Transcript Slide 1

PCMH for Your Practice?
Here’s a Place to Start
R.W. “Chip” Watkins, MD, MPH, FAAFP
SCORH Conference
Columbia, SC
15 October 2013
Who am I?
 R.W. “Chip” Watkins, MD, MPH, FAAFP
 Senior Physician Consultant on CCNC’s PCMH
Efforts
 NCQA Physician Review Oversight Committee (ROC)
 NCQA Reviewer
 NCQA’s Advisory Panel for CEC Exam
 Medical Director – High Country Community Health
 Past-President and Board Chair – NC Academy of
Family Physicians
What is a Patient-Centered
Medical Home (PCMH)?
Patient-Centered Medical Home
The PCMH is a
model of primary
care re-design
intended to improve
the quality and
efficiency of primary
care delivery
The Challenge
Medicine used to be simple, ineffective and
relatively safe.
Now it is complex, effective, and potentially
dangerous
Sir Cyril Chandler
Chairman of the Board
Great Ormond Street Hospital
For Children NHS Trust
Liverpool, England
What we have…
Atul Gawande, MD
What we need!!
Patient-Centered Medical Home
 Emphasizes the relationship between
patients and their primary care physicians
 Employs a team-based approach to care
 Integrates evidence-based practices, clinical
decision-support tools, disease registries, and
health information technology to improve
population management and preventive
care
Medical Home “Joint Principles”
1) Personal Physician
2) Physician-Directed Practice
3) Whole-Person Orientation
4) Care Coordination/Integration
5) Quality & Safety
6) Enhanced Access
7) Payment
Adopted by the American Academy of Family Physicians (AAFP),
American Academy of Pediatrics (AAP), American College of Physicians
(ACP), and American Osteopathic Association (AOA) in Febraury, 2007
Features of PCMH
Four common features in
demonstrations
 Dedicated care managers
 Expanded access to clinicians
 Data-driven analytic tools
 Use of incentives
Benefits of the PCMH Model
Quality – Outcomes for seven medical home
demonstrations
 Fewer ER visits (15%-50%)
 Fewer hospital admissions (6-24%)
 Lower mortality rates
 Better preventive service delivery
 Better chronic disease care
 Higher patient satisfaction
Source: Fields, et al. (2010) and Reid RJ, Coleman K, et al. (2010).
Benefits of the PCMH Model
Efficiency – Cost
 Lower total costs of care - (6.5-22%)
 Shorter patient wait times
 Less staff burnout/turnover (10% Vs. 30%)
 Higher staff satisfaction/productivity
Source: Fields, et al. 2010
This is a No-Brainer! Right?
 So Why Aren’t Practices RUNNING to implement
PCMH for themselves?!?
1. Time
2. Resources
3. Consultants are expensive
4. Fear
a) Gov’t interference
b) Loss of control/independence
c) Change
PCMH 2011 Overview
(6 standards/27 elements)
1.
2.
3.
Enhance Access and Continuity
4.
A.
Access During Office Hours
Provide Self-Care and Community
Resources
B.
Access After Hours
A. Self-Care Process
C.
Electronic Access
B. Referrals to Community Resources
D.
Continuity (with provider)
E.
Medical Home Responsibilities
A.
Test Tracking and Follow-Up
F.
Culturally/Linguistically Appropriate Services
B.
Referral Tracking and Follow-Up
G.
Practice Organization
C.
Coordinate with Facilities/Care Transitions
5.
Identify/Manage Patient Populations 6.
Track/Coordinate Care
Measure and Improve Performance
A.
Patient Information
A.
Measures of Performance
B.
Clinical Data
B.
Patient/Family Feedback
C.
Comprehensive Health Assessment
C.
Implements Continuous Quality Improvement
D.
Use Data for Population Management
D.
Demonstrates Continuous Quality Improvement
Plan/Manage Care
E.
Report Performance
A.
Implement Evidence-Based Guidelines
F.
Report Data Externally
B.
Identify High-Risk Patients
C.
Manage Care
D.
Manage Medications
E.
Electronic Prescribing
Optional Patient Experiences Survey
Scoring
Total 100 Points
Recognition requires achieving all 6 must
pass elements with a ≥50% score
Level
Points
Required Must Pass
1
≥ 35
6 Must Pass
2
≥ 60
6 Must Pass
3
≥ 85
6 Must Pass
Alignment with Measures of
Meaningful Use

E-prescribing – medication list, allergies

Patient tracking/registry – demographics, diagnoses,
vital signs, smoking, population management,
insurance

Care management – reminders for follow-up care,
decision support, Rx reconciliation

Electronic capability – e-health information to
patient, visit summary, e-access to health
information, provider information exchange

Performance reporting/improvement
How Much Do You Know About
CCNC?
CCNC - “How it works”
 Primary care medical home available to 1.6 million Medicaid
patients in all 100 counties
 Provides 5,000 local primary care physicians (94% of all NC
PCPs) with resources to better manage Medicaid population
 Not-for-profit networks link local community providers
(health systems, hospitals, health departments and other
community providers) to primary care physicians
 Resources include 600 local care managers, 26 pharmacists,
14 psychiatrists and 20 medical directors to improve local
health care delivery
CCNC - “How it works”
 The state identifies priorities and provides financial support
through an enhanced PMPM payment to community
networks
 Networks pilot potential solutions and monitor
implementation (physician led)
 Networks voluntarily share best practice solutions and best
practices are spread to other networks – for ALL payors
 The state provides the networks (CCNC) access to data
 Cost savings/ effectiveness are evaluated by the state and
third-party consultants (Treo Solutions, Milliman)
Watkins - 2012
20
System-Wide Results
 Community Care is in the top 10 percent in US in HEDIS for
diabetes, asthma, heart disease compared to commercial
managed care.
Cholesterol Control LDL <100
Diabetes
Cholesterol Testing
Blood Pressure Control <130/80
CCNC 2009
A1C Control <9.0
CCNC 2010
National Medicaid
HMO HEDIS mean
Cardiovascular
Disease
A1C Testing
Cholesterol Control LDL<100
Blood Pressure Control <140/90
0%
20% 40% 60% 80% 100%
Watkins - 2012
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Community Care’s
Informatics Center
Informatics Center ─ Medicaid claims data
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
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
Utilization (ED, Hospitalizations)
Providers (Primary Care, Mental Health, Specialists)
Diagnoses – Medications – Labs
Costs
Individual and Population Level Care Alerts
Real-time data
 Hospitalizations, ED visits, provider referrals
Multipayer Datafeeds
 Medicare, Medicaid, BCBSNC, and SEHP
Watkins - 2012
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What is the
Multi-Payer Advanced Primary Care
Practice Demonstration
Project (MAPCP)?
What is the Multi-Payer Demo?
 The purpose of the Multi-Payer Advanced
Primary Care Practice “demonstration project”
(MAPCP) is to evaluate the effectiveness of
the PCMH model, when supported by both
public and private payers
 NC is one of 8 states that was awarded an
MAPCP demo
What is the Multi-Payer Demo?
 7 rural counties across NC were chosen to participate in
the demo: Ashe, Avery, Bladen, Columbus, Granville,
Transylvania, and Watauga
What is the Multi-Payer Demo?
 To participate, practices in these counties must
obtain PCMH recognition from the National
Committee for Quality Assurance (NCQA) during
their first year of the demo
 In return for implementing the PCMH model,
practices will earn incentive payments from the
largest public and private payers in NC: CMS
and BCBS-NC/SHP.
Recognition of Added Value
Incentive Payments from Medicare
 CMS will pay a per member per month fee
for each Medicare patient in practices
achieving PCMH recognition through NCQA:
 Level 1 = $2.50 PMPM ($30 each year)
 Level 2 = $3.00 PMPM ($36 each year)
 Level 3 = $3.50 PMPM ($42 each year)
Recognition of Added Value
Increased Reimbursement from BCBS
 Eligibility for the Blue Quality Physicians
Program (BQPP), a recognition
program for primary care practices that
builds on PCMH recognition from NCQA
 Once you qualify for the BQPP, BCBS
will increase its fee structure by 10%
or more for all of your BCBS/SEHP
patients
Let’s Talk About Resources for
Your NCQA Submission
Resources Available
 NCQA
 PCMH Standards and Guidelines – “The Rules”
 Standards, Elements, Factors
 Policies and Procedures
 Software Products
 Online Application Account
 Business and demographic information
 Free
 Interactive Survey System (ISS)
 Responses to the Standards and Guidelines
 ISS Survey Tool
 $80
 Recognition Programs Section of NCQA’s Website
Go to NCQA Home
Then Programs
Then Recognition
Then PCMH 2011
Then Before, During,
and After I’m Recognized
for lists of online
resources
http://www.ncqa.org/Programs/Recognition.aspx
Resources Available
 CCNC
 Web-based 2011 PCMH Workbook
 Webinars for 2011 PCMH Submissions
 Introducing….
Resources Available
 Use the CCNC PCMH workbook, webinars

https://www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmhresources/
How Do You Get All This Done?
Watkins. Journal of
Medical Practice
Management,
Sept/Oct 2012,
Vol 28:2, pp. 134-6.
ASU Practicum in Primary Care
ASU College of Health Science,
School of Healthcare
Management
Creation of Partnership with
Appalachian State University
PARTNERSHIP:
 Recruit ASU students from School of Health Care
Management
 Develop curriculum, syllabus, website, core
documents
 Create new practicum course with internship
opportunity
 Teach students about PCMH, Provider Portal,
Care management process
 Send students out to practices to assist in
attaining PCMH certification, BQPP cert and QI
initiatives
ASU Practicum in Primary Care
 Fall of 2011 – 5 students
 Spring 2012 – 9 students – BSBSNC
Foundation Grant Obtained
 Summer 2012 internship – 8 students
 Fall 2012 – 14 students
 Spring 2013 – 15 students
 Fall 2013 – 16 students
ASU Practicum in Primary Care
 Developed curriculum, core documents, website
https://sites.google.com/site/pcmhprac/
ASU Practicum in Primary Care
 Worked through curriculum and have weekly didactic
meetings on ASU campus
 BAA for HIPPA compliance
 Students prepare PCMH PPT for “their” practice and give to
group
 Go through the Standards and hit high points
 Students share successes/failures with facilitators/faculty
 Placed students in field and worked with the practices
 Students give PPT
 Work with practices – develop “PCMH Team”, schedule time
with team, give weekly assignments, follow-up, etc.
Program Growth
 ASU School of Health Care Management has
made the “Practicum in Primary Care” a CORE
curriculum class
 Students willing to spend 2 semesters with us get
full credit for their internship (300 hours)
 “Keeping the Medical Home Fires Burning” is a
new initiative where practices that have been
recognized work with students on QI projects
Program Growth
 Remote Learning Initiative
 Students work with practices within 3 hours of Boone
 MOVI (secure) web-hosting
 Face-to-face visits every 3 weeks or so
CCNC’s PCMH Efforts
Beginning of
MP Project
Getting into the Weeds
Types of Documents
Time Periods
Organize the Documents
1. Create a folder on your network drive for documents the practice
MAY want to attach
2. Develop a checklist of documents already used in the practice and
documents that need to be prepared
3. Refer to published standards and use to identify what the practice
has and what needs to be created
4. Save a copy of the Record Review Workbook and/or Quality
Measurement and Improvement Worksheet to your document folder
5. Consider putting multiple examples in one document for a single
element, e.g. screenshots
6. Identify documents that may be applicable for more than one
element
 NOTE: NCQA advises a target of three (3) documents or fewer per
element (some elements require more, others just one). This will
depend on the number of factors in the element and the diversity of
document types included.
Manage the Documents
1. Use a unique naming convention for each document, that is,
don’t use the same name for multiple documents
2. Use a logical organizing principle such as:
PCMH 1 A—Name of Document.docx
PCMH 1 B—Name of Document.xls
3. Avoid special characters and punctuation in document name
(e.g. quotation marks, question marks, commas, apostrophes,
ampersands). NCQA’s system will not accept the documents.
4. Don’t put the same document in two different places in the
document library; instead, enter it once and link to multiple
elements
5. Use text boxes, arrows or other methods to identify important
sections; briefly explain the importance to the element(s).
6. If N/A is marked, explain the reason in Text/Notes section in
the Survey Tool.
Linking Documents
What is the oldest a
submitted document can
be?
Tips in Summary
1. Be efficient – use only what is needed.
a. Read the documentation requirements and provide only what is necessary.
b. Try to limit the documentation to one document per element for multiple
factors.
2. Make sure documentation is legible. Legibility impacts NCQA’s
review.
3. Clearly explain the documents and the section you want NCQA to
see.
a. Label documents with the appropriate title
b. Make use of text boxes to explain, highlight, box in a targeted section or
information and use arrows.
c. Do not handwrite notes on documents to explain data, and then scan them
into your computer. Handwritten notes are difficult to read.
d. When using textboxes to hide information in non‐PDF documents, save the
documents as ―read‐only, or convert to PDF. Otherwise, textboxes can moved
and PHI revealed.
e. For screen shots, print screens and scan, or paste print screen as a picture
into a Word document or PowerPoint slide.
Tips in Summary
4. Combine “like” documents whenever possible.
a. E.g., multiple policies written in MS Word may be combines
into one document; refer to page number for individual
elements.
5. Block PHI on all documents. Do not submit any
protected health information. Keep a master list of
patient files submitted in case of an NCQA audit.
Physician names/information can remain on the files.
6. Do not use a flash drive (USB device) as the file
path for your linked documents.
PCMH 1A – During Office Hours
Practice has written process/defined 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 (may be N/A
if the practice does not advise patients via electronic
systems)
4. Document clinical advice in the medical record
Critical Factors, such as PCMH 1A Factor 1, for Must Pass
Elements are Essential to Achieving Recognition
PCMH 1A: Scoring and
Documentation
MUST PASS
4 Points
Scoring
4 factors = 100%
3 factors (including Factor 1) = 75%
2 factors (including Factor 1)= 50%
Must get at least 2 factors
or 50% to PASS
Factor 1 = 25% (not 1 factor)
0 factors or missing factor 1 = 0%
Documentation:
F1-4: Documented process for scheduling appointments, providing clinical
advice and documenting advice and
F1-3: Reports with 5 days of data showing same-day access, response
times compared to practice defined standards
F4: Three examples of clinical advice or report with percent documented
advice in record in recent one month period
Notes Section
Ex. 1: This is an example of a practice writing an explanation to NCQA in the
“Notes” section of the survey tool.
NCQA Reviewer Note: The practice responded "Yes" to factors 1-2, 4 and "No" to
factor 3. Reviewer agrees with the practice's self-assessment.
______________________________________________________________
1A1, 1A2, 1A4. Attached policy demonstrates that: 1) 25% of appointment slots
each day are reserved for same day appointments. These appointments are usually
booked early in the morning for the same day but may be booked the afternoon
prior if needed; 2) documenting phone conversations with patients in the medical
record is expected and; 3)a response to patient phone calls is expected to occur
within 24 hours.
1A1. A report shows the % of same day appointments.
1A1. Screenshots show that the schedule template is built to accommodate 4 total
appointments per hour: 2 established patients, 1 new patient and 1 same day (workin) patient each hour. This same template is applied to every provider, every day.
1A2. Audit results attached
1A3. marked "no" because, while we have recently enabled the electronic
messaging feature through our patient portal, we have not yet received any
messages from patients.
1A4. Three examples of clinical advice documented in medical records are
attached.
PCMH 1A1- Process
HCCH Process: Providing patients access to same-day
appointments
 As primary care providers, it is essential that we maintain the
capacity to see patients when they need to obtain care and
services.
 As a patient-centered organization, our standard is that patients
are able to schedule appointments at times that meet their
needs.
 Each practice reserves appointment slots for all providers on
each scheduled day in order to provide same-day access to
patients requesting care or services.
 These slots are clearly identified in the provider’s schedule and
may only be filled on the same day. (A slot may occasionally be
filled after 3 pm on the day prior for a patient requesting an
appointment the following morning.)
What’s missing from
this document?
How long should the
process have been in
place?
PCMH 1A - Documentation
Same-Day Appts Marked
by arrow and labeled SD
5 Day Audit for Same Day Appts
5 Day Audit for Same Day Appts
Report for Red and Blue Teams Same Day availability slots for 5 days (5/145/18): Red Team has 37 slots available. Blue Team has 34 slots available.
RED TEAM
BLUE TEAM
Reviewer Comments
1A
Ex. 1: Factor 4 - The practice provided examples that did not demonstrate
clinical advice. Messages left for patients to make appointments does not
meet the intent of clinical advice.
Ex. 2: To receive credit for factor 4, the practice must submit two items, 1) a
documented process for staff to follow for entering phone and electronic
message clinical advice in the patient record and 2) at least three examples
of clinical advice documented in a patient record or generates a report
identifying how often advice is documented in the medical record.
The practice submitted a process; however the three examples provided did
not meet the intent of the factor. The three examples were communication
between clinician and nurse. The examples should show clinical advice
documented in a patient's medical record. Factor 4 was changed to no.
Ex. 3: The practice scored factors 1-4 “yes”. The reviewer changed factors 14 to “no” because the practice did not have a documented process with an
implementation date or other evidences that it has been in place for at least
3 months. The reviewer requested additional documentation to support the
practice’s “Yes” responses.
The additional documentation was submitted and now the reviewer agrees
with the practice’s assessment and has changed factors 1-4 from “No” back
to “Yes”.
Top 10 Points To Remember
About Your NCQA Submission!
Top 10 Points To Remember!
Number 10 - Eligibility
 Recognitions are awarded at the geographic site level
 Clinicians Who Are Eligible
 MDs, DOs, NPs, PAs with panels of primary care patients
 75% of those patients come for “first contact”, comprehensive,
and continuous PCP care
 Clinicians who see patients routinely at more than one
site should be listed on each site’s application
 Multi-Sites have:
 3 or more sites
 The same EMR
 The same policies and procedures for staff
 The ability to be bound by a single contract
Top 10 Points To Remember!
 Number 9 – Timing of Application Submission
 Submit Online Applications and ISS Survey Tools
in Pairs
 One application for each site first
 One ISS Tool for each site
Pair
 The Online Application Account can be used for multiple
submissions over time
 A separate Online Application must be submitted 5 days
before NCQA can accept any PCMH ISS Survey Tool
Top 10 Points To Remember!
 Number 8 – Record Review Workbook
 Really understand how to use the Record Review
Workbook
 Read and understand THE INSTRUCTIONS
 Watch the CCNC webinars and NCQA videos and webinars
 Condition 3A factor 3 must be included
 Double check you have the right number of patients in 3A
and 3B
 Use the methodology outlined in the INSTRUCTIONS
 Method 1 and 2 can be mixed and matched
No. 8 - Look at the Instructions
Three tabs
 Instructions
 Patient Conditions
 Record Review
Top 10 Points To Remember!
 Number 7 – Give Yourself Enough Time
 Online Application must precede the ISS tool by 5
days
 NCQA may take 60 days to review single site
tools and 30 days for Multi-Site Corporate tools
 Thus Multi-site Recognitions may take 90 days
 It takes time for NCQA to set up a call to discuss the
corporate tool and to copy elements into site tools
 Large Multi-sites should stagger site submissions to allow a
single reviewer to keep up
 When NCQA asks for more documentation it adds
TIME
Top 10 Points To Remember!
 Number 6 – Overestimate Pre-submission Work
Time
 Takes 100-200 hours
 Develop a PLAN and TIMELINE
 Develop a PCMH TEAM in your office with
responsibilities for each member
 Meet regularly – use Quick Look
 Give enough time to collect and upload all your
documents – up to 150 documents or more
Quick Look Worksheet in
CCNC PCMH Workbook
Top 10 Points To Remember!
 Number 5 – Don’t Let Recognitions Expire Before
Renewing
 Expired Recognitions are not retroactively
extended
 Expired practices and providers will fall off the
lists NCQA sends to P4P program sponsors
monthly
 They reappear when practices earn a new
Recognition
Top 10 Points To Remember!
 Number 4 – Pay attention to Documentation
Requirements
 Interpret the S&G document requirements
LITERALLY
 All should attend S&G training and CCNC
webinars to understand the requirements of each
element
 Read all related FAQs
 If S&G requires X types of documents, be sure
you include all of them
 NCQA does not pre-approve documentation
Top 10 Points To Remember!
 Number 3 – Use NCQA’s and CCNC’s PCMH 2011
Written and Archived Training Resources
 When a system doesn’t work, READ the
instructions
 If it still doesn’t work, FOLLOW the instructions
 Have someone on your team attend a “Facilitating
Patient-Centered Medical Home Recognition”
conference if possible
 Plan on one person in your organization or 2
people in your network attending the Content
Expert Certification
Top 10 Points To Remember!
 Number 2 – Prepare Reviewer-Friendly
Documentation
 Organize by standards, elements, and factors
 Helps to organize in 1 PDF per element
 Efficient – limit to only what is necessary for the
requirement
 Labeled and Highlighted – corresponding fields
 Dated or Date Range (where appropriate)
 Learn how to do a screenshot – think
“Greenshot” or “SnagIT”
Processes for
5C 1,2,3,4,5
Top 10 Points To Remember!
 Number 1 – Focus on the Most Critical Factors First
 Have a Plan – Timeline it
 PCMH 1A factor 1
 Providing same day appointments
 PCMH 4A factor 3 (RRWB element)
 Develops and documents self-management plans and goals in
collaboration with at least 50 percent of patients/families
 PCMH 6C – factors 1 and 2
 There is no Recognition without these
 Good places to begin early practice transformation
 Assure that your documentation meets requirements
One More Thing…
 We need to motivate and reward patients for
taking care of their OWN HEALTH!
Next Steps (Homework)
 Interested in building your own PCMH Team?
 Become a part of CCNC
 Identify a “PCMH Champion” who will help guide the
practice through the quality transformation process
 Identify a “Communicator-In-Chief” who will serve as a
point person for interactions with Community Care and
other support staff
 Identify a “Lead Administrator” who will track progress,
organize materials, and complete the Survey Tool/PCMH
application
 Use CCNC’s tools and resources for PCMH!
PCMH for Your Practice?
Here’s a Place to Start
R.W. “Chip” Watkins, MD, MPH, FAAFP
SCORH Conference
Columbia, SC
15 October 2013