NCQA Standards Workshop Physician Practice Connections - Patient-Centered Medical Home (PPC ® -PCMH™)

1. 2009 NCQA Standards WorkshopPhysician Practice Connections - Patient-Centered Medical Home (PPC®-PCMH™)

2. Agenda Patient-Centered Medical Home Overview Content of PPC-PCMH Standards Documentation examples* Recognition Process * Examples in the presentation only illustrate the element intent. They are NOT definitive nor the only methods of documenting how the elements may be met

3. The Patient-Centered Medical Home DefinedACP, AAFP, AAP, AOA Joint Principles – April 2007 • Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. • Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. • Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. • Care is coordinated and/or integratedacross all elements of the complex 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 other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

4. PPC-PCMH Content and Scoring **Must Pass Elements

5. PPC-PCMH Scoring Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1. Practices with a numeric score of 0 to 24 points or less than 5 Must Pass Elements are not Recognized.

6. 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 to 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

7. Data Sources & Health Information Technology (HIT) Guidance • Elements may have multiple suggestions for data sources and documentation– select what your practice would use to demonstrate that function and describe how it is used • Each element indicates the type of health information technology needed to perform the functions • Basic – (HIT) Basic • Paper-based or basic (mostly administrative) electronic system • Intermediate – (HIT) Intermediate • Electronic system for clinical functions • Advanced – (HIT) Advanced • Electronic system with connectivity or interoperability with other systems

8. PCMH Elements by Type of Information Technology (IT) Practice can achieve a passing score on Must Pass Elements with Basic Information Technology

9. PPC1 - Access and Communication Patient access to care and communication • PPC1A: Access and communication processes • PPC1B: Access and communication results

10. PPC 1 Element A:Access and communication processes Practice has written process for*: Scheduling patients with same clinician Coordinating visits with multiple clinicians during one trip Determining how soon a patient needs to be seen Responding to urgent calls within specified time Providing telephone advice Providing language services *Shows 6 of 12 items in Element A Must Pass - 4 points Scoring: based on 12 items 9-12 items = 100% 7-8 items = 75% 4-6 items = 50% 2-3 items = 25% 0-1 item = 0% Documentation: Written process Policies and procedures Instructions Appointment system

11. PPC1A: Scheduling Policy

12. PPC 1 Element B: Access and communication results Practice shows how it meets patient access and communication standards Visits with assigned physician Appointments scheduled to accommodate patient condition and need Timely response to phone, e-mail and Internet requests Language services if the practice’s population requires it Must Pass - 5 points Scoring: Based on number of items met of 5 5 items = 100% 4 items = 75% 3 items = 50% 2 items = 25% 0-1 item = 0% Data source: Reports Logs or screen shots showing records of appts. scheduled and time for returning calls

13. Access Standards with Specific Targets and Result Measurements Standards Results Measurements

14. PPC2 - Patient Tracking and Registry Functions Systematic use of patient information for population management to support patient care • PPC2A: Basic System for Managing Patient Care • PPC2B: Electronic System for Clinical Data • PPC2C: Use of Electronic Clinical Data • PPC2D: Organizing Clinical Data • PPC2E: Identifying Important Conditions • PPC2F: Use of System for Population Management

15. PPC2A: Basic System for Managing Patient Data Practice uses electronic data system for searchable patient information 1-9. Name, DOB, gender, marital status, language preference, race/ethnicity, address, phone, email 10-11. Internal and external IDs 12. Emergency contact info. 13. Current and past diagnoses 14. Dates of prior visits 15. Billing code 16. Legal guardian 17. Health insurance coverage 18. Preferred method of communication 2 points Scoring: Number of items met of 18 12-18 items = 100% 8-11 items = 75% 6-7 items = 50% 4-5 items = 25% 0-3 items = 0% Data source: Reports from electronic system showing data items entered for 75-100% of patients

16. Element A- Report Showing Basic Patient Information Field Use

17. PPC2B: Electronic System for Clinical Data Practice uses clinical data systems to manage care of patients has searchable data fields for clinical patient information: Preventive services Allergies/adverse reactions Blood pressure 4-5. Height and Weight 6. BMI 7-9. Lab test, imaging and pathology results Advance directives Head circumference (for patients ≤ 2 years 3 points Scoring: Number of items met of 10 9-10 items = 100% 7-8 items = 75% 5-6 items = 50% 3-4 items = 25% 0-2 items = 0% Data source: Reports or screen shots showing data fields in patient records

18. Example PPC2B: Screen Shot of Data Fields for Clinical Data

19. PPC2C: Use of Electronic Clinical Data Practice uses the fields listed in 2B consistently in patient records Preventive services Allergies Blood pressure 4-5. Height and Weight 6. BMI 7-9. Lab test, imaging and pathology results 10. Advance directives 3 points Scoring: Practice enters a percentage of patients seen in past 3 months with 7 fields completed: 75-100% of patients = 100% 50-74% of patients = 75% 25 -49% of patients = 50% 10-24% of patients = 25% <10% of patients = 0% Data source: Reports from electronic system OR Record Review Workbook

20. Element C: Report of percent of patients with clinical data items entered in system

21. What is the Record Review Workbook? Elements PPC 2C, 2D, 3D, 4B Require medical record abstraction of data Need % of patients based on numerator and denominator Two methods to collect and submit patient data Method #1 - report from the electronic system Method #2 – Record Review Workbook Excel workbook in the Survey Tool Tool to identify sample of patients and abstract data needed for Elements 2C, 2D, 3D, 4B

22. Example PPC 2C, 2D, 3D, 4B Option NCQA Medical Record Review Worksheet

23. Selecting Patients for Record Review Workbook~Use same 36 patients for EACH Workbook Element~ • STEP #3. • Use appointment or billing system to identify patients with visit on April 30 • Choose patients with any of three clinically important conditions who had a visit on this date related to the conditions STEP #1. START DATE = Today’s date June 1 STEP #4. Continue choosing patients going back on consecutive dates until all 36 patients are selected STEP #2. Go back 30 days = May 1

24. PPC2D: Organizing Clinical Data Practice uses paper or electronic charting tools used to organize and document clinical information Problem lists Medication lists (OTC) Medication lists (RX) Template for risk factors Templates for progress notes Screening for developmental testing Growth charts & BMI Based on number of items documented in records of patients seen in last 3 months Must Pass – 6 points Scoring - % of patients with 3 tools documented: 75-100% = 100% 50-74% = 75% 25-49% = 50% 10-24% = 25% <10% = 0% Data source Record Review Workbook or Electronic system report with percent of patients seen in past 3 months

25. PPC 2D - what to look for in the medical record: Documented Risk Factors And Medication Lists In Paper Flow Sheet

26. PPC2D: Pediatric Weight Chart

27. PPC2E: Identifying Important Conditions Practice identifies Most frequently seen diagnoses = most often seen, single episode or chronic; identify by number of patients, visits, total fees billed Most important risk factors = for the demographic population Three clinically important conditions (chronic or recurring) = practice identifies Must Pass – 4 points Scoring 3 items = 100% 2 items = 75% 1 item = 50% 0 items = 0% Data source Reports from EHR, practice management system, billing or scheduling system for frequent Dx Identify risk factors in reports Identify conditions and why selected in the Support Text/Notes section

28. PPC2E: Example Text Notes in Survey Tool “Attached are 3 reports: Frequent diagnoses: Dates of service and the diagnosis codes, sorted by codes for frequency. Risk factors: Source of Community Statistics for Risk Factors - www.CDC.gov and http://apps.nccd.cdc.gov/brfss/display_PF.asp Clinically important conditions: As part of a National PCMH Demonstration Project, the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia which represent the best likelihood of being amenable to care management and providing value on costs to the health care system based on regional experience.”

29. PPC2F: Use of System for Population Management Practice uses electronic information to generate lists of patients and remind patients and clinicians proactively of services needed: Pre-visit planning Clinician action Specific medications Preventive care Specific tests Follow-up visits Care management services 3 points Scoring: Practice takes action on 5-7 items = 100% 3-4 items = 75% 1-2 items = 50% 0 items = 0% Practice gets partial credit If system can generate lists but practice does not use it Two Data sources: Lists generated -- reports from EHR, registry and Example of use of the lists -- screen shots, written description of process

30. Population Management Examples EHR Query-Patients Needing Pneunomax vaccine Report – Patients on a Specific Medication

31. PPC3: Care Management Practice maintains continuous relationship with patients by using evidence-based guidelines and applying them to needs of individual patients over time. PPC3A: Guidelines for Important Conditions PPC3B: Preventive Service Clinician Reminders PPC3C: Practice Organization PPC3D: Care Management for Important Conditions PPC3E: Continuity of Care

32. PPC3A: Guidelines for Important Conditions Practice adopts and implements evidence-based diagnosis and treatment guidelines for three clinically important conditions Use same conditions in PPC2D, 2E, 3A, 3D, 4B, 9C Must Pass –3 points Scoring 3 conditions = 100% 2 conditions = 50% 1 condition = 25% 0 conditions = 0% Data source: workflow organizers that show guidelines adopted and implemented Provide source of guidelines Paper flow sheets, templates for documenting progress Screen shots showing templates for treatment plans and documenting progress

33. Example PPC3A – Adoption of Evidence –Based Diagnosis and Treatment Guidelines

34. Example – Evidence-Based Diabetic Workflow Organizer (shows what to document at each visit)

35. Example PPC3A - EHR Prompting Lipid Management Evidence-Based Guidelines

36. PPC3B: Preventive Service Clinician Reminders Practice generates reminders about preventive services for clinicians Practice uses paper or electronic guideline-based alerts and reminders to write orders and conduct assessments Screening tests Immunizations Risk assessments Counseling 4 points Scoring Reminders for 4 items = 100% Reminders for 3 items = 75% Reminders for 2 items = 50% Reminders for 1item = 25% Reminders for no items = 0% Data source: reports, screen shots, templates or paper flow sheets showing decision- support for clinicians during visits, calls and email.

37. Example PPC3B - Preventive Service Reminders for Clinicians Paper Reminder for Risk Assessments, Immunizations, Screening Tests EHR with Risk Assessment Reminders

38. PPC3C: Practice Organization Care team manages patient care: Non-physician staff remind patients of appointments and collect information before appointments Non-physician staff execute standing orders (e.g. med. refills, order tests) Non-physician staff educate patients to manage conditions Non-physician staff coordinate care with external disease management or case management organizations 3 points Scoring 4 items = 100% 3 items = 75% 2 items = 50% 0-1 item = 0% Data source Job descriptions Protocols Written standing orders

39. Example PPC3C: Practice Organization Standing Orders Note: If patient needs OV or labs, refill up to one month (one time only). If more requested, check with physician

40. PPC3D: Care Management for Important Conditions To manage care of patients with three clinically important conditions, practice uses: Pre-visit planning Individualized written care plans Individualized treatment goals Assess progress toward goal Review of medications with patients Review self-monitoring results and include in medical record Assess barriers when patient not met treatment goals Assess barriers when patient not filled prescriptions or took meds. Follow-up when patient not kept important appointments Review patient clinical data over time After-visit follow-up 5 points Scoring – patients seen in past 3 months have 4 items documented: ≥75% of patients = 100% 50-74% of patients = 75% 25-49% of patients = 50% 11-24% of patients = 25% ≤10% of patients = 0% Data source Report from electronic system showing percent of patients seen with documentation of items OR Record Review Workbook

41. PPC3D: Written Care Plan in Medical Record

42. PPC 3D - what to look for in the medical record: Documented Patient Progress and Treatment Goals Patient Progress, Treatment Goals and Medication Review Patient Progress and Treatment Goals Medication Review Patient progress Treatment plan and goals Assessment & Plan

43. PPC3E: Continuity of Care Practice provides continuity of care for patients who receive care in inpatient or outpatient facilities Identifies patients Sends information to facilities and patients Reviews information from facilities to identify patients needing proactive contact or are at risk for adverse outcomes Contacts patients post-discharge Provides or coordinates follow-up care to discharged patients Coordinates care with external disease or care management organizations Communicates with patients getting disease or high risk case management Communicates with case managers for patients getting disease or high risk case management 9. Develops written transition plan with patient for transition to other care Coordinates with new physicians 5 points Scoring 5-10 items = 100% 3-4 items = 75% 2 items = 50% 0-1 item = 0% Data source: from practice or external organization Protocols re: timeline for patient follow-up Protocols for care plans Log of patients receiving care from other facilities Registry, EHR, hospital or ER reports Health needs assessments Blinded case management or medical record notes

44. Example – ER Visit Follow-Up Log

45. Example – Follow-Up Care after Hospital Admission

46. PPC4 - Patient Self-Management Support Improve patient ability for self-management by: • PPC 4A - Documenting communication needs • PPC 4B - Providing self-management support

47. PPC4A: Documenting Communication Needs Practice assesses patient-specific barriers to communication using systematic process to: Identify and display in record patient language preference Assess both hearing and vision barriers 2 Points Scoring: 2 items = 100% 1 item = 50% 0 items = 0% Data source - How practice Records language preference: screen shots, patient assessment forms Determines % of patients preferring another language: reports from EHR, patient record review

48. PPC4A: Example Documenting Communication Needs

49. PPC4B: Self-Management Support Practice documents patient self-management support for 3 clinically important conditions Assess patient preferences, readiness and ability for self-management Provides educational resources in patient language 3. Provides self-monitoring tools for patients 4-6. Provides or connects patient with support programs, classes, resources 7. Provides patient with written care plan Must Pass – 4 points Scoring – % of patients seen in past 3 months have 3 items documented: 75-100% patients = 100% 50-74% = 75% 25-49% = 50% 11-24% = 25% ≤10% = 0% Data source Record Review Workbook or Report from electronic system

50. PPC 4B - what to look for in the medical record: Documented Use of Self-Monitoring Tools & Program Referrals