Training Webinar # 6
David Halpern, MD, MPH
February 15, 2012

© Copyright 2011 North Carolina Community Care Networks,
Inc. All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure NCQA recognition as patient-centered medical homes. All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community
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• Standard 2 – Identify & Manage Populations
– PCMH 2A: Patient Information
– PCMH 2B: Clinical Data
– PCMH 2C: Comprehensive Health Assessment
– PCMH 2D: Use Data for Population Management -
MUST PASS
• Standard 5 – Track & Coordinate Care
– PCMH 5A: Test Tracking & Follow-Up
– PCMH 5B: Referral Tracking & Follow-Up MUST PASS
– PCMH 5C: Coordinate With Facilities & Care
Transitions

• Standard 1 – Enhance Access/Continuity
• Standard 2 – Identify/Manage Populations
• Standard 3 – Plan/Manage Care
• Standard 4 – Self-Care Support/Resources
• Standard 5 – Track/Coordinate Care
• Standard 6 – Measure/Improve
Performance

– PCMH4A: Support Self-Care Process –
MUST PASS
– PCMH4B: Provide Referrals to Community
Resources

• Elements 3C, 3D, 4A
– Require medical record abstraction of data
– Need % of patients meeting the element
(based on a numerator and a 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 a sample of patients and abstract data needed for Elements 3C, 3D, 4A

1. Find Workbook in Survey Tool
2. Download and save file to computer
3. Review instructions and data needed from patient records
4. Select patient records to review
5. Review patient records for data
6. Enter data in Workbook
7. Enter numerical result in Survey Tool
8. Link Workbook to Survey Tool

~ Use same 48 patients for EACH Workbook Element ~
STEP #3.
• Use appointment or billing system to identify patients with visit on June 5th
• Choose every patient with any of 3 clinically important conditions who had a visit on this date that was related to the important condition
STEP #1 . START
DATE = Today’s date February 15th
STEP #4.
Continue choosing patients going back on consecutive dates until you have selected 48 patients STEP #2.
Go back
30 days = January 15th

RRWB = Supplemental Worksheet
Click here

Three tabs
 Instructions
 Patient Conditions
 Record Review

RRWB – Enter Important Conditions
Enter three important conditions here including an unhealthy behavior/mental health or substance abuse AND high-risk or complex patients, IF you are including them.

Enter conditions from drop down menu, for example:
 Diabetes
 Hypertension
 Depression
 High Risk/Complex

Entering NOT USED in row 1
“grays” out the column
Response Options
 Yes
 No
 Not Used
 Not applicable

Patients that Met Factor
 Number (33/48)
 Percent (69%)
 Result for ISS

Enter RRWB Responses in Survey Tool
Enter responses
From RRWB
 Yes or No
AND
 Percent

PCMH 4: Self-Care Support &
Community Resources
Elements
• PCMH4A: Provide Self-Care Support –
MUST PASS
• PCMH4B: Provide Referrals to Community
Resources

PCMH 4A: Provide Self-Care Support
• Practice conducts activities to support patients in selfmanagement: ( MUST PASS )
1. Provides education resources or refers at least 50% of patients to educational resources
2. Uses EHR to identify education resources and provide them to
10% of patients **
3. Collaborates with at least 50% of patients to develop and document self-management plans and goals-CRITICAL
FACTOR
4. Documents self-management abilities for at least 50% of patients
5. Provides self-management result recording tools to at least 50% of patients
6. Counsels at least 50% of patients on adopting health lifestyles
** Meaningful Use Requirement

PCMH 4A: Provide Self-Care Support
• MUST PASS
• 6 Points
• Scoring
– 5-6 factors (including factor 3) = 100%
– 4 factors (including factor 3) = 75%
– 3 factors (including factor 3) = 50% (must-pass)
– 1-2 factors = 25% (not sufficient for passing element)
– 0 factors = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook

PCMH 4A:
• Patient Self management tools are available by clicking on the last tab in Provider Portal or by going to the “Patient Mgmt Tools” tab at the CCNC website: www.communitycarenc.org
• These tools are all non-branded, evidence based, low literacy appropriate and have been vetted by physicians at CCNC

PCMH 4A:
Provider Portal allows you to search AND download disease-specific selfmanagement tools, handouts, and video demos, which patients can access from home

PCMH 4A: Example – Factor 1
Examples of selfmanagement tools for patients/families

PCMH 4A: Example – Factor 1

PCMH 4A: Example – Factor 1

PCMH 4A: Example – Factor 3

PCMH 4A: Example – Factor 3
Your Goal HbA1c:
Green Zone: Great Control

HbA1c is under 7

Average blood sugars typically under 150

Most fasting blood sugars under 150



Work closely with your health care team if you are going into the YELLOW zone



Yellow Zone: Caution
HbA1c between 7 and 9
Average blood sugar between 150-210
Most fasting blood glucose under 200
Red Zone: Stop and Think
HbA1c greater than 9
Average blood sugars are over 210
Most fasting blood sugars are well over 200
Call your physician if you are going into the RED zone
Green Zone Means:

Your blood sugars are under control

Continue taking your medications as ordered

Continue routine blood glucose monitoring

Follow healthy eating habits

Keep all physician appointments
Yellow Zone Means:

Your blood sugar may indicate that you need an adjustment of your medications

Improve your eating habits

Increase your activity level
Call your physician, nurse, or diabetes educator if changes in your activity level or eating habits don’t decrease your fasting blood sugar levels.
Name:___________________________
Number:__________________________
Red Zone Means:
You need to be evaluated by a physician.
If you have a blood glucose over ____, follow these instructions _____________
__________________________________
Call your physician
Physician:_________________________
Number:__________________________

PCMH 4A: Example – Factor 4
Demonstrates patient progress and selfmonitoring results
Demonstrates barriers to patient’s ability to meet goals

PCMH 4A: Example – Factor 4 & 5
The practice provides patient with selfmanagement tool
(flowsheet) and then includes completed selfmanagement tool in patient’s chart, demonstrating patient’s self-management ability.

PCMH 4A: Example – Factor 5
Example of a diabetes log book

PCMH 4A: Example – Factor 5
Example of a hypertension log book

PCMH 4A: Example – Factor 5
Example of a
CHF log book

PCMH 4A: Example – Factor 6
Example of counseling documentation in the EMR

PCMH 4A: Example – Factor 6
Example of counseling documentation in the EMR

PCMH 4B: Provide Referrals to
Community Resources
• Practice supports patients who need access to community resources:
1. Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support)
2. Tracks referrals provided to patients
3. Arranges for or provides treatment for mental health/substance abuse disorders
4. Offers opportunities for health education and peer support

PCMH 4B: Provide Referrals to
Community Resources
• 3 Points
• Scoring
– 4 factors = 100%
– 3 factors = 75%
– 2 factors = 50%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– List of community services or agencies
– Referral log or report covering at least one month
– Processes to provide/arrange for mental health/substance abuse treatment and health education support

PCMH 4B: Example – Factor 2

• Download the Record Review Workbook and start familiarizing yourself with it.

• Organize Your Documents
– Create a place on your computer (server or hard-drive) for all of your documentation
– You should have a folder for each standard
– A checklist can help you determine what you already have created/saved and what you need to prepare from scratch

– Decide which 3 “Important Conditions”
(e.g. diabetes, asthma, congestive heart failure, depression, etc) you want to track over time. One must be related to unhealthy behaviors, mental health, or substance abuse.
– Does your practice already follow evidencebased guidelines when caring for patients with these conditions?
– Are these guidelines documented anywhere?

• David Halpern, MD, MPH
Community Care of North Carolina (CCNC)
• R.W. “Chip” Watkins, MD, MPH, FAAFP
Community Care of North Carolina (CCNC)
• Brent Hazelett, MPA
North Carolina Academy of Family Physicians
(NCAFP)
• Elizabeth Walker Kasper, MSPH
North Carolina Healthcare Quality Alliance (NCHQA)

Feel free to contact me:
David Halpern, MD, MPH
(215) 498-4648 dhalpern@n3cn.org