Your Partner in Practice
Delving Into PCMH Standards
(Working with Elements 3, 4 & 6)
OP User’s Conference
April 23-25, 2015
© 2015 The Verden Group
Agenda
 Connect the dots in Elements 3 & 4 to understand the
requirements
 Selecting patients for ‘care reminders’ (3D)
 Selecting patients for ‘clinical decision support’ (3E)
 A look at Comprehensive Health Assessments (3C)
 Determining patients for ‘care management’ and managing
that care (Element 4A & B)
 Utilizing the Workbook (3C, 4B, 4C)
 Setting up performance measurement and quality
improvement processes (Element 6)
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Connecting the Dots
© 2015 The Verden Group
Connecting the Dots
3C reads as if you must implement ‘comprehensive health assessments’
(CHAs) for ALL your patients. You can, but realistically you will use the
CHAs for data mining for 3D and 3E, and 4A and 4B. So we start at 3D &
3E and then implement 3C for those ‘conditions’ selected.
Connect the dots this way:
•
•
•
3.C (comprehensive health assessments)
are used on the patients selected in 3.D and 3.E
3.D (care reminders)
• 2 different preventive care services
• 2 different immunizations
• 3 chronic / acute conditions
3.E (clinical support / evidenced based medicine)
• 1 mental health
• 1 chronic condition
• 1 acute condition
• 1 unhealthy behavior condition
• 1 well child care
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Connecting the Dots
For 4A you use the same patients identified in 3D/E and 4B utilizes
the patients ‘discovered’ in 4A. You can also use 3E6 (overuse) and
4A for improvement measures in 6B.
Connect the dots this way:
•
4.A
•
•
•
•
(identifying patients needing care management)
Behavioral health
High cost / utilization
Poorly controlled / complex conditions
Outside referrals
•
4B (care planning & self support)
Data mining the patients in 4A, you must utilize the CHAs (3C) to ensure
that care planning and self-care support is addressed
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Choosing & Working With
Preventive & Acute Care,
Immunizations and Overdue
Patients for
Point of Care Reminders
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PCMH 3D: Use Data for Population Management
At least annually practice proactively identifies
populations of patients and reminds them, or their
families/caregivers, of needed care based on patient
information, clinical data, health assessments and
evidenced-based guidelines including:
1.
2.
3.
4.
5.
At least two different preventive care services.+
At least two different immunizations.+
At least three different chronic or acute care services.+
Patients not recently seen by the practice.
Medication monitoring or alert.
+ Stage 2 Core Meaningful Use Requirement
© 2015 The Verden Group
PCMH 3D: Scoring
MUST-PASS
5 Points
Scoring
• 4-5 factors = 100%
• 3 factors = 75%
• 2 factors = 50%
• 1 factor = 25%
• 0 factors = 0%
© 2015 The Verden Group
PCMH 3D: Documentation
Documentation
• F1-5:
1) Reports or lists of patients needing services generated
within the past 12 months (Health plan data okay if 75% of
patient population)
AND
2) Materials showing how patients were notified for each
service (e.g., template letter, phone call script, screen
shot of e-notice).
• Practice must perform these functions at least annually.
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Choosing Preventive Measures
Keep it simple and use what’s readily available. OP recommends
using:

PCMH/OP Reports:



Demographic Analysis/Recall
Event Chronology
PCMH CQMs
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Choosing Preventive Measures
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Choosing Chronic / Acute Services
3 services must be targeted and can be related to only one
condition.
Chronic care management services consider a practice’s entire
population. Practices may focus on three chronic care services
related to one condition.
Examples in Pediatrics include services related to chronic
conditions such as asthma, ADHD, ADD, obesity and
depression.
Example: One condition, three services could be Asthma • Flu shot reminder
• Medication follow up
• 6-month visit follow up (newly diagnosed patient)
© 2015 The Verden Group
Choosing & Working
With
Conditions and Behaviors
for
Evidence-Based Decision Support
(3E)
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PCMH 3E: Implement Evidence-Based Decision
Support
The practice implements clinical decision
support+ (e.g., point of care reminders) following
evidence-based guidelines for:
1. A mental health or substance use disorder. (CRITICAL
FACTOR)
2. A chronic medical condition.
3. An acute condition.
4. A condition related to unhealthy behaviors.
5. Well child or adult care.
6. Overuse/appropriateness issues.
© 2015 The Verden Group
PCMH 3E: Scoring and Documentation
4 Points
Scoring
•
•
•
•
•
5-6 factors (including factor 1) = 100%
4 factors (including factor 1) = 75%
3 factors = 50%
1-2 factors = 25%
0 factors = 0%
Documentation
• Factors 1-6: Provide
 Conditions identified by the practice for each factor and
 Source of guidelines and
 Examples of guideline implementation
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Developmental and Behavioral:
• Mental / substance abuse in Peds



•
ADHD
Depression
Substance abuse (tobacco, alcohol, drugs)
Condition related to unhealthy behaviors

Pediatric Obesity
Great resource for information and guidelines:
Section on Developmental and Behavioral Pediatrics
http://www2.aap.org/sections/dbpeds/screening.asp
© 2015 The Verden Group
Acute and Chronic Conditions:
Focus on chronic or recurring conditions such as asthma,
eczema, allergic rhinitis, pharyngitis, bronchiolitis, sinusitis,
otitis media and urinary tract infection
Some examples OP recommends using:
• Asthma
•
•
•
Pharyngitis
ADD/ADHD
Depression
Tie them back to your MU measures
if you are already making clinical
decision support rules
© 2015 The Verden Group
Well Child Measure:
Any age well child visit can be used for this measure.
• Utilize Bright Futures as the clinical decision support
guidelines.
• Protocol templates are included in the OP EMR and based
on Bright Futures
• Update orders on templates
• Adjust Care Plan to meet your practice’s needs
© 2015 The Verden Group
Overuse / Appropriateness
May include
 ER visits
 Redundant imaging or lab tests
 Prescribing generic medications vs. brand name
medications
 Number of specialist referrals.
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Comprehensive Health
Assessments (3C)
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PCMH 3C: Comprehensive Health Assessment
To understand the health risks and information needs
of patients/families, the practice collects and
regularly updates a comprehensive health
assessment that includes:
1. Age- and gender appropriate immunizations and
screenings.
2. Family/social/cultural characteristics.
3. Communication needs.
4. Medical history of patient and family.
5. Advance care planning (NA for pediatric practices).
6. Behaviors affecting health.
© 2015 The Verden Group
PCMH 3C: Comprehensive Health Assessment
(cont.)
7. Mental health/substance use history of patient and family.
8. Developmental screening using a standardized tool (NA for
practices with no pediatric patients).
9. Depression screening for adults and adolescents using a
standardized tool.
10. Assessment of health literacy.
© 2015 The Verden Group
PCMH 3C: Scoring
4 Points
Scoring
•
•
•
•
•
8-10 factors = 100%
6-7 factors = 75%
4-5 factors = 50%
2-3 factor = 25%
0-2 factors = 0%
NOTE
• Factor 5 (NA for pediatric practices)
• Written explanation needed for NA responses.
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PCMH 3C: Documentation
Documentation
• F1-10: Report with numerator and denominator based on
all unique patients in a recent three month period
indicating how many patients were assessed for each
factor.
OR
• F1-10: Review of patient records selected for the record
review required in elements 4B and 4C, documenting
presence or absence of information in Record Review
Workbook.
NOTE: USE THE WORKBOOK!
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Working With Care
Management & Support
(4A & B)
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PCMH 4: Care Management and Support
Intent
Meaningful Use Alignment
The practice systematically
identifies individual patients
and plans, manages and
coordinates care, based on
need.
• Practice implements
evidence-based
guidelines
• Practice reviews and
reconciles medications
with patients
• Practice uses eprescribing system
• Patient-specific
education materials
© 2015 The Verden Group
PCMH 4: Care Management and Support
20 Points
Elements
• Element A: Identify Patients for Care Management
• Element B: Care Planning and Self-Care Support- MUST PASS
• Element C: Medication Management
• Element D: Use Electronic Prescribing
• Element E: Support Self-Care and Shared DecisionMaking
© 2015 The Verden Group
PCMH 4A: Identify Patients for Care Management
The practice establishes a systematic process and
criteria for identifying patients who may benefit from care
management. The process includes consideration of the
following:
1. Behavioral health conditions.
2. High cost/high utilization.
3. Poorly controlled or complex conditions.
4. Social determinants of health.
5. Referrals by outside organizations (e.g. insurers, health system,
ACO), practice staff or patient/family/caregiver.
6. The practice monitors the percentage of the total patient
population identified through its process and criteria. (CRITICAL
FACTOR)
© 2015 The Verden Group
Identifying Patients for Care Management
• Identify all patients in practice with conditions
referenced in 4A, Factors 1-5.
• Patients may “fit” more than one criterion (Factor).
• Patients may be identified through electronic systems
(registries, billing, EHR), staff referrals and/or health plan
data.
• Review comprehensive health assessment (Element 3C)
as a possible method for identifying patients.
• Factor 6 is critical - NO points if no monitoring
The concept is to use 3C: CHAs, to help identify these patients.
© 2015 The Verden Group
PCMH 4A: Scoring and Documentation
4 Points
Scoring
•
•
•
•
•
5-6 factors (including factor 6) = 100%
4 factors (including factor 6) = 75%
3 factors (including factor 6) = 50%
2 factor (including factor 6) = 25%
0-1 factors (or does not meet factor 6) = 0%
Documentation
• F1-5: Documented process describing criteria for identifying
patients for each factor
• F6: Report with
- Denominator = total number of patients in the practice
- Numerator = number of unique patients identified in
denominator as likely to benefit from care management.
© 2015 The Verden Group
4A1: Behavioral Health
Pediatric populations
Practices may identify children and adolescents with special health
care needs, defined by the U.S. Department of Health and Human
Services Maternal and Child Health Bureau (MCHB) as children “who
have or are at risk for chronic physical, developmental, behavioral or
emotional conditions and who require health and related services of
a type or amount beyond that required generally.”
(Bright Futures: Guidelines for Health Supervision of Infants,
Children, and Adolescents, American Academy of Pediatrics, 3rd
Edition, 2008, p. 18.)
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PCMH 4B: Care Planning and Self-Care Support
Care team and patient/family/caregiver collaborate (at
relevant visits) to develop and update an individual care
plan that includes the following features for at least 75
percent of the patients identified in 4A.
1. Incorporates patient preferences and functional/
lifestyle goals.
2. Identifies treatment goals.
3. Assesses and addresses potential barriers to meeting
goals.
4. Includes a self-management plan.
5. Is provided in writing to patient/family/caregiver.
© 2015 The Verden Group
10
PCMH 4B: Scoring and Documentation
4 Points
Scoring
•
•
•
•
•
5 factors = 100%
4 factors = 75%
3 factors = 50%
1-2 factors = 25%
0 factors = 0%
Documentation
• F1-5:
Submission of Record Review Workbook and
Examples of how each factor is met (e.g. copy of a care plan)
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Using the
Record Review Workbook
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Workbook
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Determining What & How to
‘Measure & Improve’
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PCMH 6: Measure and Improve
Use all the same
measures from
Element 3D!
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PCMH 6A4: Vulnerable Populations
4. Performance data stratified for vulnerable populations (to assess disparities
in care).
•
The data collected by the practice for one or more measures from factors 1–3 is
stratified by race and ethnicity or by other indicators of vulnerable groups that reflect
the practice’s population demographics, such as age, gender, language needs,
education, income, type of insurance (i.e., Medicare, Medicaid, commercial), disability
or health status.
•
Vulnerable populations are “those who are made vulnerable by their financial
circumstances or place of residence, health, age, personal characteristics, functional or
developmental status, ability to communicate effectively, and presence of chronic
illness or disability,” (AHRQ) and include people with multiple co-morbid conditions or
who are at high risk for frequent hospitalization or ER visits.
© 2015 The Verden Group
6A – Identifying Vulnerable Populations
Also look back to 4A to help determine ‘vulnerable’ patients. They
may include:
•
•
•
•
•
•
•
•
High level of resource use e.g. visits, medication, calls
Frequent visits for urgent or emergent care (2 or more visits in the
last 6 months)
Frequent hospitalizations (2 or more in the last year)
Multiple co-morbidities, including mental health
Non-compliance with treatment or medications
Terminal illness
Multiple risk factors
Psychosocial status, lack of social or financial support that impedes
ability for care
© 2015 The Verden Group
PCMH6B: Resource Use
Look back to 4A2 for utilization measures affecting costs.
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PCMH 6D: Implement Continuous QI
Utilize previous measures: 3D, 3E tracked
to 6A and 4A2 to 6B – reuse and recycle!
6D flows to 6E
MUST PASS!
© 2015 The Verden Group
PCMH6C: Continuous Improvement
The practice sets goals and acts to improve performance, based on
clinical quality measures (Element A), resource measures (Element B)
and patient experience measures (Element C). The goal is for the
practice to reach a desired level of achievement based on its selfidentified standard of care.
• 6A ties to 3D and 3E
• 6B ties to 4A2
USE the ‘Quality Measurement and Improvement Worksheet’
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PCMH 6C: NCQA Quality Measurement and
Improvement Worksheet
© 2015 The Verden Group
PCMH 6C: NCQA Quality Measurement and
Improvement Worksheet
© 2015 The Verden Group
Q&A
Contact Information
The Verden Group, Inc
Your Partner in Practice
www.TheVerdenGroup.com
Susanne Madden, MBA, NCQA CEC
madden@theverdengroup.com
Julie Wood, MSc, NCQA CEC
julie@theverdengroup.com
© 2015 The Verden Group