NCQA’s Patient Centered Medical
Home (PCMH) Program
Mina Harkins, MBA, MT(ASCP)
Assistant Vice President, Recognition Programs
February 5, 2011
A Strategy for Quality Improvement
Address these challenges …by acting on these priorities.
1. Eliminating harm
2. Eradicating disparities
3. Reducing disease burden
4. Removing waste
1. Engage patients and families in
managing health, making decisions
2. Improve the health of the population
3. Improve safety, reliability
4. Ensure patients receive coordinated
care within and across organizations,
settings and levels of care
5. Guarantee appropriate, compassionate
care for patients with life-limiting
illnesses
6. Eliminate overuse while ensuring the
delivery of appropriate care
Source: National Priorities and Goals:
Aligning Our Efforts to Transform America’s Healthcare, 2008
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PPC-PCMH Recognition
• NCQA has the most widely-adopted evaluation model
• States/practices can get on board with a system that has a strong
track record, Federal initiatives are expanding to military and
FQHCs
• 1500 sites recognized, over 8,000 clinicians
• NCQA provides goals and guidelines for practice transformation
based on evidence
– Practices decide how best to reach goals based on their size,
location, area conditions
• Gives physicians a roadmap to improve quality with systematic
approach to preventive and chronic care delivery
• Focuses on evidence-based requirements to improve quality and
reduced costs
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NUMBER OF PPC-PCMH SITES BY STATE
As of 12/31/10
WA
ME
ND
MT
VT
NH
MN
OR
WI
SD
ID
MI
WY
IA
NV
PA
NE
UT
CA
IL
CO
KS
OH
IN
MA
NY
RI
CT
NJ
DE
MD
WV
MO
VA
KY
NC
TN
AZ
NM
OK
AR
SC
MS
AL
GA
0 Sites
LA
TX
1-20 Sites
FL
AK
21-60 Sites
61-200 Sites
HI
1498 PPC-PCMH
SITES
201+ Sites
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PPC-PCMH RECOGNIZED PRACTICES BY STATE
(As of 12/31/10)
PPC-PCMH Level 3
PPC-PCMH Level 2
PPC-PCMH Level 1
Number of Practices
420
410
400
390
380
370
360
350
340
330
320
310
300
290
280
270
260
250
240
230
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
AK AL AR AZ CA CO CT DC FL GA HI IA ID IL IN KY LA MAMD ME MI MNMO MS NC NE NH NJ NM NV NY OH OK OR PA RI SC TN TX VA VT WA WI WV
State
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PPC-PCMH Practices*
NUMBER OF PHYSICIANS IN RECOGNIZED
PRACTICES
1-2
3-7
8-9
10-19 20-50
50+
Total
Level
1
260
217
26
41
9
0
553
Level
2
21
30
4
2
0
0
57
Level
3
295
388
81
89
34
1
888
Total
576
635
111
132
43
1
1498
* As of 12/31/10
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Evaluation of PPC-PCMH Demonstrations:
Driving Quality and Cost Savings
• Outcomes for seven medical home
demonstrations
– Reduce hospitalization rates (6-19%)
– Reduce ER visits (0-29%)
– Increase savings per patient ($71-$640)
• Four common features in demonstrations
–
–
–
–
Dedicated care managers
Expanded access to clinicians
Data-driven analytic tools
Use of incentives
Elements or
uses of NCQA’s
PCMH
evaluation
Source: Fields, et al. 2010
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PCMH 2011: Evolution
• Raise expectations through scoring and
new requirements; maintain a pathway
for those just beginning to transform
• Streamline requirements/documentation
with greater focus on areas with strongest
link to desired outcomes
• Move toward performance
reporting/benchmarking for clinical and
patient experience measures
• Embed and report HIT Meaningful Use
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What is different about the PCMH 2011 standards?
• Enhances patient-centeredness
• Emphasizes language, culturally sensitive aspects
• Integrates behaviors affecting health, substance abuse,
mental health and risk factor assessment and
management
• Enhances applicability to pediatric practices
• Aligns with CMS Meaningful Use requirements
• Emphasizes relationship with/expectations of
subspecialists
• Enhances evaluation of patient experience
• Underscores the importance of system cost-savings
• Enhances use of clinical performance measure results
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PCMH 2011
Alignment with Measures of Meaningful Use
• E-prescribing – medication list, allergies
• Patient tracking/registry – demographics, diagnoses,
vital signs, smoking, population management,
insurance
• Care management – reminders for follow-up care,
decision support, Rx reconciliation
• Electronic capability – e-health information to patient,
visit summary, e-access to health information, provider
information exchange
• Performance reporting/improvement
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Comparison of PPC-PCMH and PCMH 2011
PPC-PCMH (9 standards/30 elements)
PCMH 2011 (6 standards/27 elements)
1. Access and Communication
1.
–
–
Processes
Results
–
–
–
–
2. Patient Tracking and Registry Function
3. Care Management
–
4.
5.
6.
7.
8.
2.
3.
Continuity Between Settings
Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting and
Improvement
–
–
Access/Continuity
Measure Performance
Measure Patient/Family Experience
9. Advance Electronic Communication
Identify/Manage Patient Populations
Plan/Manage Care
–
–
–
4.
5.
Care Management (Incl. Behavioral
Health
Identify High Risk Patients
Medication Management/E-Prescribing
Self-Care and Community Referrals
Track/Coordinate Care
–
–
6.
Access/Continuity
Medical Home Responsibilities
CLAS
Practice Team
Test/Referral Tracking and Follow-Up
Facilities
Performance Measurement/Quality
Improvement
–
–
Measures of Performance
Patient Experience
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PCMH 2011 Overview (6 standards/27 elements)
1.
Enhance Access and Continuity
A.
B.
C.
D.
E.
F.
G.
2.
Provide Self-Care and
Community Resources
A. Self-Care Process
B. Referrals to Community Resources
5.
Track/Coordinate Care
A. Test Tracking and Follow-Up
B. Referral Tracking and Follow-Up
C. Coordinate with Facilities/Care
Transitions
Identify/Manage Patient Populations 6. Measure and Improve
A. Patient Information
Performance
B.
C.
D.
3.
Access During Office Hours
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate
Services
Practice Organization
4.
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
A.
B.
C.
D.
E.
Implement Evidence-Based Guidelines
Identify High-Risk Patients
Manage Care
Manage Medications
Electronic Prescribing
A. Measures of Performance
B. Patient/Family Feedback
C. Implements Continuous Quality
Improvement
D. Demonstrates Continuous Quality
Improvement
E. Report Performance
F. Report Data Externally
Optional Patient Experiences Survey
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Scoring
Total 100 Points
Recognition requires achieving all 6 must
pass elements with a ≥50% score
Level
Points
Required Must Pass
1
≥ 35
6 Must Pass
2
≥ 60
6 Must Pass
3
≥ 85
6 Must Pass
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Must Pass Elements
Rationale for Must Pass Elements
• Identifies critical concepts of PCMH
• Helps focus Level 1 practices on most important aspects of
PCMH
• Guides practices in PCMH evolution and continuous quality
improvement
• Standardizes “Recognition”
Must Pass Elements
•
•
•
•
•
•
1A: Access During Office Hours
2D: Use Data for Population Management
3C: Manage Care
4A: Self-Care Process
5B: Referral Tracking and Follow-Up
6C: Implement Continuous Quality Improvement
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PCMH 1: Enhance Access and Continuity
Standard
•
Access
–
–
•
•
•
•
•
Meaningful Use Criteria
During/after office hours
Appointments and advice
Electronic access
Continuity of care with
clinician/care team
Information to patients about
medical home
Culturally and linguistically
appropriate services (CLAS)
Specific staff roles,
responsibilities, training
Patients provided electronic:
• Copy of health information
• Clinical summary of visit
• Access to health information
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PCMH 2: Identify and Manage Populations
Standard
Meaningful Use Criteria
• Collects demographic and
clinical data
• Searchable data: diagnoses,
advance directives,
immunizations, screenings,
BMI, medications
• Assess/document risks
• Create lists; use for point of
care reminders
• Language, gender, race,
ethnicity, DOB
• Problem list
• Medication list
• Medication allergy list
• Vital signs
• Growth chart (peds.)
• Smoking status
• Lists of patients with specific
conditions for QI, decrease
disparities
• Follow-up reminders for care
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PCMH 3: Plan and Manage Care
Standard
Meaningful Use Criteria
• Identify patients with specific
conditions including high-risk
or complex, behavioral health
• Care management
– Pre-visit planning
– Progress toward goals
– Barriers to treatment goals
• Reconcile medications
• E-prescribing
• Clinical decision support
• Medication reconciliation with
transitions of care
• E-prescribing
• Drug-drug, drug-allergy
checks
• Transmit prescriptions using
EHR
• Drug-formulary checks
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PCMH 4: Provide Self-Care Support and
Community Resources
Standard
Meaningful Use Criteria
• Assess self-management
abilities
• Document self-care plan;
provide tools and resources
• Counsel on healthy behaviors
• Assess/provide/arrange for
mental health/substance
abuse treatment
• Provide community resources
Patient-specific education
materials
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PCMH 5: Track and Coordinate Care
Standard
Meaningful Use Criteria
• Track lab/imaging results;
notify patients
• Integrate results into medical
record
• Track referrals
• Coordinate with facilities
– Hospitalized patients and
ER
– Establish information
exchange with facilities
– Follow up with discharged
patients
• Incorporate lab/test results
• Exchange patient information
with other providers (meds/
allergies, tests)
• Provide summary care record
for transitions and referrals
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PCMH 6: Measure and Improve Performance
Standard
Meaningful Use Criteria
•
Report:
• Ambulatory clinical quality
measures to CMS/ state
• Immunization data to registries
• Syndromic surveillance data to
public health agencies
•
•
•
•
Measure performance
(preventive/chronic/acute
care clinical measures)
Track utilization measures
Patient experience survey identifies vulnerable
populations
Continuous quality
Improvement
Report performance
–
Clinical measures
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Emphasize Patient-Centered Care
Increasing patient-centeredness
PCMH 1: Enhance Access and Continuity
• Provide continuity of care with the same provider
• Provide information to the patient about medical home
• Provide access to care during and after office hours
• Provide patient materials and services meeting the
language needs of patients
PCMH 4: Provide Self-Care and Community Support
• Provide resources to support patient/family selfmanagement
PCMH 6: Measure and Improve Performance
• Involve patients/families in quality improvement
• Obtain performance data for key vulnerable populations
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Focus on Behavioral Health
Incorporating attention to behaviors affecting health, mental health and
substance abuse
• PCMH 1: Enhance Access and Continuity
– Comprehensive assessment includes depression screening, behaviors affecting
health and patient and family mental health and substance abuse
• PCMH 3: Plan and Manage Care
– One of three clinically important conditions identified by the practice must be a
condition related to unhealthy behaviors (e.g. obesity) or a mental health or
substance abuse condition
– Practice must plan and manage care for the selected condition
• PCMH 4: Provide Self-Care and Community Resources
– Self-care support includes educational and community resources and adopting
healthy behaviors
• PCMH 5: Track and Coordinate Care
– Tracks referrals and coordinates care with mental health and substance abuse
services
• PCMH 6: Measure and Improve Performance
– Preventive measures include depression screening
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Focus on Pediatrics
• Goal for PCMH 2011 to enhance applicability to pediatric practices
• AAP participated on the PCMH Advisory Committee
• Throughout the Standards
–
–
–
–
“Families” has been incorporated where appropriate
“NA for pediatric practices” has been used where appropriate
Pediatric examples and explanations have been added
References to Bright Futures have been included
• PCMH 1: Enhance Access and Continuity
– Explanation addresses unique pediatric issues, such as teen privacy and
guardianship
• PCMH 2: Identify and Manage Patient Populations
– Includes pediatric clinical data and age appropriate screenings
• PCMH 3: Plan and Manage Care
– Explanation specifies relevant pediatric clinical conditions, including well-child
care and children/youth with special health care needs
• PCMH 4: Provide Self-Care and Community Support
– Population specific referrals include parenting and respite care
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Focus on Patient Experience
Increasing the emphasis on patient feedback
PCMH 6: Measure and Improve Performance
• Expanded the survey categories (access, communication,
coordination, self-management support, whole person orientation,
comprehensiveness, shared decision-making) and the
requirements for the practice.
• Use of patient survey results for quality improvement
• Involve patients/families in quality improvement
• Optional Recognition for reporting results using a standardized
Patient Experiences survey & methodology
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The Case for Patient-Centered
Medical Home Recognition
• Gives physicians a roadmap to improve quality
with systematic approach to preventive and
chronic care delivery
• Focuses on evidence-based requirements to
improve quality and reduced costs
• Considers capabilities of small and large
practices, without sacrificing quality
• Program is built on what is shown to improve
care and can be copied or replicated
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The Case for Patient-Centered
Medical Home Recognition
• Requires electronic information when
necessary
– electronic systems alone are not sufficient
• Incentivizes investment in quality
infrastructure and processes
• Complements evaluation of clinical
effectiveness, patient experiences and
efficiency
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Patient Perspective
PCMH Practices
Focus Group Findings
• PCMH patients emerge as highly satisfied with their current PCP
practices, and deem “continuity of care” as related rationale (with
one participant using the term).
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Patient Perspective
Non-PCMH Practices
Focus Group Findings
• Conversely, a majority of General Population Patients emerge
overall with less satisfaction. (A few General Population Patients
who have long-standing PCP relationships emerge as satisfied and
convey practices similar to care coordination practices described
by PCMH Patients).
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Benefits of PCMH
• Clinician Burnout
– 10% of PCMH staff reported high emotional exhaustion at 12
months compared with 30% of controls, despite similar rates at
baseline
• Total Cost
– 29 percent fewer emergency visits and 6 percent fewer
hospitalizations.
– Estimated total savings of $10.3 per patient per month
• Patient Experience
– Improved access, coordination, goal-setting
• Quality
– Improved HEDIS results
Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health
Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health
Affairs 29:5 (2010): 835-843.
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NCQA Contact Information
Contact NCQA Customer Support to:
• Order FREE Information/Application Packets
• Purchase ISS Tool
• 1-888-275-7585
Visit NCQA Web Site to:
• View Frequently Asked Questions
• View Recognition Programs Training Schedule
• www.ncqa.org/medicalhome.aspx
Send Questions to: pcmh@ncqa.org
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