Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 1
David Halpern, MD, MPH
November 9, 2011
Nice To “Meet” You
David Halpern, MD, MPH
Practice Support Consultant for CCNC
Primary Care Physician at Duke
Training:
• MD (2004) Cornell University
• MPH (2010) UNC-Chapel Hill
• Internship/Residency in Internal Medicine
at University of Pennsylvania
• Fellowship in Geriatric Medicine at UNC
• Fellowship in Preventive Medicine at UNC
Legal Disclaimer
© 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
Care Networks, Inc. are strictly prohibited. Works copyrighted by
third parties and included herein are used with the permission of the
respective copyright owners in each case.
Acknowledgements
Today’s Agenda
• What is a Patient-Centered Medical Home
(PCMH)?
• What are the Benefits for Me and My Practice?
• What is the National Committee for Quality
Assurance (NCQA)?
• How Does My Practice Apply for PCMH
Recognition?
What is a Patient-Centered
Medical Home (PCMH)?
Patient-Centered Medical Home
• A practice in which an individual can
receive quality, timely, efficient, and
patient-centered comprehensive care and
care coordination from a compassionate
team of health-care professionals.
Patient-Centered Medical Home
• The PCMH is a model for re-designing
primary care practices.
• The model is intended to improve the
quality and efficiency of care delivery.
Medical Home “Joint Principles”
1)
2)
3)
4)
5)
6)
7)
Personal Physician
Physician-Directed Practice
Whole-Person Orientation
Care Coordination/Integration
Quality & Safety
Enhanced Access
Payment
Adopted by the American Academy of Family Physicians (AAFP),
American Academy of Pediatrics (AAP), American College of Physicians
(ACP), and American Osteopathic Association (AOA) in Febraury, 2007
Medical Home “Joint Principles”
1) Personal Physician
Each patient has an ongoing
relationship with a personal
physician, who provides
comprehensive, continuous primary
care.
Medical Home “Joint Principles”
2) Physician-Directed Practice
The physician is responsible for
directing a team that takes collective
responsibility for patient care.
Medical Home “Joint Principles”
3) Whole-Person Orientation
The physician is responsible for
providing comprehensive care at all
stages of life and for coordinating care
as necessary with appropriate
specialists.
Medical Home “Joint Principles”
4) Care Coordination/Integration
A patient’s care is coordinated across
all elements of our complex health
system (subspecialty care, hospitals,
nursing homes, etc) through disease
registries, information technology,
health information exchange to ensure
that the patient is getting needed and
desired care in an appropriate manner.
Medical Home “Joint Principles”
5) Quality & Safety
Quality and safety are hallmarks of a
PCMH; evidence-based practices,
clinical decision-support tools, regular
quality improvement efforts, and
information technology all combine to
ensure that patient outcomes attain
the highest level of excellence.
Medical Home “Joint Principles”
6) Enhanced Access
Patients have enhanced access to their
physicians and their practices as a
result of open scheduling, expanded
hours, and/or additional options for
communication between patients,
physicians, and staff.
Medical Home “Joint Principles”
7) Payment
Reimbursement appropriately reflects
the added value patients receive from
being part of a PCMH practice.
What are the Benefits for Me and
My Practice?
Benefits of the PCMH Model
PCMH practices provide care that is:
Higher Quality
– Better Patient Outcomes
More Efficient
– More Timely and Cost-Effective
Benefits of the PCMH Model
Quality – Patient Outcomes
– Fewer ER visits
– Fewer hospital admissions
– Lower mortality rates
– Better preventive service delivery
– Better chronic disease care
– Higher patient satisfaction
Benefits of the PCMH Model
Efficiency – Cost
– Lower total costs of care
– Shorter patient wait times
– Less staff burnout/turnover
– Higher staff satisfaction/productivity
Recognition of Added Value
Higher Reimbursement from BCBS-NC
– Eligibility for the Blue Quality Physicians
Program (BQPP), a recognition program
for primary care practices that builds on
PCMH recognition from NCQA
– Once you qualify for the BQPP, you will be
eligible for reimbursement rates that are at
least 10% higher than BCBS’s base fee
structure.
Recognition of Added Value
CMS Incentives for EHR Meaningful Use
• The Medicare and Medicaid EHR Incentive
Programs will provide incentive payments to
eligible professionals as they adopt,
implement, upgrade or demonstrate
meaningful use of certified EHR technology.
• Medicare - $44,000 over five years
• Medicaid - $63,750 over six years
What Is the National Committee
for Quality Assurance (NCQA)?
NCQA
• National Committee on Quality Assurance (NCQA)
– 501(c)(3) dedicated to improving health care
quality
– NCQA offers “recognition” programs for
various aspects of clinical care: diabetes,
cardiovascular disease, back pain
– One of the recognition programs is for PCMH
– 3 levels of accreditation: Level 1 (lowest),
Level 2, and Level 3 (highest)
NCQA Lingo
• The metrics that NCQA uses to assess your
practice are called “standards”
• There are two sets of standards:
– PPC-PCMH (2008, no longer available)
– PCMH (2011, released at the end of March)
• NCQA grants recognition for 3 years at a time
2008/2011 Comparison
2008 Standards
2011 Standards
PPC-PCMH 1: Access & Communication
PCMH 1: Enhance Access & Continuity
PPC-PCMH 2: Patient Tracking and
Registry Function
PCMH 2: Identify and Manage Patient
Populations
PPC-PCMH 3: Care Management
PCMH 3: Plan and Manage Care
PPC-PCMH 4: Self Management Support
PCMH 4: Provide Self-Care &
Community Support
PPC-PCMH 5: Electronic Prescribing
PCMH 5: Track and Coordinate Care
PPC-PCMH 6: Test Tracking
PPC-PCMH 7: Referral Tracking
PPC-PCMH 8: Performance Reporting
and Improvement
PPC-PCMH 9: Electronic Communication
PCMH 6: Measure and Improve
Performance
NCQA Lingo
each “standard”
is composed of
several
“elements”
each
“element” is
composed
of several
“factors”
PCMH (2011) Overview
1.
Enhance Access and Continuity
A.
B.
C.
D.
E.
F.
G.
2.
Identify/Manage Patient Populations
A.
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
Patient Information
Clinical Data
Comprehensive Health Assessment
Use Data for Population Management
Plan/Manage Care
A. Implement Evidence-Based Guidelines
B. Identify High-Risk Patients
C. Manage Care
3.
Plan/Manage Care (continued)
D. Manage Medications
E. Electronic Prescribing
4.
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
6.
Measure & Improve Performance
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
“Must Pass” Elements
• Some elements are “Must Pass”
• **To “Pass” one of these elements, you must
receive a 50% score or higher**
• In the 2011 Standards, you must pass all 6/6
of the “Must Pass” elements to achieve any
level of recognition.
Scoring a Standard
• Each Element in a Standard is worth a
certain number of points. To achieve the
points, you must complete some (or all) of the
factors in that element.
• Note: The actual details of scoring each
element depends on that specific element
and is NOT the same across the board.
Scoring a Standard
Example 1:
Element is worth 4 points and has 6 factors
6/6
4-5/6
3/6
1or2/6
0/6
4 points 3 points
2 points
1 point 0 points
Scoring a Standard
Example 2:
Element is worth 6 points and has 8 factors
>4/8
3/8
2/8
1/8
0/8
6 points 4.5 points 3 points 1.5 point 0 points
Point Requirements
Level of
Recognition
Points Required
(2011)
Level I
35-59 (6/6 must pass)
Level 2
60-84 (6/6 must pass)
Level 3
85-100 (6/6 must pass)
How Does My Practice Apply For
PCMH Recognition?
Applying for PCMH Recognition
• Interactive Survey Tool ($80)
– Self-directed practice assessment
• Application (free)
– Demographic information
• When ready, submit Interactive Survey
Tool, Application, and final application fee
NCQA’s
Interactive Survey System (ISS)
• ISS is the web-based application software
• The practice uses ISS (also called the
“Survey Tool”) for:
– Entering responses to each Factor for
each Element
– Attaching documents and providing text
to support the responses
Pricing
(including 20% CCNC discount)
NCQA’s PCMH Survey Process
1. NCQA receives and evaluates Survey Tool
• Responses, documentation, and explanations
• Practice may be contacted for clarification
2. On-site audit - 5% of practices
3. Final decision and status determined
4. NCQA grants certificate and recognition packet
• Recognition status posted on NCQA Web site
• Practices that don’t pass - not reported publicly
Upgrading PCMH Recognition
• Practices that initially achieve Level 1 or 2
can complete an add-on survey to
upgrade to a higher level anytime within
their 3 year recognition period
Next Steps (Homework)
• Build Your PCMH Team:
– Identify a “PCMH Champion” who will help
guide the practice through the quality
transformation process
– Identify a “Communicator-In-Chief” who will
serve as a point person for interactions with
Community Care and other support staff
– Identify a “Lead Administrator” who will track
progress, organize materials, complete the
PMCH application (should have computer skills)
Next Steps (Homework)
• Begin team discussions about where the
manpower will come from. Practice
transformation is valuable for your patients
and your practice, but it takes time.
– Will you:
• Be able to reduce your patient load?
• Have to extend your hours?
• Need to work on the weekends?
• Need to shift duties/responsibilities?
Next Steps (Homework)
• Peruse the NCQA “Standards and
Guidelines” document
• This is a long, but important document that
is the backbone of the recognition process
and familiarity with it is CRUCIAL to your
success.
Next Steps (Homework)
Get the EMR ball rolling today…
– Sign up for AHEC’s REC services
(free) by completing an application at
www.ncahecrec.net
Community Care PCMH Team
• 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)
Questions?
Feel free to contact me:
David Halpern, MD, MPH
(215) 498-4648
dhalpern@n3cn.org