NCQA PCMH 2011
Standards Overview
Learning Session 2
September 2012
Goals of NCQA Standards
• Increase patient-centeredness
• Align requirements with processes that improve
quality and eliminate waste (i.e., ER visits, Hospital
readmissions, using brand vs. generic, etc.)
• Increase emphasis on patient experience
• Enhance use of clinical performance measure
results
• Integrate: unhealthy behaviors, mental health, and
substance abuse
• Enhance coordination of care
• Enhance applicability to pediatric practices
Eligible Applicants
• Outpatient primary care practices that
meet scoring criteria for either Level 1, 2,
or 3 (3 is highest)
• NCQA defines a practice as a clinician or
clinicians practicing together at a single
geographic location, includes nurse-led
practices in states where state licensing
designates NPs as independent
practitioners
Eligible Applicants (Cont’d)
• Recognition is at the practice-site level
• Assessment for recognition must include a
survey for every site that the practices wants to
identify as a recognized PCMH
• PCMH recognition identifies primary care
clinicians practicing at the site, including nurse
practitioners and physician assistants that have
their own patient panels
Six Standards
1. Enhance Access and Continuity
2. Indentify and Manage Patient
Populations
3. Plan and Manage Care
4. Provide Self-Care Support and
Community Resources
5. Track and Coordinate Care
6. Measure and Improve Performance
Composition of Standards
• Consist of Standard, Element, and Factor
• There is always a MUST PASS Element and
a Critical Factor in each standard
• EXAMPLE:
Standard 1 Enhance Access and Continuity
• Element 1A (of 7): Access During Office
Hours
• Factor 1 (of 4): Provide same-day
appointments—CRITICAL FACTOR!
Must Pass Elements
• PCMH 1, Element A: Access During Office Hours
• PCMH 2, Element D: Use Data for Population
Management
• PCMH 3, Element C: Care Management
• PCMH 4, Element A: Support Self-Care Process
• PCMH 5, Element B: Referral Tracking and Follow-up
• PCMH 6, Element C: Implement Continuous Quality
Improvement
PCMH Scoring
6 standards = 100 pts
6 MUST PASS elements*
Level
Points
Must Pass
Elements at 50%
Performance Level
Level 3
Level 2
Level 1
85-100
60-84
35-59
6
6
6
*Must pass elements require a ≥50% performance
level to pass!
Standards
Standard 1
Enhanced Access & Continuity
Points
A.
Access During Office Hours**
4
B.
After-Hours Access
4
C.
Electronic Access
2
D.
Continuity
2
E.
Medical Home Responsibilities
2
F.
Culturally & Linguistically Appropriate
2
G.
Practice Team
4
TOTAL
** Must Pass
20
Standards (Cont’d)
Standard 2 Identify & Manage Patient Populations
Points
A.
Patient Information
3
B.
Clinical Data
4
C.
Comprehensive Health Assessment
4
D.
Use Data for Population Management**
5
TOTAL
16
Standard 3
Plan & Manage Care
Points
A.
Implement Evidence-Based Guidelines
4
B.
Identify High-Risk Patients
3
C.
Care Management**
4
D.
Medication Management
3
E.
Use Electronic Prescribing
3
TOTAL
** Must Pass
17
Standards (Cont’d)
Standard 4 Provide Self-Care Support & Community
Resources
Points
A.
Support Self-Care Process**
6
B.
Provide Referrals to Community
Resources
3
TOTAL
9
Standard 5
Track & Coordinate Care
Points
A.
Test Tracking & Follow-Up
6
B.
Referral Tracking & Follow-Up
6
C.
Coordinate with Facilities/Care
Transition
6
TOTAL
** Must Pass
18
Standards (Cont’d)
Standard 6 Measure & Improve Performance
Points
A.
Measure Performance
4
B.
Measure Patient/Family Experience
4
C.
Implement Continuous Quality
Improvement
4
D.
Demonstrate Continuous Quality
Improvement
3
E.
Report Performance
2
F.
Report Data Externally
2
G.
Use of Certified EHR Technology
0
TOTAL
** Must Pass
20
Crosswalk Between MU and NCQA
REQUIREMENTS
REQUIREMENT
Meaningful Use
NCQA
Certified EHR
Required
Not Required
Unit of Measurement
Clinician
Practice SITE
Reporting Period
12 months
12 months IF EHR has
been in place for > 1
year; if not, 3 months
Crosswalk: MU, NCQA Standards
PA SPREAD Measures
Meaningful
Use
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NCQA PCMH
2011
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Self-Management Goal
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Tobacco Query
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HbA1C >9%
HbA1C <8%
BP <140/90
LDL <100
Urine Screening
Eye Exam
Foot Exam
Notes
• Can use any 3 of these diabetes measures to meet
Meaningful Use Clinical Quality Measure reporting
requirement.
• Can choose to use any 3 of these to meet NCQA PMCH 2,
Element D (Must Pass Element): generate lists of patients
who need chronic care management services and use the
lists to remind patients of needed services for at least three
chronic care services.
• NCQA PCMH 4, Element A.4 (Must Pass Element and Critical
Factor): develop and document self-management plans and
goals in collaboration with at least 50% of all (not just
diabetes) patients/families.
• Meaningful Use Core Measure #9: Must record smoking
status as structured data for more than 50% of patients ages
13 and older (tobacco query).
• Meaningful Use Clinical Quality Measure Core Set: Must
report both the percentage of patients age 18 and older
who have been asked about their tobacco use in the past 24
months and the percentage of patients age 18 and older
who use tobacco who have been provided a tobacco
cessation intervention.
• NCQA PCMH 2, Element B.8: use an electronic system to
record as structured (searchable) data the status of tobacco
use for patients 13 years and older for more than 50% of
patients.
Practice Needs for PCMH Survey
1. Computer system and staff skill with:
• Email
• Internet access
• Microsoft Word
• Microsoft Excel
• Adobe Acrobat Reader (free online!)
• Document scanning and screen shots
2. Access to the electronic systems used by the practice,
including billing system, registry, practice management
system, electronic prescription system, EHR, Web
portal, etc.
NCQA Recognition Process
1.
2.
3.
4.
5.
6.
Obtain standards and guidelines
Participate in trainings
Create online account
Purchase Survey Tool software license
Self-assess current performance on survey
Implement new PCMH capabilities at least
three months prior to survey submission
Recognition Process (cont’d)
7. Complete online application information:
electronic agreements, practice site & clinician
details, and application for survey
8. Submit application
9. Receive email confirmation that the practice can
submit survey tool and documentation
10. Submit survey tool and application fee when
ready
Receive decision in 30-60 days!
NCQA Educational Resources
• Free online training
http://www.ncqa.org/tabid/109/Default.aspx
Patient-Centered Medical Home (PCMH)
• Getting on Board with PCMH
• PCMH 2011 Standards
• The Online Application and How to Submit as a
Multi-Site Practice
Other Resources
• PA SPREAD: http://www.paspread.com
• Patient Centered Primary Care Collaborative
http://www.pcpcc.net/
Notes
• Need a person to coordinate process!
• Lots of policies and procedures, brochures/pt
welcome letters, required for submission—not hard,
just tedious!
• Need to report on THREE CONDITIONS (i.e., DM,
Hypertension, well woman, stroke, whatever makes
sense for your practice) PLUS a high risk population
(lab or other values not improving? Uninsured? MA
Population? Migrant worker? ESL? No Shows?
Noncompliant with care plan?). Pick one you can
easily retrieve data on!
Notes (cont’d)
• Screen shots of various screens required
• They are very willing to help and have lots of tools
on their website
• Recommend spending the $80 for the survey tool so
you can see what you will be required to submit and
also be able to gauge where you are!
• Current standards and tools good until at least 2014
• Aligns with Meaningful Use criteria!