Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 2
David Halpern, MD, MPH
November 23, 2011
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
CCNC’s PCMH Resources
www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmh-resources/
Let’s Review
• 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?
PCMH (2011) Scoring
6 standards = 100 points
NOTE: Must Pass elements require a ≥50% performance level to pass
Level of Qualifying
Points
Must Pass Elements
at 50% Performance Level
Level 3
85 - 100
6 of 6
Level 2
60 – 84
6 of 6
Level 1
35 – 59
6 of 6
Not Recognized
0 – 35
<6
NOTE: Practices with a numeric score of 0 to 34 points AND practices
that achieve less than 6 “Must Pass” Elements will not be Recognized.
NCQA Lingo
each “standard”
is composed of
several
“elements”
each
“element” is
composed
of several
“factors”
Definitions
• Factor – A scored item in an element. For example, an
element may require the practice to demonstrate how the
team provides several different patient care services. Each of
these services is a factor.
• Critical Factor – A factor that is required for practices
to receive more than minimal points, or in some cases any
points for the element. Critical factors are identified in the
scoring section of the element.
• Explanation – Specific requirements that a practice
must meet in order to earn points; guidance for demonstrating
performance of the factor.
• Examples/Documentation – Descriptions of the
evidence practices must submit to demonstrate performance
for a specific factor. Each factor must be documented.
Today’s Agenda
• What is a “Must-Pass” Element?
• Element 1A (Must-Pass)
• Element 2D (Must-Pass)
• Element 5B (Must-Pass)
“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.
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”
PCMH (2011) Overview
1.
Enhance Access and Continuity
3.
D. Manage Medications
E. Electronic Prescribing
A. Access During Office Hours
B.
C.
D.
E.
F.
G.
2.
Access After Hours
Electronic Access
Continuity (with provider)
Medical Home Responsibilities
Culturally/Linguistically Appropriate Services
Practice Organization
Identify/Manage Patient Populations
4.
3.
Plan/Manage Care
A. Implement Evidence-Based Guidelines
B. Identify High-Risk Patients
C. Manage Care
Provide Self-Care and Community
Resources
A. Self-Care Process
B.
5.
Referrals to Community Resources
Track/Coordinate Care
A. Test Tracking and Follow-Up
A. Patient Information
B. Clinical Data
C. Comprehensive Health Assessment
D. Use Data for Population Management
Plan/Manage Care (continued)
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
• Must Pass Elements
1.
2.
3.
4.
5.
6.
1A: Access During Office Hours (4 pts)
2D: Use Data for Population Management (5 pts)
3C: Manage Care (4 pts)
4A: Self-Care Process (6 pts)
5B: Referral Tracking and Follow-Up (6pts)
6C: Implement Continuous Quality Improvement
(4 pts)
Must Pass Elements = up to 29 points
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
• Scoring
–
–
–
–
–
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 2D: Use Data For
Population Management
• Practices uses patient data and evidencebased guidelines to generate lists and
remind patients about needed services:
1. At least three different preventive care
services**
2. At least three different chronic care services**
3. Patients not recently seen by the practice
4. Specific medications
** Meaningful Use Requirement
PCMH 2D: Use Data For
Population Management
• MUST PASS
• 5 Points
• Scoring
–
–
–
–
–
4 factors = 100%
3 factors = 75%
2 factors = 50%
(must-pass threshold)
1 factors = 25% (not sufficient for passing element)
0 factors = 0%
• Data Sources:
– Lists or summary reports of patients who need services
• Reports must contain at least three different immunizations or
screenings and three different acute/chronic care services
• A registry is not specifically required but will facilitate the process
– Materials demonstrating patient notification
PCMH 2D: Example – Factor 1
List of patients who have
not received pneumovax
Patient list is
blinded to
protect
confidentiality
PCMH 2D: Example – Factor 2
patient
names
and
MRNs
have
been
blinded
List of patients who have
not received appropriate
hypertensive care
PCMH 2D: Example – Factor 3
List of diabetics who
have not been seen
in past 6 months
PCMH 2D: Example – Factor 4
List of patients in the
practice taking Toprol XL
(names of patients blinded for HIPAA)
PCMH 5B: Referral Tracking
and Follow-Up
• Practice coordinates referrals:
1. Provides specialist with reason and key information for the
referral
2. Tracks referral status
3. Follows up to obtain specialist reports
4. Has agreements with specialists documented in the record
5. Asks patients about self-referrals and requests specialist
reports
6. Demonstrates electronic exchange of key clinical
information**
7. Provides electronic summary of care for more than 50% of
referrals**
** Meaningful Use Requirement
PCMH 5B: Referral Tracking
and Follow-Up
• MUST PASS
• 6 Points
• Scoring
–
–
–
–
–
5-7 factors= 100%
4 factors = 75%
3 factors = 50%
(must-pass threshold)
1-2 factors= 25% (not sufficient for passing element)
0 factors = 0%
• Data Sources:
– Reports or logs demonstrating tracking system data collection
– Documented processes with three examples
– Reports from electronic system showing frequency of information
exchange and summary of care records
PCMH 5B: Example – Factor 2
PCMH 5B: Example – Factor 2
PCMH 5B: Example – Factor 2
Patient
Name
MRN
Referring
Clinician
Reason for
Referral
Date of
Referral
Referred to
Completed?
Insurance
(Y/N & Date)
Joe Smith
12345
Halpern
Back Pain
6/16/11
Triangle
Ortho
No
BCBS-NC
Mary Jones
54321
Halpern
Colonoscopy
6/16/11
Durham GI
Yes 6/21/11
Duke
Select
Next Steps (Homework)
• Review the requirements for each
standard, element and factor
– What does the practice already do?
– What does the practice need to create?
– Are there elements the practice clearly does
not have in place but does not wish to
implement in the near-term?
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
Next Steps (Homework)
• Begin To Think About 3 Important
Conditions (e.g. diabetes, asthma,
congestive heart failure, depression, etc)
that you can track over time
– Does your practice already follow evidencebased guidelines when caring for patients with
these conditions?
– Are these guidelines documented anywhere?
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)
NCQA Contact Information
Contact NCQA Customer Support to:
• Order FREE Copy of requirements
• Order FREE Application Information
• 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: ppc-pcmh@ncqa.org
Happy Thanksgiving!
Questions?
Feel free to contact me:
David Halpern, MD, MPH
(215) 498-4648
dhalpern@n3cn.org