NCQA PCMH 2011 Standards Overview

1. NCQA PCMH 2011 Standards Overview Learning Session 2 September 2012

2. Goals of NCQA Standards • Increase patient-centeredness • Align requirements with processes that improve quality and eliminate waste (i.e., ER visits, Hospital readmissions, using brand vs. generic, etc.) • Increase emphasis on patient experience • Enhance use of clinical performance measure results • Integrate: unhealthy behaviors, mental health, and substance abuse • Enhance coordination of care • Enhance applicability to pediatric practices

3. Eligible Applicants • Outpatient primary care practices that meet scoring criteria for either Level 1, 2, or 3 (3 is highest) • NCQA defines a practice as a clinician or clinicians practicing together at a single geographic location, includes nurse-led practices in states where state licensing designates NPs as independent practitioners

4. Eligible Applicants (Cont’d) • Recognition is at the practice-site level • Assessment for recognition must include a survey for every site that the practices wants to identify as a recognized PCMH • PCMH recognition identifies primary care clinicians practicing at the site, including nurse practitioners and physician assistants that have their own patient panels

5. Six Standards • Enhance Access and Continuity • Indentify and Manage Patient Populations • Plan and Manage Care • Provide Self-Care Support and Community Resources • Track and Coordinate Care • Measure and Improve Performance

6. Composition of Standards • Consist of Standard, Element, and Factor • There is always a MUST PASS Element and a Critical Factor in each standard • EXAMPLE: Standard 1 Enhance Access and Continuity • Element 1A (of 7): Access During Office Hours • Factor 1 (of 4): Provide same-day appointments—CRITICAL FACTOR!

7. Must Pass Elements • PCMH 1, Element A: Access During Office Hours • PCMH 2, Element D: Use Data for Population Management • PCMH 3, Element C: Care Management • PCMH 4, Element A: Support Self-Care Process • PCMH 5, Element B: Referral Tracking and Follow-up • PCMH 6, Element C: Implement Continuous Quality Improvement

8. PCMH Scoring 6 standards = 100 pts 6 MUST PASS elements* *Must pass elements require a ≥50% performance level to pass!

9. Standards ** Must Pass

10. Standards (Cont’d) ** Must Pass

11. Standards (Cont’d) ** Must Pass

12. Standards (Cont’d) ** Must Pass

13. Crosswalk Between MU and NCQA REQUIREMENTS

14. Crosswalk: MU, NCQA Standards

15. Practice Needs for PCMH Survey • Computer system and staff skill with: • Email • Internet access • Microsoft Word • Microsoft Excel • Adobe Acrobat Reader (free online!) • Document scanning and screen shots • Access to the electronic systems used by the practice, including billing system, registry, practice management system, electronic prescription system, EHR, Web portal, etc.

16. NCQA Recognition Process • Obtain standards and guidelines • Participate in trainings • Create online account • Purchase Survey Tool software license • Self-assess current performance on survey • Implement new PCMH capabilities at least three months prior to survey submission

17. Recognition Process (cont’d) 7. Complete online application information: electronic agreements, practice site & clinician details, and application for survey 8. Submit application 9. Receive email confirmation that the practice can submit survey tool and documentation 10. Submit survey tool and application fee when ready Receive decision in 30-60 days!

18. NCQA Educational Resources • Free online training http://www.ncqa.org/tabid/109/Default.aspx Patient-Centered Medical Home (PCMH) • Getting on Board with PCMH • PCMH 2011 Standards • The Online Application and How to Submit as a Multi-Site Practice

19. Other Resources • PA SPREAD: http://www.paspread.com • Patient Centered Primary Care Collaborative http://www.pcpcc.net/

20. Notes • Need a person to coordinate process! • Lots of policies and procedures, brochures/pt welcome letters, required for submission—not hard, just tedious! • Need to report on THREE CONDITIONS (i.e., DM, Hypertension, well woman, stroke, whatever makes sense for your practice) PLUS a high risk population (lab or other values not improving? Uninsured? MA Population? Migrant worker? ESL? No Shows? Noncompliant with care plan?). Pick one you can easily retrieve data on!

21. Notes (cont’d) • Screen shots of various screens required • They are very willing to help and have lots of tools on their website • Recommend spending the $80 for the survey tool so you can see what you will be required to submit and also be able to gauge where you are! • Current standards and tools good until at least 2014 • Aligns with Meaningful Use criteria!