The Long and Winding Road to PCMH

1. The Long and Winding Road to PCMH

2. Presenters • Laurel Domanski Diaz, MNO, Director of Business Operations • Dan Gauntner, CNP, Director of Clinical Operations • Marianella Napolitano, RN, MBA, Clinical Quality Coordinator

3. Objectives • Identify all of the workflows needed to implement PCMH • Deep dive into NFP PCMH application • Identify the challenge areas within the application • Describe how to overcome the challenges presented due to limited ability to produce needed data

4. NFP Background • A Federally Qualified Community Health Center founded in 1980 • Last year served 13,400 patients on the near west side of Cleveland • NCQA recognized as PCMH Level 3 under 2011 standards • 17 Providers on staff--7 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives • Focus on the medically underserved • Serve a large Hispanic population

5. What is a Care Team? • A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

6. Our Care Team Composition • Three Providers—combination of Family MDs, Family CNPs, one team’s providers consists of 3 Certified Nurse Midwives • One to two RNs • One to two Patient Advocates • Medical Assistant for each Provider • Front Office representative at each team meeting

7. Care Team Implementation Activities • Developing new procedures around scheduling, registering patients & directing phone calls to teams. • Conducting activities around team formation, structure and ongoing activities. • Organizing providers and support staff into integrated care teams • Redesigning of Nursing staff structure to provide individual nurses to care teams. • Adding a Patient Advocate to each team, vital role in the PCMH model • Extended Team Support includes: • On-site Clinical Pharmacist • CareSource RN • Wellness Coordinator • Refugee Health Services • Medication Assistance Program • Diabetes Education

8. The PCMH Team & Application Plan • Identify the PCMH Application Team • Identify Key Application Facilitators • Delegation of different areas of application to relevant person • Need to have a variety of people on team, clinical and non-clinical • Organization of application and documents • Tackle each section, utilizing organization’s resources as needed • Weekly working sessions, day long sessions as submission time approached

9. Survey & Intake – What we needed to create • Inventory of Policies and Procedures, update the manual with EMR implementation, focused on PCMH relevant documents • Inventory of reports that existed, what needed to be created, etc. • Surveyed current workflows and determined how they needed to change to meet the requirements: • Patient Advocate role and new responsibilities to meet requirements • Front Office no-show work • Clinical Teams work flow around self management goals and patient education • Referral follow up process

10. Deep Dive Into the PCMH Application

11. Element 1: Enhanced Access & Continuity • A—Access During Office Hours: • Phone reporting system was used to demonstrate volume of incoming calls that RNs used to triage patient calls • B—After Hours Access: • Reports from our Answering Service that shows when the patients called NFP and at what time NFP providers returned the call.

12. After Hours Documentation

13. Element 1: Enhanced Access & Continuity • E—Medical Home Responsibilities • CareEverywhere capabilities allowed us to demonstrate care coordination/communication across different settings. • G—The Practice Team • Standing Orders Protocol Development • Pre-Orders Workflow Implementation (insert workflow)

14. Pre-Orders Workflow

15. Pre-Order Protocol

16. Element 2- Identify and Manage Populations • A—Patient Information • Primary Caregiver is defined as the name of the Emergency contact for patients under 18 • NFP did not identify a legal guardian/health care proxy • D—Use Data for Population Management • Solutions (Chronic Care, Well Child Care, Coumadin report) • Managed Care Plans registries • Patient Schedule for pre-natal care outreach & chronic disease management • No Show report within EPIC • Televox report for daily reminders

17. Element 3 – Plan and Managed Care and Element 4 – Provides Self-Care Support and Community Resources • 3A—Implement Evidence-Based Guidelines • Defined guidelines used and inserted screenshots of patient charts where they were used • Health maintenance and best practice alerts • 3B–-Identify High Risk Patients • High Risk Definition (Solutions) • Rosters – Ability to analyze data using excel • 3C, 3D, 4A • NFP Patient Examples • NCQA Manual Chart Audit option

18. Element 5 – Track and Coordinate Care • 5B—Referral Tracking and Follow-up • Access to portals for other Epic providers in the region to obtain reports • Item 7 - Providing an electronic summary of the care record to another provider for more than 50 percent of referrals • NFP provides electronic access to outside providers through Care Everywhere – which is used by majority of healthcare providers in region.

19. Element 6 – Measure and Improve Performance • Leadership commitment to Quality • FQHCs: used your Quality Management Plan from your HRSA grant • UDS reports and trends • Solutions reports • Utilization measures (preventative care measures) • Reinforcement of workflows/training • Immunization Registries • Make mention of any Quality Collaborative that you are currently participating

20. Questions?