pcmh: part 4 – learn how to start or improve your quality improvement program
TRANSCRIPT
PCMH: PART 4 CARE COORDINATION AND PERFORMANCE
IMPROVEMENT AND QUALITY IMPROVEMENT PROGRAMS JUNE 24, 2016
Confidential © 2015 Galen Healthcare Solutions
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Presenter
Christy Erickson, MSN, PMP, PCMH CCE
Director, Clinical TransformationOver 10 years of Healthcare IT & Clinical Informatics experienceOver 25 years of Nursing & Nurse Practitioner experience
Agenda• PCMH Overview
• Standard 5- Care Coordination and Care Transitions
• Standard 6- Performance Measurement and Quality Improvement
• Brief review of changes between 2011 and 2014 standards
• MU Alignment of Standards
This just in……….MACRA• MACRA- The Medicare Access and CHIP Reauthorization Act of
2015- WEDNESDAY, 4/27/16 ruling released– Changes payment for Medicare beneficiaries FFS program replacing
sustainable growth rate (SGR) formula
• 2 Paths– MIPS
• Quality (PQRS) (50%)• Advancing Care Information (MU) (25%)• Clinical Practice Improvement Activities (15%)• Resource Use Measures (VM) (10%)
– APM’S• CPC Plus• ACO’s (MSSP, Next Generation ACO Model)• Comprehensive End Stage Renal Disease Care Model• Oncology Care Program
What is PCMH?• Patient Centered Medical Home
• Primary Care Program
• Emphasizes care coordination/management and team based care
• Triple aim
NCQA Roadmap – Download Standards
Scoring Levels Level 1= 35-59 points Level 2= 60-84 points Level 3= 85-100 points
* MUST PASS Elements
PCMH 5: Care Coordination and Care Transitions
• Element A: Test Tracking and Follow-Up
• Element B: Referral Tracking and Follow-Up
• Element C: Coordinate Care Transitions
18 POINT
S
Element 5A: Test Tracking and Follow-Up
1. Tracks lab tests until results are available, flagging and following up on overdue results.
2. Tracks imaging tests until results are available, flagging and following up on overdue results.
3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot
screening7. More than 30 percent of laboratory orders are electronically recorded in the patient
record. +8. More than 30 percent of radiology orders are electronically recorded in the patient
record. +9. Electronically incorporates more than 55 percent of all clinical lab test results into
structured fields in medical record. +10. More than 10 percent of scans and tests that result in an image are accessible
electronically +
+ Stage 2 Core Meaningful Use RequirementCritical Factor
Meaningful Use Alignment 5A-Test Tracking and Follow-Up
NCQA Requirements Modified Stage 2 Ruling NCQA ResponseElectronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record.
Removed as MU Measure NCQA maintaining requirement but will accept an example of capability in lieu of a report
More than 10 percent of scans and tests that result in an image are accessible electronically
Removed as MU Measure NCQA maintaining requirement but will accept an example of capability in lieu of a report
Element 5A: Scoring6.0 points
• 8-10 factors (including factors 1 and 2) = 100%• 6-7 factors (including factors 1 and 2) = 75%• 4-5 factors (including factors 1 and 2) = 50%• 3 factors (including factors 1 and 2) = 25%• 0-2 factors (doesn’t meet factors 1 and 2) = 0%
Element 5A Factor 1-10: Documentation
PCMH 5A1-6• Process/Policy
• Date• Practice Name• Define process
• tracking labs and imaging studies• overdue labs and imaging studies• abnormal labs and imaging studies• patient notification• newborn hearing and screening tests
• Define timeline and frequency of lab/imaging results monitoring
• Report or Log or Examples• For each factor• Across patients
Element 5A Factor 1-10: Documentation
PCMH 5A7-10• Report
• 3 months of recent data• Numerator• Denominator
PCMH 5A1-2, 3-5
Element 5A2: Overdue Order Tracking
Element 5A3: Abnormal Results Tracking
Element 5A5: Sample Lab Notification to Patient
Element 5A7-8: CPOE Labs/Imaging
Element 5B: Referral Tracking and Follow-Up
1. Considers available performance information on consultants/specialists when making referral recommendations.
2. Maintains formal and informal agreements with a subset of specialists based on established criteria.
3. Maintains agreements with behavioral healthcare providers. 4. Integrates behavioral healthcare providers within the practice site. 5. Gives the consultant or specialist the clinical question, the required
timing and the type of referral. 6. Gives the consultant or specialist pertinent demographic and clinical
data, including test results and the current care plan. 7. Has the capacity for electronic exchange of key clinical information+ and
provides an electronic summary of care record to another provider for more than 50 percent of referrals. +
8. Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports.
9. Documents co-management arrangements in the patient’s medical record.
10.Asks patients/families about self-referrals and requesting reports from clinicians. + Stage 2 Core MU Requirement
Critical Factor
MUST PASS
Meaningful Use Alignment 5B-Referral Tracking and Follow-
UpNCQA Requirements Modified Stage 2
RulingNCQA Response
Has the capacity for electronic exchange of key clinical information+ and provides an electronic summary of care record to another provider for more than 50 percent of referrals
Health Information Exchange with a lower threshold of “more than 10%” (includes an exclusion)
NCQA will accept a report demonstrating a more than 10 percent threshold
Element 5B: Scoring6.0 points
• 9-10 factors (including factor 8) = 100%• 7-8 factors (including factor 8) = 75%• 4-6 factors (including factor 8) =
50%• 2-3 factors (including factor 8) = 25%• 0-1 factors (doesn’t meet factor 8) = 0%
Must meet at least 4 factors (including Factor 8) to pass this Must-Pass Element
Element 5B: Documentation• PCMH 5B1-3
• Examples• PCMH 5B4
• Examples/Materials• PCMH 5-6, 8, 10
Process/Policy• Date• Practice Name• Define process
• Clinical question • Supporting documentation• Tracking of referrals, timeframe, roles/responsibilities• Intake process- query of referrals since last visitReport or Log or Examples
• For each factor (report 5 days)
Element 5B: Documentation
• PCMH 7Screen Shot andReport • 3 months of recent data• Numerator• Denominator
• PCMH 9• 3 Examples
PCMH 5B1
PCMH 5B2: Sample Agreement
PCMH 5B4: Behavioral Healthhttp://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html#PracticeModel2
Coordinated Co-Located IntegratedMinimal collaboration-separate facilities and systems, communicate sporadically
Basic collaboration- mental health services on site, different systems
Close collaboration- fully integrated, part of same team, same facility/systems
Basic collaboration-separate facilities and systems, periodic communication
Close collaboration-partially integrated, some systems in common (EHR, Scheduling), close proximity for face-to-face
Close collaboration-mental health services are integrated to some degree with primary care services
PCMH 5B5-6: Examples following process
PCMH 5B8: Referral Tracking
Element 5C: Coordinate Care Transitions1. Proactively identifies patients with unplanned hospital admissions
and emergency department visits. 2. Shares clinical information with admitting hospitals and emergency
departments. 3. Consistently obtains patient discharge summaries from the hospital
and other facilities. 4. Proactively contacts patients/families for appropriate follow-up care
within an appropriate period following a hospital admission or emergency department visit.
5. Exchanges patient information with the hospital during a patient’s hospitalization.
6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.
7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care. +
+ Stage 2 Core MU Requirement
Meaningful Use Alignment 5C-Coordinate Care Transitions
NCQA Requirements Modified Stage 2 Ruling
NCQA Response
Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.
PCMH 5C aligns with Objective 5: Health Information with a lower threshold of “more than 10%” (includes an exclusion)
NCQA will accept a report demonstrating a more than 10 percent threshold.
Element 5C: Scoring6.0 points
• 7 factors = 100%• 5-6 factors = 75%• 3-4 factors = 50%• 1-2 factors = 25%• 0 factors = 0%
Element 5C: Documentation• PCMH 5C1
Process• Date• Practice Name• Define process for identifying patients who’ve been in the
ER/hospitalized.• Reporting/Log of patients who’ve been hospitalized
• PCMH 5C2Process
• Date• Practice Name• Define process for providing hospitals and ER’s clinical
information• 3 de-identified data examples of patient information sent to
hospital/ER
Element 5C: Documentation• PCMH 5C3
Process• Date• Practice Name• Define process for obtaining hospital discharge summaries• 3 examples of discharge summaries
• PCMH 5C4Process
• Date• Practice Name• Define process for providing patient care follow up post
admission and ER visit.• 3 de-identified examples of patient follow up post
discharge
Element 5C: Documentation• PCMH 5C5
Process• Date• Practice Name• Define process for two way communication with hospitals• Example of two-way communication
• PCMH 5C6Process
• Date• Practice Name• Define process for obtaining proper consent for release of
information• PCMH 5C7
Report-3 months• Numerator/Denominator • Or Example showing capability
PCMH 5C1-4: Sample Process
PCMH 5C3: Sample De-Identified Discharge Data
PCMH 6: Performance Measurement and Quality Improvement
• Element A: Measure Clinical Quality Performance
• Element B: Measure Resource Use and Care Coordination
• Element C: Measure Patient/Family Experience
• Element D: Implement Continuous Quality Improvement
• Element E: Demonstrate Continuous Quality Improvement
• Element F: Report Performance• Element G: Use Certified EHR Technology
20 POINT
S
Element 6A: Measure Clinical Quality Performance
At least annually
1. At least two immunization measures.
2. At least two other preventive care measures.
3. At least three chronic or acute care clinical measures.
4. Performance data stratified for vulnerable populations (to assess disparities in care).
+ Stage 2 Core MU Requirement
Element 6A: Scoring3.0 points
• 4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factors = 25%• 0 factors = 0%
Element 6A1-4: Documentation• For each measure
• Period of measurement• Number of patients represented by
data• Rate (percentage) based on
numerator/denominator
PCMH6A: Report Sample
Element 6B: Measure Resource Use and Care Coordination
1. At least two measures related to care coordination.
2. At least two utilization measures affecting health care costs.
Element 6B: Scoring3.0 points
• 2 factors = 100%
• 1 factors = 50%
• 0 factors = 0%
Element 6B1-2: Documentation
Report• Showing practice performance results
• Initial submission: Data <1 year old
PCMH 6B1 Documentation
Element 6C: Measure Patient/Family Experience
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. – Whole person care/self-management support.
2. The practice uses the PCMH version of the CAHPS Clinician & Group Survey Tool. 3. The practice obtains feedback on experiences of vulnerable patient groups. 4. The practice obtains feedback from patients/families through qualitative means.
Element 6C: Scoring4.0 points
• 4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factor = 25%• 0 factors = 0%
Element 6C: DocumentationPCMH 6C1-4
• Report with summarized results of patient feedback
• If going for NCQA Distinction must provide a report
Element 6C: Sample Patient Survey Data
Element 6D: Implement Continuous Quality Improvement
MUST PASS1. Set goals and analyze at least three clinical quality
measures from Element A. 2. Act to improve at least three clinical quality measures
from Element A. 3. Set goals and analyze at least one measure from
Element B. 4. Act to improve at least one measure from Element B. 5. Set goals and analyze at least one patient experience
measure from Element C. 6. Act to improve at least one patient experience measure
from Element C. 7. Set goals and address at least one identified disparity in
care/service for identified vulnerable populations.
Element 6D: Scoring4.0 points
• 7 factors = 100%• 6 factors = 75%• 5 factors = 50%• 1-4 factors = 25%• 0 factors = 0%
Must meet at 5 factors to pass this Must-Pass Element
Element 6D: Documentation
• PCMH 6D1-7 Report • Showing how each measure met
OR
• PCMH Quality Measurement and Improvement Worksheet
Element 6D: Quality Measurement and Improvement Worksheet
Element 6D: Quality Measurement
Element 6E: Demonstrate Continuous Quality Improvement
1. Measuring the effectiveness of the actions it takes to improve the measures selected in Element D.
2. Achieving improved performance on at least two clinical quality measures.
3. Achieving improved performance on one utilization or care coordination measure.
4. Achieving improved performance on at least one patient experience measure.
Element 6E: Scoring3.0 points
•4 factors = 100%• 3 factors = 75%• 2 factors = 50%• 1 factors = 25%• 0 factors = 0%
Element 6E: Documentation
• PCMH 6E1-4 Report • Showing how each measure met
OR
• PCMH Quality Measurement and Improvement Worksheet
Element 6E: Tracking Improvement Over Time
Element 6F: Report Performance
1. Individual clinician performance results with the practice.
2. Practice-level performance results with the practice.
3. Individual clinician or practice-level performance results publicly.
4. Individual clinician or practice-level performance results with patients.
Element 6F: Scoring3.0 points
• 3-4 factors = 100%• 2 factors = 75%• 1 factors = 50%• No scoring option= 25%• 0 factors = 0%
Element 6F: Documentation• PCMH 6F1 Report of clinician results
• Provided to clinicians and practice staff and explain how results shared with group
• PCMH 6F2 Report of practice results
• Explain how results shared with group
• PCMH 6F3-4- Report• Example of how report is shared with
patients and public
Element 6F: Reports
Element 6F: Reports
Element 6G: Use of Certified EHR Technology
1. The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies. +
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically.
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 data to immunization registries or immunization information systems electronically.
8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10. The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10 percent of patients/families/caregivers about needed preventive/follow-up care.+
+ Stage 2 Core MU Requirement
Element 6G: Scoring0 points
No Scoring option
http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2011-pcmh-2014-crosswalk
Standard 55A6: Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening 5B1: Considers available performance information on consultants/specialists when making referral recommendations 5B2: Maintains formal and informal agreements with a subset of specialists based on established criteria 5B3: Maintains agreements with behavioral healthcare providers 5B4: Integrates behavioral healthcare providers within the practice site 5B8: Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports 5B9: Documents co-management5C4: Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit 5C5: Exchanges patient information with the hospital during a patient’s hospitalization 5C6: Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners
Cross Walk 2011-2014
http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2011-pcmh-2014-crosswalk
Standard 66A1: At least two immunization measures 6A2: At least two other preventive care measures 6A3: At least three chronic or acute care clinical measures6B1: At least two measures related to care coordination 6B2: At least two measures affecting health care costs 6E1: Measuring the effectiveness of the actions it takes to improve the measures selected in Element D 6E2: Achieving improved performance on at least two clinical quality measures 6E3: Achieving improved performance on one utilization or care coordination measure 6E4: Achieving improved performance on at least one patient experience measure
Cross Walk 2011-2014
Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
• Gap Analysis/Audit
• Identify areas requiring work• Process/Policy• Organizational change• Reports, Samples
• Focus on areas that are quick wins first
Next Steps- Tips/Tricks
Gap Analysis Sample
Gap Analysis Sample
Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
Referenceshttp://store.ncqa.org/index.php/recognition/patient-centered-medical-home-pcmh.html
http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8.%20PCMH%20Recognition%202014_Appendix%206_Summary%20of%20Updates%20to%20PCMH%202014%2003.28.2016%20FINAL.pdf?ver=2016-04-01-142019-047
http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2011-pcmh-2014-crosswalk
Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
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Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
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