2014 pcmh standards: how cpci can help with transformation pdfs/hit/hcnn/qi/nys-hccn_p… · 2014...

2014 PCMH Standards: How CPCI Can Help with

Transformation

CHCANYS Quality Improvement Program November 20, 2014

Agenda

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• Review of PCMH 2014 Standards and Stage II MU Crosswalk

• PCMH Transformation and the CPCI

Today’s Presenters

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• Kathy Alexis, Director, Quality Improvement Program, CHCANYS

• Amy Grandov, Managing Director, NYS-HCCN, CHCANYS

• Heather Budd, VP of Clinical Transformation, Azara Healthcare

PCMH 2014: Key Changes

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• Additional emphasis on team-based care

• Care management focused on high-risk patients

• More focused, sustained Quality Improvement (QI) on patient experience, utilization, clinical quality

• Alignment with Meaningful Use stage 2

• Further integration of Behavioral Health

Adapted from NCQA’s Intro to PCMH: Foundational Concepts of the Medical Home

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PCMH 2014 Content and Scoring (6 standards/27 elements)

1: Enhance Access and Continuity A. *Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access

Pts 4.5 3.5 2

10

2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate

Services (CLAS) D. *The Practice Team

Pts 3 2.5 2.5 4

12

3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence-Based Decision-

Support

Pts 3 4 4 5 4

20

4: Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making

Pts 4 4 4 3 5

20 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. *Referral Tracking and Follow-Up C. Coordinate Care Transitions

Pts 6 6 6 18

6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology

Pts 3 3 4 4 3 3 0 20

*Must Pass Elements Scoring Levels

Level 1: 35-59 points. Level 2: 60-84 points. Level 3: 85-100 points.

PCMH 2014 Standards and Related MU Stage 2 Alignment

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PCMH 1: Patient-Centered Access

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Intent of Standard The practice provides access to team-based care for both routine and urgent needs of patients/families/care-givers at all time.

A. Patient-centered appointment access B. 24/7 Access to clinical advice C. Electronic access


PCMH 1: MU Stage II Alignment

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PCMH 1 Element C: Electronic Access aligns to: • Core 7: Provide patients the ability to view online,

download and transmit their health information within four business days of the information being available to the EP

• Core 8: Provide clinical summaries for patients for each office visit

• Core 17: Use secure electronic messaging to communicate with patients on relevant health information

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf

PCMH 2: Team-Based Care Meaningful Use Alignment • No alignment

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Intent of Standard The practice provides continuity of care using culturally and linguistically appropriate, team-based approaches.

A. Continuity B. Medical Home Responsibilities C. CLAS D. The Practice Team


PCMH 3: Population Health Management

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Intent of Standard The practice uses a comprehensive health assessment and evidence-based decision support based on complete patient information and clinical data to manage the health of its entire patient population.

A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management E. Implement Evidence-Based Decision Support



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PCMH 3 Element A: Patient Information aligns to: • Core 3: Record the following demographics: preferred language,

sex, race, ethnicity, date of birth

PCMH 3 Element B: Clinical Data aligns to: • Core 4: Record and chart changes in vital signs • Core 5: Record smoking status for patients 13 years old or older • Menu 2: Record electronic notes in patient records • Menu 4: Record patient family health history as structured data


PCMH 3: MU Alignment

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PCMH 3 Element D Use Data for Population Management aligns to: • Core 11: Generate lists of patients by specific conditions to

use for quality improvement, reduction of disparities, research, or outreach

PCMH 3 Element E Implement Evidence-Based Decision Support aligns to: • Core 6: Use clinical decision support to improve performance

on high-priority health conditions


PCMH 4: Care Management and Support

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Intent of Standard The practice systematically identifies individual patients and plans, manages and coordinates care, based on need.

A. Identify Patients for Care Management B. Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making



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PCMH 4 Element C Medication Management aligns to: • Core 14: The EP who receives a patient from another setting of care or

provider of care or believes an encounter is relevant should perform medication reconciliation.

PCMH 4 Use Electronic Prescribing aligns to: • Core 1: Use computerized provider order entry (CPOE) for medication,

laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.

• Core 2: Generate and transmit permissible prescriptions electronically (eRx).

• Core 6: Use clinical decision support to improve performance on high-priority health conditions



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PCMH 4 Element E Support Self-Care and Shared Decision-Making aligns to: • Core 13: Use clinically relevant information from Certified EHR

Technology to identify patient-specific education resources and provide those resources to the patient


PCMH 5: Care Coordination and Care Transitions

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Intent of Standard The practice systematically tracks, test and coordinates care across specialty care, facility based care and community organizations.

A. Track and follow-up B. Referral Tracking and Follow-up C. Coordinate Care Transitions



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PCMH 5 Element A Track and Follow-up aligns to: • Core 1 : Use computerized provider order entry (CPOE) • Core 10: Incorporate clinical lab-test results into Certified EHR

Technology as structured data • Menu 3: Imaging results consisting of the image itself and

any explanation or other accompanying information are accessible through CEHRT

https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf


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PCMH 5 Element B Referral Tracking & Follow-up AND Element C Coordinate Care Transitions both align to: • Core 15: The EP who transitions their patient to another

setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral


PCMH 6: Performance Measurement and Quality Improvement

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Intent of Standard The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology Adapted from NCQA’s Intro to PCMH: Foundational Concepts of the Medical Home

PCMH 6: MU Stage II Alignment (1 of 2)

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PCMH 6 Element G Use Certified EHR Technology aligns to: • Core 9: Protect electronic health information created or

maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities Core 12: reminders for preventive/follow-up care

• Core 16: Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice.

• Menu 1: Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice. https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf

PCMH 6: MU Stage II Alignment (2 of 2)

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PCMH 6 Element G Use Certified EHR Technology aligns to (cont): • Menu 5: Capability to identify and report cancer cases to a

public health central cancer registry, except where prohibited, and in accordance with applicable law and practice.

• Menu 6: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.

• Clinical Quality Measures


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Using CPCI as a Tool to Transform Your Practice

© Azara Healthcare 2014

Patient Centered Medical Home Practice Transformation Supported by CPCI at all levels of Care Delivery

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External Performance

QI & Population Management

Point of Care

Team-based, proactive care planning to maximize opportunity

for delivering care and engaging patient.

Performance tracking, continuous quality improvement to test

change, and meet strategic QI goals, Population Management for

outreach, tracking and follow-up.

• Visit Planning for huddle prep • Registries for care managers

• Scorecards / Dashboards • Measure Analyzer • Registries • Referral Management

Proof of performance and tracking for regulatory, grant, program and

board reporting. Mid-period performance evaluation for

proactive management.

• Scorecards / Dashboards • Measure Analyzer (graphics) • Regulatory reports (UDS, MU,

PCMH, state, grant, etc.)

TRANSFORMATION GOALS CPCI TOOLS


Putting the Visit Planning Report into Daily Practice: Team Based Care Visit Planning Responsibilities

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Sample Care Team Members

Provider

MA

Patient

Front Desk

Care Manager

BH

Pharmacist

Patient Health

Educator

BH

Transition of Care

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Visit Planning Responsibilities

MA 1. Run Azara DRVS Visit Planning Report for scheduled patients daily and for

walk-in patients if there is time.

2. Identify missing data for Diagnostics or Labs. If scanned only results exist, enter in EHR as structured data (especially Mammogram, Pap, Colonoscopy).

3. Assist Provider with completing alerts for patients, supported by standing orders. Enter reminders in the secondary chief complaint field. Primary chief complaint still used for true chief complaint. Order labs and diagnostics as needed (supported by standing orders).

4. Cancel pre-ordered labs for patients who cancel or no-show by the end of each session.

Front Desk 1. Check what has been ordered for the patient in order to charge the correct

co-pay at check in and avoid needing to send patient out to FD during visit.

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Visit Planning Responsibilities Health Educator/ Care Manager / Pharmacy/ BH/ Other

1. Huddle with MA to determine high risk patients to see face-to-face or offer additional education or care coordination.

2. Share any special patient circumstances with the team.

Provider 1. Delegate standing order tasks to appropriate support team members. Visit

Planning Report provides technology foundation for trust. 2. Ensure huddles are happening. May take many forms but at the very least

there should be some conversation with your MA about the plan for patients- a quick team meeting, or passing check in. Essential for MAs to feel supported when acting on Standing Orders.

3. Delete secondary chief complaint items not addressed in visit. All

1. Data Hygiene: Report data errors so they can be addressed and fixed. Workflows and inputs change overtime. Azara will find root cause and update. Send an email with details to [email protected].

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PCMH Update Timeline PCMH 2011

• PCMH 2011 survey tools are no longer available for purchase

• December 31, 2014 last date to submit PCMH 2011 Corporate survey tools

• March 31, 2015 last date to submit PCMH 2011 survey tools

PCMH 2014 Available • Standards and Guidelines • Survey tools


11/20/2014 www.chcanys.org 29

Resources

Order the PCMH 2014 Online Application from NCQA

2014 pcmh standards: how cpci can help with transformation pdfs/hit/hcnn/qi/nys-hccn_p… · 2014...

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