Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 7
David Halpern, MD, MPH
March 7, 2012

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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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• What Is The Record Review Workbook?
• Standard 4 – Self-Care Support &
Community Resources
– PCMH4A: Support Self-Care Process – MUST PASS
– PCMH4B: Provide Referrals to Community
Resources

• 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

• Standard 3 – Plan & Manage Care
– PCMH3A: Implement Evidence-Based
Guidelines
– PCMH3B: Identify High-Risk Patients
– PCMH3C: Care Management MUST PASS
– PCMH3D: Medication Management
– PCMH3E: Use Electronic Prescribing

PCMH 3A: Implement
Evidence-Based Guidelines
• Practice implements guidelines through point of care reminders for patients with:
1) The first important condition *
2) The second important condition
3) The third condition, related to unhealthy behaviors or mental health or substance abuse
* Meaningful Use Requirement

PCMH 3A: Implement
Evidence-Based Guidelines
• 4 Points
• Scoring
– 3 factors = 100%
– 2 factors (including factor 3) = 50%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Identification of 3 conditions; (these are not screening or a single preventive service process)
– Name and source of guidelines
– Demonstration of how guidelines are implemented

PCMH 3A: Choose Conditions
• Examples of eligible conditions include: COPD, hypertension, hyperlipidemia, HIV/AIDS, asthma, diabetes, or congestive heart failure.
• One of the 3 conditions (Factor 3) must be related to unhealthy behavior (e.g. obesity, smoking), substance abuse (e.g. illicit drug use, prescription drug addiction, alcoholism), or a mental health condition (e.g. depression, anxiety, bipolar disorder, ADHD, dementia).

PCMH 3A: Provide Justification

PCMH 3A: Select
Evidence-Based Guidelines

PCMH 3A: Select
Evidence-Based Guidelines

PCMH 3A: Select
Evidence-Based Guidelines

PCMH 3A: Implement
Evidence-Based Guidelines
• You must adopt AND implement the guidelines
• Guidelines can be implemented by embedding them into the EMR or using paper-based supporting documentation (flow sheets or templates used to document treatment plans or patient progress)

PCMH 3A: Implement
Evidence-Based Guidelines
Diabetes Management Flow Sheet

PCMH 3A: Implement
Evidence-Based Guidelines

PCMH 3A: Implement
Evidence-Based Guidelines

PCMH 3B: Identify
High-Risk Patients
• The practice does the following to identify high-risk patients:
1) Establishes criteria and a process to identify high-risk or complex patients
2) Determines the percentage of high-risk patients in the population

PCMH 3B: Identify
High-Risk Patients
• 3 Points
• Scoring
– 2 factors = 100%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Process to identify patients
– Report showing number and percentage of high-risk patients

PCMH 3B: Explanation of Factor 1
• The practice should have specific criteria and a process for identifying complex or high-risk patients who need care planning and management services.
• This may be based on (alone or in combination):
– High resource use (e.g. visits, medications, treatments, other cost measures)
– Frequent visits for urgent or emergent care
– Frequent hospitalizations
– Multiple comorbidities (including mental health)
– Non-adherence with prescribed treatments/meds
– Terminal illness (palliative care/hospice involvement)
– Barriers to care (e.g. lack of social/financial support)
– Advanced age and frailty
– Multiple risk factors (smoking, family history, obesity, etc)

PCMH 3B: Explanation of Factor 2
• The practice may identify patients through a billing or practice management system, through the EMR, through key staff members, or through profiles from health plan (as long as these encompass 75% or more of patients)
• The factor requires a report that shows a number and percentage of patients identified as high risk, meaning you need to show a numerator (# of high risk patients) and denominator (total # of patients)

PCMH 3C &3D: REMEMBER!
• The patients you use for the review in 3C and 3D are those who have one of the 3 conditions listed in 3A , or are designated “high-risk” as described in 3B
• You should only use visits that are “relevant” (i.e. related to the chronic condition in question or a combination of the factors which make them
“high risk”)
• NCQA does NOT expect you to care manage every
patient in your practice.

PCMH 3C: Care Management
• Care team performs the following for at least
75% of patients from Elements 3A and 3B :
1) Conducts pre-visit preparations
2) Collaborates with patient to develop care plan, including treatment goals
3) Gives patient written care plan
4) Assesses and addresses barriers to treatment goals
5) Gives patient clinical summary at relevant visits
6) Identifies patients who need more care management support
7) Follows up with patients who have not kept important appointments

PCMH 3C: Care Management
• MUST PASS
• 4 Points
• Scoring
– 6-7 factors = 100%
– 5 factors = 75%
– 3-4 factors = 50%
– 1-2 factors = 25%
– 0 factors = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook

PCMH 3C: Record Review Workbook

PCMH 3C: Example – Factor 1

PCMH 3C: Example – Factor 3

PCMH 3C: Example – Factor 4

PCMH 3C: Example – Factor 7

PCMH 3D: Medication Management
• Practice manages medications in the following ways:
1) Reviews and reconciles medications for more than 50% of care transitions * - CRITICAL FACTOR
2) Reviews and reconciles medications for more than 80% of care transitions
3) Provides information about new prescriptions to more than 80% of patients
4) Assess patient understanding of medications for more than 50% of patients
5) Assesses patient response to medication and barriers to adherence for more than 50% of patients
6) Documents OTCs, herbal/supplements, for more than 50% of patients, with date of update
* Meaningful Use Requirement

PCMH 3D: Medication Management
• 3 Points
• Scoring
– 5-6 factors (including factor 1) = 100%
– 3-4 factors (including factor 1) = 75%
– 2 factors (including factor 1) = 50%
– Factor 1 = 25%
– 0 factors or does not meet Factor 1 = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook

PCMH 3D: Record Review Workbook

PCMH 3D: Example – Factor 2

PCMH 3D: Example – Factor 2 & 6

PCMH 3D: Example – Factor 2

PCMH 3E: Use Electronic Prescribing
• Practice uses e-prescribing system with the following capabilities:
1) Generates and transmits at least 40% of prescriptions to pharmacies *
2) Generates at least 75% of eligible prescriptions *
3) Integrates with patient medical records
4) Performs patient-specific checks for drug-drug and drug-allergy interactions *
5) Alerts prescribers to generic alternatives
6) Alerts prescribers to formulary status *
* Meaningful Use Requirement

PCMH 3E: Use Electronic Prescribing
• 3 Points
• Scoring
– 5-6 factors (including factor 2) = 100%
– 4 factors = (including factor 2) = 75%
– 2-3 factors = (including factor 2) = 50%
– 1 factor = 25%
– 0 factors = 0%
• Data Sources:
– Reports showing percent of electronic prescriptions written and transmitted, and demonstrating the system’s capabilities

PCMH 3E: Example – Factors 1 & 2
EXPLANATION
 January to March 2009 prescribing method is documented in the table.
 Certain prescriptions (Schedule II) must be printed on special paper prescription pads in our state.
 96% of prescriptions were generated from our electronic medical record.

PCMH 3E: Example – Factors 1 & 2

PCMH 3E: Example – Factors 3 & 4
Drug-Allergy
Interaction

PCMH 3E: Example – Factor 4

PCMH 3E: Example – Factors 3, 5, 6

PCMH 3E: Example – Factors 3, 5, 6

Capturing A Screenshot
• Press the Print Screen key on your keyboard. It may be labeled
[ PrtScn ].
• Open a word processing program like Microsoft Word.
• Go to the Edit tab and choose Paste (or press control V).
• Optional: Use your image editor's crop tool to crop out unnecessary portions of the screen shot.
• Annotate the image by typing above or below.
• Go to the File tab and choose Save As.
• Navigate to the folder where you want to save the image.
• Type a file name for the image.
• Click the Save button.

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