Patient-Centered Medical Home NCQA’s PCMH 2011 Standards

1. Patient-Centered Medical HomeNCQA’s PCMH 2011 Standards

2. Acknowledgements

3. Today’s Agenda What is a Patient-Centered Medical Home (PCMH)? What are the Benefits for Me and My Practice? What is the National Committee for Quality Assurance (NCQA)? How Does My Practice Apply for PCMH Recognition?

4. What is a Patient-Centered Medical Home (PCMH)?

5. Patient-Centered Medical Home A practice in which an individual can receive quality, timely, efficient, and patient-centered comprehensive care and care coordination from a compassionate team of health-care professionals.

6. Patient-Centered Medical Home The PCMH is a model for re-designing primary care practices. The model is intended to improve the quality and efficiency of care delivery.

7. Medical Home “Joint Principles” Personal Physician Physician-Directed Practice Whole-Person Orientation Care Coordination/Integration Quality & Safety Enhanced Access Payment Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) in Febraury, 2007

8. Medical Home “Joint Principles” Personal Physician Each patient has an ongoing relationshipwith a personal physician, who provides comprehensive, continuous primary care.

9. Medical Home “Joint Principles” Physician-Directed Practice The physician is responsible for directing a team that takes collective responsibility for patient care.

10. Medical Home “Joint Principles” Whole-Person Orientation The physician is responsible for providing comprehensive care at all stages of life and for coordinating care as necessary with appropriate specialists.

11. Medical Home “Joint Principles” Care Coordination/Integration A patient’s care is coordinated across all elements of our complex health system (subspecialty care, hospitals, nursing homes, etc) through disease registries, information technology, health information exchange to ensure that the patient is getting needed and desired care in an appropriate manner.

12. Medical Home “Joint Principles” Quality & Safety Quality and safety are hallmarks of a PCMH; evidence-based practices, clinical decision-support tools, regular quality improvement efforts, and information technology all combine to ensure that patient outcomes attain the highest level of excellence.

13. Medical Home “Joint Principles” Enhanced Access Patients have enhanced access to their physicians and their practices as a result of open scheduling, expanded hours, and/or additional options for communication between patients, physicians, and staff.

14. Medical Home “Joint Principles” Payment Reimbursement appropriately reflects the added value patients receive from being part of a PCMH practice.

15. What are the Benefits for Me and My Practice?

16. Benefits of the PCMH Model PCMH practices provide care that is: Higher Quality Better Patient Outcomes More Efficient More Timely and Cost-Effective

17. Benefits of the PCMH Model Quality – Patient Outcomes Fewer ER visits Fewer hospital admissions Lower mortality rates Better preventive service delivery Better chronic disease care Higher patient satisfaction

18. Benefits of the PCMH Model Efficiency – Cost Lower total costs of care Shorter patient wait times Less staff burnout/turnover Higher staff satisfaction/productivity

19. Recognition of Added Value CMS Incentives for EHR Meaningful Use The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology. Medicare - $44,000 over five years Medicaid - $63,750 over six years

20. What Is the National Committee for Quality Assurance (NCQA)?

21. NCQA • National Committee on Quality Assurance (NCQA) • 501(c)(3) dedicated to improving health care quality • NCQA offers “recognition” programs for various aspects of clinical care: diabetes, cardiovascular disease, back pain • One of the recognition programs is for PCMH • 3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)

22. NCQA Lingo • The metrics that NCQA uses to assess your practice are called “standards” • There are two sets of standards: • PPC-PCMH (2008, no longer available) • PCMH (2011, released at the end of March) • NCQA grants recognition for 3 years at a time

23. 2008/2011 Comparison

24. NCQA Lingo each “standard” is composed of several “elements” each “element” is composed of several “factors”

25. PCMH (2011) Overview • 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/Manage Patient Populations • Patient Information • Clinical Data • Comprehensive Health Assessment • Use Data for Population Management • Plan/Manage Care • Implement Evidence-Based Guidelines • Identify High-Risk Patients • Manage Care • Plan/Manage Care (continued) • Manage Medications • Electronic Prescribing • Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources • Track/Coordinate Care • Test Tracking and Follow-Up • Referral Tracking and Follow-Up • Coordinate with Facilities/Care Transitions • Measure & Improve Performance • Measures of Performance • Patient/Family Feedback • Implements Continuous Quality Improvement • Demonstrates Continuous Quality Improvement • Report Performance • Report Data Externally

26. “Must Pass” Elements • Some elements are “Must Pass” • **To “Pass” one of these elements, you must receive a 50% score or higher** • In the 2011 Standards, you must pass all 6/6 of the “Must Pass” elements to achieve any level of recognition.

27. Scoring a Standard • Each Element in a Standard is worth a certain number of points. To achieve the points, you must complete some (or all) of the factors in that element. • Note: The actual details of scoring each element depends on that specific element and is NOT the same across the board.

28. Scoring a Standard Example 1: Element is worth 4 points and has 6 factors 6/6 4-5/6 3/6 1or2/6 0/6 4 points 3 points 2 points 1 point 0 points

29. Scoring a Standard Example 2: Element is worth 6 points and has 8 factors >4/8 3/8 2/8 1/8 0/8 6 points 4.5 points 3 points 1.5 point 0 points

30. Point Requirements

31. How Does My Practice Apply For PCMH Recognition?

32. Applying for PCMH Recognition • Interactive Survey Tool ($80) • Self-directed practice assessment • Application (free) • Demographic information • When ready, submit Interactive Survey Tool, Application, and final application fee

33. NCQA’s Interactive Survey System (ISS) • ISS is the web-based application software • The practice uses ISS (also called the “Survey Tool”) for: • Entering responses to each Factor for each Element • Attaching documents and providing text to support the responses

34. Pricing (including 20% discount)

35. NCQA’s PCMH Survey Process • NCQA receives and evaluates Survey Tool • Responses, documentation, and explanations • Practice may be contacted for clarification • On-site audit - 5% of practices • Final decision and status determined • NCQA grants certificate and recognition packet • Recognition status posted on NCQA Web site • Practices that don’t pass - not reported publicly

36. Upgrading PCMH Recognition • Practices that initially achieve Level 1 or 2 can complete an add-on survey to upgrade to a higher level anytime within their 3 year recognition period

37. Next Steps (Homework) Build Your PCMH Team: Identify a “PCMH Champion” who will help guide the practice through the quality transformation process Identify a “Communicator-In-Chief” who will serve as a point person for interactions with Community Care and other support staff Identify a “Lead Administrator” who will track progress, organize materials, complete the PMCH application (should have computer skills)

38. Next Steps (Homework) Begin team discussions about where the manpower will come from. Practice transformation is valuable for your patients and your practice, but it takes time. Will you: Be able to reduce your patient load? Have to extend your hours? Need to work on the weekends? Need to shift duties/responsibilities?

39. Next Steps (Homework) • Peruse the NCQA “Standards and Guidelines” document • This is a long, but important document that is the backbone of the recognition process and familiarity with it is CRUCIAL to your success.