NCQA PCMH 2011 Standards OverviewLearning Session 2September 2012

Goals of NCQA Standards• Increase patient-centeredness• Align requirements with processes that improve

quality and eliminate waste (i.e., ER visits, Hospital readmissions, using brand vs. generic, etc.)

• Increase emphasis on patient experience• Enhance use of clinical performance measure results• Integrate: unhealthy behaviors, mental health, and

substance abuse• Enhance coordination of care• Enhance applicability to pediatric practices

Eligible Applicants• Outpatient primary care practices that

meet scoring criteria for either Level 1, 2, or 3 (3 is highest)

• NCQA defines a practice as a clinician or clinicians practicing together at a single geographic location, includes nurse-led practices in states where state licensing designates NPs as independent practitioners

Eligible Applicants (Cont’d)

• Recognition is at the practice-site level• Assessment for recognition must include a

survey for every site that the practices wants to identify as a recognized PCMH

• PCMH recognition identifies primary care clinicians practicing at the site, including nurse practitioners and physician assistants that have their own patient panels

Six Standards1. Enhance Access and Continuity2. Indentify and Manage Patient Populations3. Plan and Manage Care4. Provide Self-Care Support and

Community Resources5. Track and Coordinate Care6. Measure and Improve Performance

Composition of Standards• Consist of Standard, Element, and Factor• There is always a MUST PASS Element and

a Critical Factor in each standard • EXAMPLE:Standard 1 Enhance Access and Continuity

• Element 1A (of 7): Access During Office Hours• Factor 1 (of 4): Provide same-day

appointments—CRITICAL FACTOR!

Must Pass Elements• PCMH 1, Element A: Access During Office Hours• PCMH 2, Element D: Use Data for Population

Management • PCMH 3, Element C: Care Management• PCMH 4, Element A: Support Self-Care Process• PCMH 5, Element B: Referral Tracking and Follow-up• PCMH 6, Element C: Implement Continuous Quality

Improvement

PCMH Scoring6 standards = 100 pts

6 MUST PASS elements*

Level Points Must Pass Elements at 50% Performance Level

Level 3 85-100 6Level 2 60-84 6Level 1 35-59 6

*Must pass elements require a ≥50% performance level to pass!

Standards

Standard 1 Enhanced Access & Continuity Points

A. Access During Office Hours** 4

B. After-Hours Access 4

C. Electronic Access 2

D. Continuity 2

E. Medical Home Responsibilities 2

F. Culturally & Linguistically Appropriate 2

G. Practice Team 4

TOTAL 20

** Must Pass

Standards (Cont’d)

** Must Pass

Standard 3 Plan & Manage Care Points

A. Implement Evidence-Based Guidelines 4

B. Identify High-Risk Patients 3

C. Care Management** 4

D. Medication Management 3

E. Use Electronic Prescribing 3

TOTAL 17

Standard 2 Identify & Manage Patient Populations Points

A. Patient Information 3

B. Clinical Data 4

C. Comprehensive Health Assessment 4

D. Use Data for Population Management** 5

TOTAL 16

Standards (Cont’d)

** Must Pass

Standard 5 Track & Coordinate Care Points

A. Test Tracking & Follow-Up 6

B. Referral Tracking & Follow-Up 6

C. Coordinate with Facilities/Care Transition

6

TOTAL 18

Standard 4 Provide Self-Care Support & Community Resources

Points

A. Support Self-Care Process** 6

B. Provide Referrals to Community Resources

3

TOTAL 9

Standards (Cont’d)

** Must Pass

Standard 6 Measure & Improve Performance Points

A. Measure Performance 4

B. Measure Patient/Family Experience 4

C. Implement Continuous Quality Improvement

4

D. Demonstrate Continuous Quality Improvement

3

E. Report Performance 2

F. Report Data Externally 2

G. Use of Certified EHR Technology 0

TOTAL 20

Crosswalk Between MU and NCQA REQUIREMENTS

REQUIREMENT Meaningful Use NCQACertified EHR Required Not RequiredUnit of Measurement Clinician Practice SITEReporting Period 12 months 12 months IF EHR has

been in place for > 1 year; if not, 3 months

Crosswalk: MU, NCQA StandardsPA SPREAD Measures Meaningful

UseNCQA PCMH

2011Notes

HbA1C >9% ☒ ☐ • Can use any 3 of these diabetes measures to meet Meaningful Use Clinical Quality Measure reporting requirement.

• Can choose to use any 3 of these to meet NCQA PMCH 2, Element D (Must Pass Element): generate lists of patients who need chronic care management services and use the lists to remind patients of needed services for at least three chronic care services.

HbA1C <8% ☒ ☐BP <140/90 ☒ ☐LDL <100 ☒ ☐Urine Screening ☒ ☐Eye Exam ☒ ☐Foot Exam ☒ ☐

Self-Management Goal ☐ ☒ • NCQA PCMH 4, Element A.4 (Must Pass Element and Critical Factor): develop and document self-management plans and goals in collaboration with at least 50% of all (not just diabetes) patients/families.

Tobacco Query ☒ ☒ • Meaningful Use Core Measure #9: Must record smoking status as structured data for more than 50% of patients ages 13 and older (tobacco query).

• Meaningful Use Clinical Quality Measure Core Set: Must report both the percentage of patients age 18 and older who have been asked about their tobacco use in the past 24 months and the percentage of patients age 18 and older who use tobacco who have been provided a tobacco cessation intervention.

• NCQA PCMH 2, Element B.8: use an electronic system to record as structured (searchable) data the status of tobacco use for patients 13 years and older for more than 50% of patients.

Practice Needs for PCMH Survey1. Computer system and staff skill with:

• Email• Internet access• Microsoft Word• Microsoft Excel• Adobe Acrobat Reader (free online!)• Document scanning and screen shots

2. Access to the electronic systems used by the practice, including billing system, registry, practice management system, electronic prescription system, EHR, Web portal, etc.

NCQA Recognition Process1. Obtain standards and guidelines2. Participate in trainings3. Create online account4. Purchase Survey Tool software license 5. Self-assess current performance on survey6. Implement new PCMH capabilities at least

three months prior to survey submission

Recognition Process (cont’d)

7. Complete online application information: electronic agreements, practice site & clinician details, and application for survey

8. Submit application9. Receive email confirmation that the practice can

submit survey tool and documentation10. Submit survey tool and application fee when

readyReceive decision in 30-60 days!

NCQA Educational Resources• Free online training

http://www.ncqa.org/tabid/109/Default.aspx

Patient-Centered Medical Home (PCMH)• Getting on Board with PCMH • PCMH 2011 Standards • The Online Application and How to Submit as a

Multi-Site Practice

Other Resources• PA SPREAD: http://www.paspread.com• Patient Centered Primary Care Collaborative

http://www.pcpcc.net/

Notes• Need a person to coordinate process!• Lots of policies and procedures, brochures/pt

welcome letters, required for submission—not hard, just tedious!

• Need to report on THREE CONDITIONS (i.e., DM, Hypertension, well woman, stroke, whatever makes sense for your practice) PLUS a high risk population (lab or other values not improving? Uninsured? MA Population? Migrant worker? ESL? No Shows? Noncompliant with care plan?). Pick one you can easily retrieve data on!

Notes (cont’d)

• Screen shots of various screens required• They are very willing to help and have lots of tools

on their website• Recommend spending the $80 for the survey tool so

you can see what you will be required to submit and also be able to gauge where you are!

• Current standards and tools good until at least 2014• Aligns with Meaningful Use criteria!