Regional Care Collaborative
March 26, 2015
Slide 1
2011/2014 Crosswalk
(Standards 1-6)
Maia Bhirud
Slide 2
Standard 1 Crosswalk
PCMH 1: Enhance Access
PCMH
1: Enhance Access
and Continuity
and Continuity
2011
2011
Access
during
office hours
A.A. Access
during
office
B. hours
After-hours access
B. After-hours access
Electronic
access
C.C. Electronic
access
Continuity
D.D. Continuity
E.E. Medical
home
Medical
home responsibilities
responsibilities
Culturally
and linguistically
F.F. Culturally
and
appropriate services
linguistically
services
G. appropriate
The Practice
Team
G. The Practice Team
Slide 3
PCMH 1: PatientCentered Access
2014
A. Patient-centered
appointment access
B. 24/7 Access to clinical
advice
C. Electronic access
2014 Standard 1: Must Pass
PCMH 1A: Patient-Centered Appointment Access
The practice has a written process and defined standards for
providing access to appointments and regularly assesses its
performance on:
1. Providing same-day appointments for routine and urgent care
(critical factor)
2. Providing routine and urgent-care appointments outside of
regular business hours
3. Providing alternative types of clinical encounters
4. Availability of appointments
5. Monitoring no-show rates
6. Acting on identified opportunities to improve access
Slide 4
• Standard 1B: 24/7 Access
– Basically the same as 2011. Telephone access during and after hours has
been combined into one factor
• Standard 1C: Electronic Access
– Also basically the same as 2011 – MU reports but MU stage 2
Slide 5
Standard 2
PCMH 1: Enhance Access
PCMH
1: Enhance
and Continuity
Access
2011
and Continuity
D. Continuity
2011
Medical Home
D.E. Continuity
Responsibilities
E. Medical
Home
F. Responsibilities
Culturally and linguistically
F. Culturally
andServices
Appropriate
linguistically
G. The Practice Team
Appropriate Services
G. The Practice Team
Slide 6
PCMH 2: Team-Based
Care
2014
A. Continuity
B. Medical Home
Responsibilities
C. Culturally and
Linguistically
Appropriate Services
D. The Practice Team
• Standard 2A: Continuity
– Mapped to 2011 1D Continuity
– Factor 3: process to orient pts to staff and they really are looking for a
process
– Factor 4: transition plan for pts transitioning from pediatric to adult care
(formerly 5B)
• Documentation: written transition plan
• Standard 2B: Medical Home Responsibilities
– Same idea with added criteria to add into your brochure or website
• Standard 2C: Culturally and Linguistically Appropriate Services
– Unchanged
Slide 7
2014 Standard 2: Must Pass
PCMH 2D: The Practice Team (10 factors)
The practice uses a team to provide a range of patient care services
by:
1. Defining roles for clinical and nonclinical team members.
2. Identifying the team structure and the staff who lead and
sustain team based care.
3. Holding scheduled patient care team meetings or a
structured communication process focused on individual
patient care (critical factor).
4. Using standing orders for services.
Slide 8
2014 Standard 2: Must Pass
5.
Training and assigning members of the care team to coordinate
care for individual patients.
6. Training and assigning members of the care team to support
patients/ families/caregivers in self-management, self-efficacy
and behavior change.
7. Training and assigning members of the care team to manage the
patient population.
8. Holding schedule team meetings to address practice functioning.
9. Involving care team staff in the practice’s performance evaluation
and quality improvement activities.
10. Involving patients/families/caregivers in quality improvement
activities or on the practice’s advisory council.
Slide 9
Standard 3 Crosswalk
PMCH
2: 2:
Identify
andand Manage
PMCH
Identify
Manage
PatientPatient
Populations
Populations
2011
2011
Patient
Information
A.A. Patient
Information
B.B. Clinical
Data
Clinical
Data
C.C. Comprehensive
Comprehensive Health
Health
Assessment
Assessment
D. Use of Data for
D. Population
Use of Data for Population
Management
Management
Slide 10
PCMH 3: Population
Health Management
2014
A. Patient Information
B. Clinical Data
C. Comprehensive Health
Assessment
D. Use of Data for Population
Management
E. Implement Evidence-Based
Decision Support
•
•
•
•
•
•
3A: Patient Information (2011 2A)
3B: Clinical Data (2011 2B)
(remember now aligned with MU Stage 2)
3C: Comprehensive Health Assessment (2011 2C)
Review of completeness
Report clearly showing how many patients had incomplete or
complete assessments for all factors
• Or Review of patient records (using record review workbook)
Slide 11
2014 Standard 3: Must Pass
PCMH 3D: Use Data for Population Management
At least annually the 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 evidence based guidelines including:
1. At least two different preventive care services
2. At least two different immunizations
3. At least three different chronic or acute care services
4. Patients not recently seen by the practice
5. Medication monitoring or alert
Slide 12
• 3E: Implement Evidence Based Decision Support
– Different from proactive pop mngt activities that are reminding pts to come in
to receive specific services - Point of care reminders related to your clinical
decision support. – Pick conditions and show templates of the tools or
electronic system organizer
Slide 13
Standard 4
PCMH 3: Plan and Manage
2011
A. Implement Evidence-Based
Guidelines
B. Identify High-Risk Patients
C. Care Management (Must Pass)
D. Medication Management
E. Use Electronic Prescribing
PCMH 4: Provide Self-Care Support
and Community Resources
A. Support Self-Care Process (Must
Pass)
B. Provide Referrals to Community
Resources
PCMH 4: Care
Management and Support
2014
A. Identify Patients for Care
Management
B. Care Planning and SelfCare Support
C. Medication Management
D. Use Electronic Prescribing
E. Support Self-Care and
Shared Decision Making
Slide 14
• 4A: Care Management and Support (2011 3A)
– New from 2011 is designation of specifically high cost/utilization population
as well as a population specifically made vulnerable by a social determinant of
health (such as exposure to crime, access to education, housing status, etc.
– Documentation: process and criteria for identifying populations; percentage
of the total patient population to benefit from care management based on
the number/type of conditions selected for factors 1-5
Slide 15
Standard 4: Must Pass
PCMH 4B: Care Planning and Self-Care Support
The 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% of the patients identified in Element A:
1.
2.
3.
4.
5.
Incorporates patient preferences and functional/lifestyle goals.
Identifies treatment goals.
Assesses and addresses potential barriers to meeting goals.
Includes a self-management plan.
Is provided in writing to the patient/family/caregiver.
Slide 16
• 4C: Medication Management (2011 3D)
– Just like 3D although now aligned w Meaningful Use Stage 2
• 4D: Use Electronic Prescribing (2011 3E)
– Just like 3E in 2011
• 4E: Support Self-Care and Shared Decision Making
– Adapted from 2011 4A and 4B, emphasis on providing educational resources
to patients for their use in self management, including referrals to available
community resources.
Slide 17
Standard 5
PCMH 5: Track and Coordinate
Care
PCMH 5: Care Coordination and
Care Transitions
2011
A. Test Tracking and FollowUp
B. Referral Tracking and
Follow-Up (Must-Pass)
C. Coordination with Facilities
and Care Transitions
2014
A. Test Tracking and FollowUp
B. Referral Tracking and
Follow-Up (Must-Pass)
C. Coordinate Care
Transitions
Slide 18
• 5A: Test Tracking and Follow Up
– Very closely aligned with 5A from 2011. Larger thresholds for the percent of
lab and radiology orders that are electronically recorded in the pt record.
Slide 19
Standard 5: Must Pass
PCMH 5B: Referral Tracking and Follow-Up
The practice:
1. Considers available performance information on
consultants/specialists when making referral
recommendations.
2. Maintains formal and informal agreements with a subset of
specialists based on established criteria.
3. Maintains agreements with behavioral healthcare providers.
4. Integrates behavioral healthcare providers within the
practice site.
5. Gives the consultant or specialists pertinent demographic
and clinical data, including test results and the current care
plan.
Slide 20
Standard 5: Must Pass
PCMH 5B: (continued)
The practice:
6. Gives the consultant or specialist pertinent demographic and clinical
data, including test results and the current care plan.
7. Has the capacity for electronic exchange of key clinical information and
provides an electronic summary of care record to another provider for
more than 50% of referrals.+
8. Tracks referrals until the consultant or specialist’s report is available,
flagging and following up on overdue reports. (critical factor)
9. Documents co-management arrangements in the patient’s medical
record.
10. Asks patients/families about self-referrals and requesting reports from
clinicians.
Slide 21
• 5C: Coordinate Care Transitions
– very similar to 2011
Slide 22
Standard 6
PCMH 6: Measure and Improve
Performance
2011
A. Measure Performance
B. Measure Patient/Family
Experience
C. Implement Continuous
Quality Improvement (Must
Pass)
D. Demonstrate Continuous
Quality Improvement
E. Report Performance
F. Report Data Externally
PCMH 6: Performance Measurement
and Quality Improvement
A.
B.
C.
D.
E.
F.
G.
Slide 23
2014
Measure Clinical Quality
Performance
Measure Resource Use and Care
Coordination
Measure Patient/Family
Experience
Implement Continuous Quality
Improvement (Must Pass)
Demonstrate Continuous Quality
Improvement
Report Performance
Use Certified EHR Technology
• 6A: Measure Clinical Quality Performance
– Like Population management, separated measurement of immunization
measures from other preventative care measures
• 6B: Measure resource use and care coordination
– Added two measures related to care coordination. Examples include: biopsy
follow up, patient follow up after ER visit (see pg. 82 in standards for more
examples)
•
6C: Measure Patient/Family Experience
– Exactly aligned 2011 standards for measuring patient experience(2011 6B)
Slide 24
Standard 6: Must Pass
PCMH 6D: Implement Continuous Quality Improvement
The practice uses an ongoing quality improvement process to:
1.
2.
3.
4.
5.
6.
7.
Set goals and analyze at least three clinical quality measures from Element A.
Act to improve at least three clinical quality measures from Element A.
Set goals and analyze at least one measure from Element B.
Act to improve at least one measure from Element B.
Set goals and analyze at least one patient experience measure from Element C.
Act to improve at least one patient experience measure from Element C.
Set goals and address at least one identified disparity in care/service for
identified vulnerable populations.
Slide 25
• 6E: Demonstrate Continuous Quality Improvement
– Closely aligned with 2011 6D…credit for achieving improvement on measures
from elements A through C
• 6F: Report Performance
– Report performance data internally and publicly by individual clinician and at
the practice-level
• 6G: Use Certified EHR Technology
– Not scored so no impact on points but they want you to report whether or
not you use an EHR to perform a number of capabilities
Slide 26