Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 4
David Halpern, MD, MPH
January 4, 2012
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
Let’s Review
• Standard 6 – Measure & Improve
Performance
– PCMH6A: Measure Performance
– PCMH6B: Measure Patient/Family Experience
– PCMH6C: Implement Continuous Quality
Improvement – MUST PASS
– PCMH6D: Demonstrate Continuous Quality
Improvement
– PCMH6E: Report Performance
– PCMH6F: Report Data Externally
Today’s Agenda
• Standard 1 – Enhance Access &
Continuity
– PCMH1A: Access During Office Hours – MUST
PASS (review from Webinar #2)
– PCMH1B: After-Hours Access
– PCMH1C: Electronic Access
– PCMH1D: Continuity
– PCMH1E: Medical Home Responsibilities
– PCMH1F: Culturally and Linguistically Appropriate
Services
– PCMH1G: The Practice Team
PCMH 1A: Access During Office Hours
•
Practice has written process/standards
and demonstrates that it monitors
performance against the standards to:
1. Provide same-day appointments –
CRITICAL FACTOR
2. Provide timely advice by telephone
3. Provide timely advice by electronic message
4. Document clinical advice
PCMH 1A: Access During Office Hours
• MUST PASS
• 4 Points:
–
–
–
–
–
4 factors= 100%
3 factors (including factor 1) = 75%
2 factors (including factor 1)= 50%
(must-pass threshold)
Factor 1= 25% (not sufficient for passing element)
0 factors or missing factor 1 = 0%
• Data Sources:
– Documented process for scheduling appointments, providing
clinical advice and documenting advice
– Report showing same-day access, response times
– Screen shots or copies of documented clinical advice
PCMH 1A: Example – Factor 1
This is the practice’s
written policy on
same-day scheduling
PCMH 1A: Example – Factor 1
(Your Practice Name)
This is the practice’s
written policy on
same-day scheduling
PCMH 1A: Example – Factor 1
Brown
Smith
Jones
PCMH 1A: Example – Factor 2
Element 1A,
Factor 2
PCMH 1A: Example – Factor 2
Percent of calls returned on the same day
PCMH 1B: After-Hours Access
• Practice has written process/standards
and monitors performance:
1. Provide access to routine and urgent-care
outside business hours
2. Provide continuity of medical record information
for care and advice when office is closed
3. Provide timely advice by phone when office is
closed – CRITICAL FACTOR
4. Provide timely advice using interactive electronic
system when office is closed
5. Document after-hours advice
PCMH 1B: After-Hours Access
• 4 Points:
–
–
–
–
–
5 factors= 100%
4 factors (including factor 3) = 75%
3 factors (including factor 3)= 50%
1-2 factors= 25%
0 factors = 0%
• Data Sources:
– Documented process for arranging after hours access, making
medical records available after hours, providing timely advice after
hours, documenting advice after hours
– Report showing after hours availability, response times
– Materials communicating practice hours
– Screen shots or copies of documented clinical advice
PCMH 1B: Example – Factor C
•
•
POLICY - The designated lead physician or manager will prepare and maintain a
schedule for members of the medical staff to provide on-call services. The schedule
will provide for one physician to be on call for Lakeside Family Physicians and one
physician for Lakeside Primary Care. Call will transfer to the designated physician at
the end of primary care hours on the day listed on the schedule.
PROCEDURE - Physician Procedure: The primary care physician assigned to on-call
coverage will be available at all times and capable of responding by telephone within
fifteen minutes. The on call physician will document on phone note the following
information:
– Patient name
– Person calling if other than the patient
– Physician name
– Time and date of call
This is an example of a
– Reason for call
practice’s policy on after– Advice given
hours telephone call.
– Follow up needed
PCMH 1C: Electronic Access
• Practice provides through a secure
electronic system:
1. Electronic copy of health information within 3 days to
more than 50% of patients who request it**
2. Electronic access to current health information within
4 days to at least 10% of patients**
3. Clinical summaries provided for more than 50% of
office visits within 3 days**
4. Two-way communication
5. Request for appointments or prescription refills
6. Request for referrals or test results
** Meaningful Use Requirement
PCMH 1C: Electronic Access
• 2 Points:
–
–
–
–
–
5-6 factors = 100%
3-4 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
• Data Sources:
– Report showing percentage of patients who received
electronic copy of health information, access to requested
health information, electronic clinical summaries
– Screen shots of its secure web site or portal, web page
where patients can make requests and communication
capability with patients
PCMH 1C: Example – Factors 4, 5, 6
PCMH 1C:
PCMH 1C: Example – Factors 1, 2
this screenshot demonstrates online lab results
PCMH 1C: Example – Factors 5
this screenshot demonstrates online scheduling system
PCMH 1C: Example – Factor 5
this screenshot demonstrates online refill requests
PCMH 1D: Continuity
•
Practice provides continuity by:
1. Expecting patients to select a personal
clinician
2. Documenting the choice of clinician
3. Monitoring percent of patient visits with
clinician
PCMH 1D: Continuity
• 2 Points:
–
–
–
–
3 factors = 100%
2 factors = 50%
1 factor = 25%
0 factors = 0%
• Data Sources:
– Documented process or materials for clinician selection
– Screen shot showing patients choice of clinician
– Report showing patient encounters with clinician
PCMH 1D: Example – Factor 3
“Assigned Visits”
= patients who
are assigned to
that PCP
“Unassigned Visits”
= patients who are
not assigned to that
PCP
PCMH 1D: Example – Factor 3
PCMH 1D:
PCMH 1E: Medical Home
Responsibilities
•
Practice has process and provides
materials about role of medical home:
1. Practice responsible for coordinating patient care
2. How to obtain care/advice during/after office
hours
3. Patients provide complete medical history and
information on care obtained outside practice
4. Care team gives patient access to evidencebased care and self-management support
PCMH 1E: Medical Home
Responsibilities
•
2 Points:
–
–
–
–
–
•
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
–
–
Documented process for providing patient information
Patient materials
PCMH 1E: Example – Factor 1
www.pcpcc.net/content/emmi
PCMH 1E: Example – Factor 1
Patient Center Medical Home FACT SHEET
•
•
•
What is a patient centered medical home? A patient centered medical home is a care team, led by a
primary care physician that focuses on each patient’s health goals and needs, and coordinates that
patient’s care across all settings. The concept of a medical home was initially introduced by the American
Academy of Pediatrics in 1967. In March 2007, the AAP, the American College of Physicians , the
American Academy of Family Physicians, and the American Osteopathic Association issued the Joint
Principles of the Patient Centered Medical Home in response to several large national employers seeking
to create a more effective and efficient model of health care delivery. Patient-Centered Medical Home is
not an actual building, house or hospital. It’s a team approach to providing comprehensive health care in
a high-quality and cost-effective manner.
A Patient-Centered Medical Home is based on a continuous relationship with a personal physician. The
physician leads a team of medical professionals who together take responsibility for a person’s care
through all stages of life. The patient has one place to call; they have greater access to services; they get
personalized care; that care is safe and scientifically valid; and there is a focus on preventive care which
keeps costs down and patients healthier.
Care is coordinated and/or integrated across 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.
PCMH 1E: Example – Factor 2
PCMH 1E: Example – Factor 1 & 4
Examples of information
about PCMH model and
self-management tools
for patients/families
PCMH 1E: Example – Factor 4
PCMH 1E: Example – Factor 4
PCMH 1E: Example – Factor 4
• 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 1E: Example – Factor 4
PCMH 1E: Example – Factor 4
PCMH 1E: Example – Factor 4
PCMH 1F: Culturally & Linguistically
Appropriate Services
•
Practice meets the cultural and linguistic
needs of its patients:
1.
2.
3.
4.
Assesses racial/ethnic diversity of patients
Assesses language needs of patients
Provides interpretation services
Provides printed materials in patient language
PCMH 1F: Culturally & Linguistically
Appropriate Services
•
2 Points:
–
–
–
–
–
•
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
Data Sources:
–
–
–
Report showing assessment of racial/ethnic/language of
patients
Documentation showing use of interpretation service
Materials in other languages or website in other languages
PCMH 1F: Example – Factor 2
PCMH 1F: Example – Factor 2
PCMH 1F: Example – Factor 2
PCMH 1F: Example – Factor 3
PCMH 1F:
Use the “Meducation” tab
to show non-English
speakers how to use an
inhaler, glucometer, etc.
For non-English
speakers, you
also can print
these instructions
in 13 languages.
CCNC Provider Portal
Reports are specific to NC Medicaid enrollees,
but patient materials can be
used/downloaded (for free) for any patients
To sign up, visit:
https://portal.n3cn.org
PCMH 1G: Practice Team
•
Practice provides patient care services by:
1.
2.
3.
4.
5.
Defining roles for clinical/nonclinical team members
Holding regular team meetings - CRITICAL FACTOR
Using standing orders
Training and assigning care team to coordinate care
Training on self-management, self-efficacy and
behavior change
6. Training on patient population management
7. Training on communication skills
8. Care team involvement in performance evaluation
and QI
PCMH 1G: Practice Team
•
4 Points:
–
–
–
–
–
•
7-8 factors (including factor 2) = 100%
5-6 factors (including factor 2) = 75%
4 factors (including factor 2) = 50%
2-3 factors = 25%
0-1 factors = 0%
Data Sources:
–
–
–
–
–
Staff position descriptions
Description of staff communication processes
Written standing orders
Description of training process, schedule, materials
Description of how staff is involved in practice improvements
PCMH 1G: Example – Factor 1, 3
Next Steps (Homework)
• Review the requirements for Standard 1
– What does the practice already do?
– What does the practice need to
adopt/implement?
– Are there elements the practice clearly does
not have in place and does not plan to have in
place in time for submission?
Next Steps (Homework)
• 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
Next Steps (Homework)
• Go to NCQA’s website and take
advantage of the various (free) training
presentations they have available:
– 2011 Standards
– Using the ISS Interactive Survey System
– Submitting As a Multi-Site Practice
• http://www.ncqa.org/tabid/109/Default.aspx
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