technology) HIT certification program+
2. The practice attests to conducting a security risk analysis of its electronic health record (EHR) system
(or modules) and implementing security updates as
necessary and correcting identified security deficiencies+
3. The practice demonstrates capability to submit
electronic syndromic surveillance data to public health agencies electronically++/+++
77 Patient-Centered Specialty Practice Recognition Program
PCSP 6E: Use Certified EHR Technology
4. The practice demonstrates capability to identify and report
cancer cases to a public health central cancer registry
electronically+++
5. The practice demonstrates capability to identify and report
specific cases to a specialized registry electronically (other
than a cancer registry)+++
6. The practice reports clinical quality measures to Medicare or
Medicaid agency as required for Meaningful Use.
7. The practice demonstrates the capability to submit electronic
data to immunization registries or immunization information
systems.++/+
+ Stage 1/2 Core Meaningful Use Requirement
++ Stage 1 Menu Meaningful Use Requirement
+++Stage 2 Menu Meaningful Use Requirement
78 Patient-Centered Specialty Practice Recognition Program
PCSP 6E: Use Certified EHR Technology
• 0 Points
• Documentation
– Factors 1-7: Responding
“yes” or “no” in each
element of the survey tool
is an attestation that the
practice meets the
respective requirements
79 Patient-Centered Specialty Practice Recognition Program
Meaningful Use Attestation Accepted Attestation
Attestation Tracking Information
Attestation Confirmation Number
80 Patient-Centered Specialty Practice Recognition Program
NCQA Contact Information
Contact NCQA Customer Support: 1-888-275-7585 PCSP standards documents, application account,
and survey tools Questions about your user ID, password, access
Visit NCQA Web Site: http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx
View Frequently Asked Questions
View Recognition Programs Training Schedule View other Recognition Programs – PCMH, DRP, HSRP
Submit to questions about interpretation of PCSP standards to: [email protected]
81 Patient-Centered Specialty Practice Recognition Program
Questions about the Medical
Neighborhood?
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