NCQA Patient-Centered Medical Home 2011 Recognition Program

1. NCQA Patient-Centered Medical Home 2011Recognition Program PCPCC Consumer EngagementDate

2. Today • Content and focus of PCMH 2011 standards • Criteria related to consumer engagement

3. PCMH 2011 Advisory Committee Susan Edgman-Levitan - CHAIR Massachusetts General Hospital Melinda Abrams, MS Commonwealth Fund Bruce Bagley, MD American Academy of Family Physicians Michael Barr, MD, MBA, FACP American College of Physicians Duane E. Davis, MD Geisinger Health Plan Tom Foels, MD, MMM Independent Health Alan Glaseroff, MD Humboldt-Del Norte Foundation for Medical Care/IPA Foster Gesten, MD New York State Department of Health Veronica Goff National Business Group on Health Paul Grundy, MD, MPH IBM Marjie Grazi Harbrecht, MD HealthTeam Works Edward G. Murphy, MD Carilion Clinic Mary Naylor, PhD, RN University of Pennsylvania Ann O’Malley, MD, MPH Center for Studying Health System Change Amanda H Parsons, MD, MBA NYC Department of Health and Mental Hygiene Lee Partridge National Partnership for Women and Families Carol Reynolds-Freeman, MD Potomac Physicians Marc Rivo, MD, MPH Prestige Health Choice Health Choice Network Xavier Sevilla, MD, FAAP Whole Child Pediatrics Jeff Schiff Minnesota Department of Human Services Ann Torregrossa Governor's Office, Pennsylvania Ed Wagner, MD, MPH Group Health Cooperative

4. What is different about the PCMH 2011 standards? • Enhances patient-centeredness • Emphasizes language, culturally sensitive aspects • Integrates behaviors affecting health, substance abuse, mental health and risk factor assessment and management • Enhances applicability to pediatric practices • Aligns with CMS Meaningful Use requirements • Emphasizes relationship with/expectations of subspecialists • Enhances evaluation of patient experience • Underscores the importance of system cost-savings • Enhances use of clinical performance measure results

5. PCMH 2011 Overview (6 standards/27 elements) • Enhance Access and Continuity • Access During Office Hours • Access After Hours • Electronic Access • Continuity (with provider) • Medical Home Responsibilities • Culturally/Linguistically Appropriate Services • Practice Organization • Identify and Manage Patient Populations • Patient Information • Clinical Data • Comprehensive Health Assessment • Use Data for Population Management • Plan and Manage Care • Implement Evidence-Based Guidelines • Identify High-Risk Patients • Care Management • Medication Management • Use Electronic Prescribing • Provide Self-Care Support and Community Resources A. SupportSelf-Care Process B. ProvideReferrals to Community Resources • Track/Coordinate Care • Track Tests and Follow-Up • Track Referrals and Follow-Up • Coordinate with Facilities/Care Transitions • Measure and Improve Performance • Measure Performance • Measure Patient/Family Experience • Implement Continuous Quality Improvement • Demonstrate Continuous Quality Improvement • Report Performance • Report Data Externally Optional Patient Experiences Survey

6. PCMH Scoring 6 standards = 100 points 6 Must Pass elements NOTE: Must Pass elements requirea≥ 50% performance level to pass Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.

7. Must Pass Elements Rationale for Must Pass Elements Identifies critical concepts of PCMH Helps focus Level 1 practices on most important aspects of PCMH Guides practices in PCMH evolution and continuous quality improvement Standardizes “Recognition” Must Pass Elements 1A: Access During Office Hours 2D: Use Data for Population Management 3C: Manage Care 4A: Self-Care Process 5B: Referral Tracking and Follow-Up 6C: Implement Continuous Quality Improvement

8. PCMH 1: Enhance Access and Continuity Intent of Standard • Patients have access to routine/urgent care and clinical advice during/after hours that are culturally and linguistically appropriate • Electronic access • Clinician selected by patient • Team-based care; trained staff Elements • Access During Office Hours • After-Hours Access • Electronic Access • Continuity • Medical Home Responsibilities • Culturally and Linguistically Appropriate Services • The Practice Team Meaningful Use Criteria Patients provided electronic: • Copy of health information • Clinical summary of visit • Access to health information

9. PCMH 2: Identify/Manage Patient Populations Intent of Standard • Collects demographic and clinical data for population management • Assess/document risks • Create lists; use for point of care reminders Elements • Patient Information • Clinical Data • Comprehensive Health Assessment • Use Data for Population Management Meaningful Use Criteria • Language, gender, race, ethnicity, DOB • Problem list • Medication list • Medication allergy list • Vital signs • Growth chart (peds.) • Smoking status • Lists of patients with specific conditions for QI, decrease disparities • Follow-up reminders for care

10. PCMH 3: Plan and Manage Care Intent of Standard • Identify patients with specific conditions including high-risk or complex, behavioral health • Care management • Pre-visit planning • Progress toward goals • Barriers to treatment goals • Reconcile medications • E-prescribing Elements • Implement Evidence-Based Guidelines • Identify High-Risk Patients • Care Management • Medication Management • Electronic Prescribing Meaningful Use Criteria • Clinical decision support • Medication reconciliation with transitions of care • E-prescribing • Drug-drug, drug-allergy checks • Transmit prescriptions using EHR • Drug-formulary checks

11. PCMH 4: Provide Self-Care/Community Resources Intent of Standard • Assess self-management abilities • Document self-care plan; provide tools and resources • Counsel on healthy behaviors • Assess/provide/arrange for mental health/substance abuse treatment • Provide community resources Elements • Supports Self-Care Process • Provides Referrals to Community Resources Meaningful Use Criteria Patient-specific education materials

12. PCMH 5: Track and Coordinate Care Intent of Standard • Tracks, follows-up on and coordinates tests, referrals and patient care in other facilities. • Establish information exchange with facilities • Follows up with discharged patients Elements • Track Tests and Follow-Up • Track Referrals and Follow-Up • Coordinate with Facilities/ Care Transitions Meaningful Use Criteria • Incorporate lab/test results • Exchange patient information with other providers (meds/allergies, tests) • Provide summary care record for transitions and referrals

13. PCMH 6: Measure and Improve Performance Intent of Standard • Practice uses performance and patient experience data to continuously improve • Track utilization measures • Identifies vulnerable populations Elements • Measure Performance • Measure Patient/Family Experience • Implements Continuous Quality Improvement • Demonstrates Continuous Quality Improvement • Report Performance • Report Data Externally Meaningful Use Criteria Report: • Ambulatory clinical quality measures to CMS/ state • Immunization data to registries • Syndromic surveillance data to public health agencies

14. Proposed Plan for Optional Patient Experience Survey • PCMH 2011 standards will allow practices to provide reports of patient experience results as documentation for meeting relevant elements • Voluntary standardized survey will allow practices to obtain additional distinction for reporting results

15. Optional Patient Experience Survey Provide practices with distinction Require Patient-Centered Medical Home version of the CAHPS Clinician & Group survey tool on: Access Communication Coordination Whole person care Require standardized sampling approach Require use of approved data collection methodologies Require reporting data to NCQA beginning January 2012 Over time, increase requirements for standardization to allow results to be scored against benchmarks

16. Enhance Patient-Centeredness • Goal for PCMH 2011 to Increase patient-centeredness • PCMH 1: Enhance Access and Continuity • Provide continuity of care with the same provider • Provide information to the patient about medical home • Provide access to care during and after office hours • Provide patient materials and services to meet the language needs of patients • PCMH 4: Provide Self-Care and Community Support • Provide resources to support patient/family self-management • PCMH 6: Measure and Improve Performance • Involve patients/families in quality improvement • Obtain performance data for key vulnerable populations

17. Focus on Behavioral Health • Goal for PCMH 2011 to integrate behaviors affecting health, mental health and substance abuse • PCMH 1:Enhance Access and Continuity • Comprehensive assessment includes depression screening, behaviors affecting health and patient and family mental health and substance abuse • PCMH 3: Plan and Manage Care • One of three clinically important conditions identified by the practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition • Practice must plan and manage care for the selected condition • PCMH 4: Provide Self-Care and Community Resources • Self-care support includes educational and community resources and adopting healthy behaviors • PCMH 5: Track and Coordinate Care • Tracks referrals and coordinates care with mental health and substance abuse services • PCMH 6: Measure and Improve Performance • Preventive measures include depression screening

18. Questions?

19. Where to Find PCMH 2011 • Standards • No charge to view or download • Go to www.ncqa.org/view-pcmh2011 • PCMH 2011 Survey Tool • Available March 28 • Preorders are accepted now • Go to http://www.ncqa.org/tabid/629/Default.aspx • NCQA Customer Support • 1-888-275-7585 • Questions • pcmh@ncqa.org