12 Tips for Completing the PCMH Application and Survey

1. 12 Tips for Completing the PCMH Application and Survey Cross Trails Medical Center’s Journey and Lessons Learned Cross Trails Medical Center

2. Cross Trails Medical Center • Community Health Center in Southeast Missouri • Stoddard County, Cape Girardeau County, Bollinger County • 3 Clinic Locations • Medical, dental and mental health services • 2010 – 14,603 users, 44,065 encounters Cross Trails Medical Center

3. Cross Trails Medical Center Cross Trails Medical Center

4. 1. Educate Staff and Board Members • Continuously, but don’t overdo it • Keep to the main points • Canned presentations available Cross Trails Medical Center

5. 2. Pick the Right Team (5 people) • Task oriented individuals • Well respected individuals • Team members should have access to EHR’s and must be available to attend meetings, find documentation, etc. • Tip: Don’t get bogged down trying to read every piece of information you can get regarding PCMH. A few good, reputable sources are all you need to follow. Cross Trails Medical Center

6. 3. Purchase Survey Tool • Purchase the survey tool ($80) on the website • http://www.ncqa.org/tabid/629/Default.aspx • You will then get a user name and password via e-mail to log on to the Survey Tool website • https://iss.ncqa.org • When you get to the welcome page, you will see a License Number. You need this License Number to complete the application materials online. Cross Trails Medical Center

7. 4. Complete Online Application • Do this early in the process • This is different than the survey and includes • Agreement (Attestation, Data Release, NCQA Agreement, HIPAA Business Associate Agreement) • Practice Background Information Worksheet • Application • Multi-Site Group Survey Assessment Questionnaire (if applicable) • Determine survey costs • After application approved, a user name, password and a link to the web-based survey tool will be sent via e-mail Cross Trails Medical Center

8. 5. Set a Date and Work Backwards • Choose a date that you plan to submit the final survey and work backwards. • Set a timeline of when projects should be completed to fit your survey submission date. • Process will take an average of 6 months from start to finish. • FQHC’s have an advantage, with most of the standards already being met. Just need to find documentation. Cross Trails Medical Center

9. 6. Complete the Survey on Paper as a Team • Ask individuals to go through the survey on their own so that you don’t waste precious meeting time becoming familiar with the tool. • Go through as a team and establish baseline. This takes several hours and/or meeting times. • May focus on just ‘Must Pass’ elements or all elements. • Determine what level you plan to seek (Level 1, 2 or 3). • Determine multi-site or site-specific. • Note: Must have a physician at site to seek recognition. However, documentation can be from physician or mid-levels. Cross Trails Medical Center

10. 7. Note Weaknesses and Deficiencies • Conduct Gap Analysis. • Team members assigned to find necessary documentation. • Team members assigned to revise policies. • New/revised policies must be in place for at least 3 months, prior to submission. Do this first! • Need an EHR in place for Level 2 and 3. • Must adopt and implement evidence-based guidelines for three clinically important conditions. CTMC had to add Depression as the third condition. Cross Trails Medical Center

11. 8. Assign Team to Find Documentation • Minimize, minimize, minimize (our lesson learned). • Use one piece of documentation for more than one element. Must track and link on the survey tool. Looks intimidating, but easy once you dive in. Cross Trails Medical Center

12. 9. Complete Record Review Workbook • The Record Review Workbook consists of chart audits of individuals • The Record Review Workbook is provided upon purchase of the survey to help with the chart review process. • Sample size is 36 patients and is based on 3 Clinically Important Conditions. • Clinics can query their EHR, instead, if fully populated. • Satisfies four elements • PPC 2C, PPC 2D, PPC 3D, PPC 4B • Based on the three Clinically Important Conditions • Patients seen in the last 3 months Cross Trails Medical Center

13. 10. Create Database File • Create internal database file/hard drive to house documentation by element. Accessible to all for uploading of documentation. • Limited to 100 documents. Process recommends no more than 3 documents for each element. • De-identify documentation and insert text boxes/post-its in document to explain to the reviewer what they are looking at. Cross Trails Medical Center

14. 11. Complete Online Survey & Upload Documentation • Complete online survey as you did on paper • Attach documentation in Document Library and link to element Cross Trails Medical Center

15. 12. Submit • Submit Survey • 60 day turn around on approval • Recognized for a 3-year period, if approved Cross Trails Medical Center

16. Questions • Contact CTMC if you have questions about our process: • Chrissy Warren • Chief Operating Officer • 573-339-1196 • cwarren@crosstrails.us • Good, easy to follow resource: • Obtaining Patient-Centered Medical Home Recognition: A How To Manual, A Guide for Obtaining PPC-PCMH Recognition for Safety-Net Providers. Primary Care Development Corporation. www.pcdcny.org. November 2009. Cross Trails Medical Center