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Agenda. NCQA Introduction Development of Physician Practice Connections (PPC) and PPC-PCMH PPC-PCMH Standards Overview The Recognition Process What Have We Learned?. NCQA. MissionTo improve the quality of health careVisionTo transform health care through Quality measurementTransparencyAccountability.
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1. TRICARE West Region Health Leadership ConferenceMina L. Harkins, MBA, MT(ASCP)NCQA AVP, Physician Recognition Programs Recognizing Patient-Centered Medical Homes with NCQA’s PPC-PCMH Program
3. NCQA Mission
To improve the quality of health care
Vision
To transform health care through
Quality measurement
Transparency
Accountability
4. Measurement
We can’t improve what we don’t measure
Transparency
For measurement to be accepted we have to show how we intend to measure
Accountability
Once we can measure we can hold everyone accountable for improvement
5. MEASUREMENT, TRANSPARENCY, AND ACCOUNTABILITY Quality measurement means:
Objective measures based on evidence
Results that are comparable across organizations
Impartial third-party evaluation and audit
Public Reporting
NCQA’s quality programs include:
Performance-based Health Plan accreditation
HEDIS clinical measures
CAHPS consumer survey
Measurement of quality in provider groups
Physician Recognition
7. NCQA Recognition Programs
8. What are Recognition Programs? Voluntary evaluation programs that assess structure, outcomes and processes of care at the physician level.
Requirements based on clinical evidence and agreed upon best practices.
Developed collaboratively with national health organizations and professionals.
Recognition is granted for either two to three years, depending on the program.
9. Current programs: DPRP, HSRP, BPRP, PPC, PPC-PCMH
What measures included: Structure, process and outcomes of excellent care management
Where they come from: partnership with leading national health organizations and professionals
Who supports recognized physicians: health plans, medical boards, state and national government agencies and coalitions of employers
Who is recognized: more than 15,000 physicians nationally NCQA Recognition ProgramsPhysician-Level Measurement
10. NUMBER OF PPC & PPC-PCMH CLINICIAN RECOGNITIONS BY STATE
11. Steps in Development of Physician Recognition Programs Identification of need and market opportunities
Development of potential content and review by expert panel
Feasibility testing
Development of draft program standards and scoring and review by expert panel
Review and approval of measures by Committee on Performance Measurement (if measures included)
Review and approval by Committee on Physician Programs
Review and approval by NCQA Board of Directors
12. Early Development of PPC Document evidence base linking specific systems to clinical performance
Medline Review
Cochrane Collaborative
Manuscripts in press
Convene expert panel to review evidence and suggest standards/measures
Conduct analysis of practice defects using six sigma process (with GE in BTE project)
Create standards
Test survey tool incorporating standards developed related to chronic care model and patient-centered care literature
13. Principles Focus on evidence-based requirements related to improved quality and reduced costs
Consider capabilities of small and large practices, but don’t sacrifice quality
Balance desirable requirements with feasibility and burden of review
Require electronic information when necessary; electronic systems are not sufficient
14. Goals forPhysician Practice Connections (PPC)
Evaluate systematic approach to delivering preventive and chronic care (Wagner Chronic Care Model)
Build on IOM’s recommendation to shift from “blaming” individual clinicians to improving systems
Create measures that are actionable for physician practices
Validate measures by relating them to clinical performance and patient experience results
15. Theoretical Frameworks Informing Physician Practice Connections
16. Wagner Model for Effective Prevention and Chronic Illness Care
17. Identified Needs Response to IOM reports
To Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systems
Change from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeed
Raise awareness of physicians of importance of systems in enhancing quality
Link health services research on systems and clinical outcomes to practice
18. Adapting PPC for thePatient-Centered Medical Home New PPC-PCMH version released in January 2008
Aligned standards with Joint Principles
Incorporated critical attributes of PCMH
Defined foundational elements (“must pass” requirements)
PPC-PCMH endorsed by ACP, AAFP, AAP, AOA, other specialties and PCPCC
19. The Patient-Centered Medical Home DefinedACP, AAFP, AAP, AOA Joint Principles – April 2007 Personal physician – patient has ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice – personal physician leads a team at the practice level who take responsibility for the ongoing care of patients.
Whole person orientation – personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
Care is coordinated and/or integrated across all elements of health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and to assure that patients get care when and where they need and want it in a culturally and linguistically appropriate manner.
21. Physician Practice Connections®?Patient-Centered Medical Home (PPC-PCMH™) Encourage practices to adopt proven systems for improving care
Provides mechanism for incentivizing investment in quality infrastructure and processes
Complements measurement of clinical effectiveness, patient experiences, and efficiency
22. Patient-Centered Medical Home Standards
23. NCQA PPC-PCMH Standards
24. PPC-PCMH Content and Scoring
25. PCMH Must Pass Elements PPC1A: Written standards for patient access and patient communication
PPC1B: Use of data to show meeting this standard
PPC2D: Use of paper or electronic-based charting tools to organize clinical information
PPC2E: Use of data to identify important diagnoses and conditions in practice
PPC3A: Adoption and implementation of evidence-based guidelines for three conditions
PPC4B: Active support of patient self-management
PPC6A: Tracking system for tests and identify abnormal results
PPC7A: Tracking referrals with paper-based or electronic system
PPC8A: Measurement of clinical and/or service performance
PPC8C: Performance reporting by physician or across the practice
26. PPC-PCMH Scoring
27. Access & Communication The practice establishes in writing standards for the following processes to support patient access and measures to show whether it meets the standards
scheduling each patient with a personal clinician for continuity of care
coordinating visits with multiple clinicians and/or diagnostic tests during one trip
determining through triage how soon a patient needs to be seen
maintaining the capacity to schedule patients the same day they call
scheduling same day appointments based on practice's triage of patients' conditions
scheduling same day appointments based on patient's/family’s requests
providing telephone advice on clinical issues during office hours by physician, nurse or other clinician within a specified time
providing urgent phone response within a specific time, with clinician support available 24 hours a day, 7 days a week
28. Patient Tracking & Registry The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed
patients needing clinician review or action
patients on a particular medication
patients needing reminders for preventive care
patients needing reminders for specific tests
patients needing reminders for follow-up visits such as for a chronic condition
patients who might benefit from care management support.
29. Care Management For the three clinically important conditions, the physician and nonphysician staff use the following components of care management support:
-conducting pre-visit planning with clinician reminders-writing individualized care plans-writing individualized treatment goals-assessing patient progress toward goals-reviewing medication lists with patients/families -reviewing self-monitoring results and incorporating them into the medical record at each visit-assessing barriers when patients have not met treatment goals-assessing barriers when patients have not filled, refilled or taken prescribed medications-following up when patients have not kept important appointments-reviewing longitudinal representation of patient’s historical or targeted clinical measurements
30. Patient Self-Management Support For the three clinically important conditions, the physician and nonphysician staff use the following components of care management support:
- conducting pre-visit planning with clinician reminders- writing individualized care plans- writing individualized treatment goals- assessing patient progress toward goals- reviewing medication lists with patients/families - reviewing self-monitoring results and incorporating them into the medical record at each visit- assessing barriers when patients have not met treatment goals- assessing barriers when patients have not filled, refilled or taken prescribed medications- following up when patients have not kept important appointments- reviewing longitudinal representation of patient’s historical or targeted clinical measurements
31. Test and Referral Tracking Tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice.
Tracking laboratory tests
until results are available to the clinician,
flagging overdue results
flagging abnormal test results
follows up with patients/families for all abnormal test results
notifies patients/families of all normal test results
32. Quality Measurement & Improvement The practice measures or receives data on the following types of performance by physician or across the practice
clinical process (e.g., percentage of women 50+ with mammograms or childhood vaccination rates)
clinical outcomes (e.g., HbA1c levels for diabetics)
service data (e.g., backlogs or wait times)
patient safety issues (e.g., medication errors)
The practice collects data on patient experience with care in the following areas
1. patient access to care
2. quality of physician communication
3. patient/family confidence in self care
4. patient/family satisfaction with care.
33. What is the PPC-PCMH application and survey process?
34. How PPC-PCMH Recognition Works Physician/practice
Self-assess, collect data using Web-based software
Submit documentation to NCQA when ready
May be asked to submit more data if needed
NCQA
Evaluates and scores all applications
Checks licensure of physician
Audits a sample of applications
Posts Recognized physicians and practices on web
Distributes list of Recognized physicians and practices monthly to health plans and others
Practices sent media kit, press releases, letter & certificate
35. Who is Recognized? NCQA Recognizes a practice and the clinicians who meet the criteria described by the endorsed principles of the Patient-Centered Medical Home
Clinicians listed on NCQA Web site
A practice is a physician or physicians and clinicians practicing together at a single geographic location
An organization with multiple sites submits a survey for each site.
36. What is a Multi-Site Survey? The multi-site survey is a process for organizations with multiple sites to complete the PPC-PCMH assessments for multiple locations more efficiently
Practice completes a questionnaire about shared electronic processes in the organization
NCQA reviews and approves those elements that can be answered once in a multi-site survey and links those results with each associated practice site survey submitted
37. Recognition Process Practices may use the Survey Tool to self-assess before submitting to NCQA
Recognition is based on:
Responses in Web-based Survey Tool
Supporting documentation attached to Survey Tool
Element specifies type of documentation
Reports
Reports from EHR, registry, practice management & billing systems
Documentation of processes
Policies and procedures, protocols
Records or files
NCQA’s Medical Record Review Workbook
Screen shots from EHR
38. NCQA Web-Based Survey Tool Interactive System Survey (ISS) Tool allows practices to:
Enter responses in Survey Tool
Attach documents to Survey Tool that support responses
Survey Tool scores the responses
Practices can use the Tool to self-assess
40. Training
Scheduled audio-conference workshops on standards and meeting the documentation requirements
WebEx demonstrating the Interactive Survey System software (ISS)
Recorded versions of both training programs
Live training presentations may be arranged
Resources
Customer Support 888-275-7585
Dedicated email address ppc-pcmh@ncqa.org for on-going Q&A answered within 2 business days
FAQs posted on web site covering each standard
Guided multi-site application process for large practices sharing systems across multiple sites
41. What Have We Learned?
42. How to further assess patient-centeredness, including patient survey results?
How to engage patients?
How to make name resonate positively?
When should performance results be part of scoring?
How to adapt to promote quality and cost gains across settings?
Primary care—subspecialty
Physician—hospital, other facilities
How to streamline requirements, documentation?
For all practices
For practices renewing Significant PPC-PCMH Issues for Future
43. Study of Validity: Accuracy of Self-Report Test accuracy of self-reports of practice systems using on site audit as “gold” standard
Varies by domain, by staff position, and by medical group
The predictive value of a positive report of a practice system is generally high.
Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management).
Several factors may explain lack of agreement
Variable implementation of systems across sites and conditions
Variations in staff members’ exposure to systems
Lack of familiarity with systems
44. Studies of Correlation with Clinical Performance and Patient Experience Overall score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma)
Overall score does NOT appear to correlate with patient experiences of care
Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures
However, practices with fully functional EMR’s achieve highest scores
45. Evidence: Higher patient ratings of care improve adherence and outcomes Patients who report being treated with dignity and were involved in decisions were likelier to adhere to doctor recommendations (Beach 2005)
Sustained provider relationship and trust are associated with receipt of preventive services (Parchman 2003)
Lower patient satisfaction is associated with more poorly controlled diabetes, migraine-related disabilities, and hassles with the healthcare system (Redekop 2002, Walling 2005, Parchman 2005)
There are simple and effective methods for training physicians to improve interaction with patients (Rodriguez 2008)
46. Goals Incorporate patient experiences into evaluation
Encourage practices to use patient experiences data
Allow opportunity for holding practices accountable for achieving patient-centeredness from patient’s point of view
47. NCQA Contact Information Contact NCQA Customer Support to:
Acquire standards documents, application materials, and survey tools
Questions about your user ID, password, access
1-888-275-7585
Visit NCQA Web Site to:
View Frequently Asked Questions
View Recognition Programs Training Schedule
Submit to questions to ppc-pcmh@ncqa.org
Please use this e-mail box to:
Ask about interpretation of standards or elements
Submit application materials (physician workbook and application)
Request registration for ISS Survey Tool demonstration (Web-ex)
48. Questions?