ACHIEVING NCQA PCMH RECOGNITIONA TOOLKIT FOR PRACTICES SEEKING TO APPLY

CHIPRA QUALITY DEMONSTRATION GRANT

BACKGROUNDIn February 2010 as part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA), the Centers for Medicare and Medicaid Services (CMS) awarded 10 quality demonstration grants, funding 18 states, to improve health care quality and delivery systems for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). Under this grant opportunity, Florida and Illinois have worked collaboratively on developing and implementing a variety of initiatives related to medical home practice transformation for child-serving practices. Ongoing medical home projects in both states demonstrated the value of and practice desire to achieve the National Committee on Quality Assurance’s (NCQA’s) Patient-Centered Medical Home (PCMH) recognition, and also exposed the difficulty in achieving this goal without additional assistance. This experience led Florida and Illinois to collaborate on an additional medical home venture – to provide direct technical assistance to child-serving practices working to achieve NCQA PCMH recognition, and to use this experience to develop an understanding of practice needs for transformation to the PCMH model of care, including understanding the resources and effort necessary for practices to achieve PCMH recognition and identifying transformation areas and processes that are the most challenging for individual practices. Through this project, this toolkit of key resources was developed. The intention of this toolkit is to share more broadly with practices considering applying for recognition the tools created through this work that the involved practices found most useful, and to inform the medical community and federal and state policy makers of needed resources and the lessons learned from this work. This toolkit is not intended to be a comprehensive guide to achieving recognition. Rather, it is a compilation of the tools that the practices involved in this project found useful and most helpful. There are many other resources available – many of which, including trainings and other resources – are developed by NCQA directly. This toolkit is a supplement to other available resources – filling in gaps that typically impede practices in their pursuit of recognition.

TOOLKIT CONTENTS

Considering Recognition

Determine need for TA

Build PCMH team

Assessing Status

Assessment tool

Preparing for

Application

Strategic Plan template

Timeline template

Tracking Tool

Completing Application

Factor overlap crosswalk

Documentation library

Document preparation tip

sheet

Internal documentation

checklists

CONSIDERING RECOGNITIONNCQA PCMH Certified Content Experts Becoming NCQA PCMH recognized is a complex, daunting process, for multi-site hospital-based practices and solo provider practices alike. The process of transformation to the medical home, and the ability to document and display that to NCQA, requires thoughtful and carefully planned action. Recognizing this, NCQA created a certification for PCMH “experts” – called NCQA PCMH Certified Content Experts (CCEs) – a credential highlighting an individual’s knowledge of the NCQA PCMH recognition program, including the requirements, application process, and documentation. CCEs are available to provide technical assistance to practices to aide in the recognition application process. Our project employed teams of two to three CCEs that provided direct technical assistance to the involved practices and developed this toolkit and the resources it contains. NCQA’s list of CCEs can be accessed at http://cce.ncqa.org/pcmh/.

The Need for Technical Assistance The intention of this toolkit is to provide resources for practices considering recognition; we strongly recommend practices consider seeking technical assistance directly from an outside source. It is possible to achieve recognition on your own; however, this project has shown the value in receiving technical assistance from knowledgeable certified experts. We discovered that practices of varying sizes and structures all benefited from the level of expertise that an expert can provide. There are many levels of consultation that can be useful to practices. Practices should assess their resources and need for a consultant. Some practices engage consultants to be on-site and involved in every step of the transformation/recognition process. Other practices consult with an expert on an “as needed” basis (by e-mail or phone) to obtain clarification on standards/elements/factors or only for documentation review prior to submission. Technical assistance can be structured to meet the needs of the practice and its resources. Practices with limited resources are encouraged to locate online resources and/or engage another practice that has achieved recognition. Most recognized practices are willing to share tips and documentation examples. A complete listing of recognized practices can be found on NCQA’s website, at www.recognition.ncqa.org. Free consultation may be available from provider organizations or insurers/health plans with whom practices contract.

Building a PCMH TeamCreating a solid group of individuals to navigate collaboratively through the transformation and recognition process is vital. The process is long, complicated and time-consuming – and if possible, should not be attempted by one person. Four key roles need to be filled, which we refer to here as the PCMH Champion, Communicator-in-Chief, Lead Administrator, and Report Master. Though it is possible for one person to wear multiple hats, and/or one role to be

shared among multiple team members, establishing who is responsible for each task at the outset it critical to ensure accountability. First, you must identify your “PCMH Champion”; who will help guide the practice through the quality transformation processes. A “Communicator-in-Chief” will serve as the point person for all communication and interactions with staff and other support individuals, as well as community and other organizations. The “Lead Administrator” is in charge of tracking the transformation process, organizing the documents, and ultimately completes and submits the application. It is highly encouraged the individual(s) have strong computer skills. Finally, a “Report Master” is needed, who is an individual with a strong understanding of the EHR and the ability to pull various reports and billing information.Once you have formed your team, key discussions must be made by the team to set realistic expectations and ensure buy-in. Things to consider in these discussions include: Where will the manpower come from? A reduction in patient load? Extended work hours? Working on weekends? Will this require a shift in duties and/or responsibilities? Where, when, and how will the team meet? Other issues may arise and discussing them as early as possible is beneficial. Medical home transformation is valuable to your patients and practice, but it is not a quick process. Creating a unified team is a major asset.

Additional Resources/ToolkitsThere are many facets of PCMH to consider, and a variety of toolkits and resources are available. While this toolkit contains a compilation of the tools that the practices involved in this project found useful and most helpful in order to fill in gaps that typically impede practices in their pursuit of recognition, additional resources should also be considered and explored. Here are some additional resources you may find helpful.PCMH Toolkit - Resources for Connecticut FQHCs: This resource was developed for Connecticut FQHCs and contains a variety of tools that address the core components of a PCMH approach to primary care.

AHRQ Patient Centered Medical Home Resource Center: The Agency for Healthcare Research and Quality's (AHRQ) Patient Centered Medical Home Resource Center includes tools and resources for practices, practice facilitators, researchers and policymakers.

Patient-Centered Primary Care Collaborative: PCPCC advances primary care and the patient-centered medical home among policymakers, health care professionals, employers, researchers, and consumers through a variety of initiatives and special projects.

NCQA PCMH 2014 Recognition Levels

ASSESSING STATUSAssessing Current StatusTo put into context where a practice needs to be in order to achieve recognition, it is helpful to first understand where the practice currently stands. To begin, we recommend assessing the current level of medical homeness according to NCQA’s standards. This will help frame how near or far the practice is to recognition, and will highlight the areas that need additional work. Practices should begin the recognition process by completing a baseline assessment to determine its current status.

The Scoring ProcessNCQA PCMH 2014 recognition is awarded based on whether a practice achieves a certain amount of points toward recognition, and is divided into three levels. This leveling system allows practices with varying degrees of medical homeness to achieve recognition, while also recognizing practices with greater medical home capabilities with a higher recognition level. Six standards make up NCQA’s PCMH program, and each standard contains several elements, each of which is made up of multiple factors. For each present factor within a practice, a point is awarded. Some factors are considered critical – all critical factors must be achieved in order to reach any level of recognition. Some elements are “Must Pass” – scores of 50 percent or higher must be achieved on all of these elements to reach any level of recognition. The percentage scored on a given element are based on NCQA’s scoring mechanism, which differs for each element.1 Determining a practice’s score can be a daunting process – and one easily prone to error if done by hand. NCQA’s scoring page can be accessed here. 1 When trying to determine the score of an element, note the scoring section in the Standards and Guidelines for each element. Every element has different requirements to achieve 100% of the points. Some elements do not require completion of all factors to earn 100%. All “Must Pass” elements must achieve at least 50% in scoring and all “Critical Factors” must be met to receive recognition.

The NCQA 2014 Medical Home Assessment Tool The NCQA 2014 Medical Home Assessment Tool provides an efficient means of assessing baseline status. Practices can follow through each tab (representing each standard) on this excel workbook, created by the Primary Care Development Corporation, marking which factors are currently met by the practice. The workbook will automatically calculate the score, based on the results entered. It also provides aggregate statistics, including status on achieving the critical factors and “Must Pass” elements. Practices completing this tool will have a solid understanding of where they stand in terms

of currently meeting NCQA’s PCMH recognition standards. The NCQA 2014 Medical Home Assessment Tool can be accessed here. A sample from the NCQA 2014 Medical Home Assessment Tool workbook showing PCMH Standard 1, Element A.

PCMH 1: PATIENT CENTERED ACCESS

Factor Factor Present?(Yes = 1, No=0)

Documentation Required

ELEMENT A: PATIENT CENTERED APPOINTMENT ACCESS (MUST PASS)

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) P/R

2. Providing routine and urgent-care appointments outside regular business hours. P/R

3. Providing alternative types of clinical encounters. P/R

4. Availability of appointments. P/R

5. Monitoring no-show rates. P/R

6. Acting on identified opportunities to improve access. P/R

Total Possible Points for PCMH 1A: 4.5 Additional Notes for 1A:

Total # of Factors with "Yes" for PCMH 1A: 0

% Points Received for PCMH 1A: 0%

Total # of Points Received for PCMH 1A: 0.00

MUST PASS Element - Passed at 50% Level? NO

PREPARING FOR APPLICATIONStrategic Plan TemplateWhile completion of the assessment tool will inform a practice of how close or far they are to achieving the needed points for NCQA PCMH 2014 recognition, it will not inform them where to go next. It’s easy for practices to get mired in the pursuit of achieving individual factors, and “missing the forest through the trees” – the end goal is recognition after all, and every factor does not need to be met to achieve this. We recommend practices create a strategic plan to determine how best to proceed with

recognition. Essential elements to include in the strategic plan are: Current scores in comparison to recognition levels Assessment of needs related to Critical Factors and “Must Pass” elements, including how many are still needed,

and how much is missing (e.g., are processes lacking, or just the documentation?) Current scores in comparison to what the current score would be if all Critical Factors and “Must Pass” elements

are achieved (i.e., if these factors and elements are achieved, is it enough to achieve a level of recognition? Or is more work needed?)

Of the needed elements/factors to achieve a level of recognition, what is the practice capable of doing on their own? Where is outside technical assistance needed?

What is the feasibility of achieving a higher level of recognition (Level 2 or 3)? How many of the additional points would come from areas that would be relatively simple for the practice to achieve, vs. those that are a “heavier lift”? What would be the timetable to achieve the needed points for a higher level, and is this feasible?

What is the practice’s timeline for achieving recognition? Given this timeline, how can resources be best allocated – achieving a lower level of recognition? Receiving technical assistance?

We created a Strategic Plan template to assist practices in organizing these analyses. The template can be accessed here.

Timeline TemplateDetermining the timeline for recognition application is a critical step. A number of issues must be considered in determining an appropriate and realistic timeline. While some issues relate to the recognition requirements, specific characteristics of the practice must also be considered. We recommend that the practice works to establish a reasonable timeline, given both types of issues. We

do not recommend that a practice begins with PCMH Standard 1, and try to work through the process in a sequential order. A timeline should be established that considers issues inherent to the recognition process, such as:

Some standards take longer to complete. Certain factors must be in place for specific time period before a practice can apply for recognition. These need

to implemented accordingly. Certain factors need to be achieved before another factor can be worked on. These need to begin early. Some factors align with other factors. These should be worked on concurrently.

We have designed a generic timeline template that accounts for these issues, based on a 12-month timeline. This timeline is a good starting point for practices, but practices must also consider and include practice-level characteristics and issues in finalizing their own timeline. These include:

Is the practice applying for single or multi-site recognition? How many factors are needed, and what is needed to achieve them (documentation, or processes?) How many team members, consultants, etc. are available, and what is their availability to devote time to this

project?The timeline can be adjusted based on the practices’ own time requirements. The timeline template can be accessed here.

Tracking ToolAccurate tracking of the application process is needed to ensure ownership, accountability, and that the process progresses according to the timeline. Important elements to include in a tracking document include the owner, due date, status, and whether the documentation has been uploaded to

NCQA. In designing a tracking tool for the practices, we determined it would have greater utility if it were embedded in their assessment tool. This would limit the need to go back and forth between multiple documents, which could potentially create a version control issue. We also flagged the Critical Factors and “Must Pass” elements. This tracking tool, which is built on PCDC’s Medical Home Assessment Tool but includes the tracking fields that the Florida-Illinois CHIPRA team has added, can be accessed here as an example. However, we recommend that these tracking fields are imported into the Medical Home Assessment tool (described above) that the practice has already completed (if it has done so already) to ensure version control. A sample of the tracking tool (embedded in the NCQA 2014 Medical Home Assessment Tool workbook).

PCMH 1: PATIENT CENTERED ACCESS TRACKING

FactorFactor

Present?(Yes = 1, No=0)

Doc Required Owner Due

Date StatusDocument Uploaded

(Y/N)

ELEMENT A: PATIENT CENTERED APPOINTMENT ACCESS (MUST PASS)

The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on: *MUST PASS*

1. Providing same-day appointments for routine and urgent care. (CRITICAL FACTOR) P/R

2. Providing routine and urgent-care appointments outside regular business hours. P/R

3. Providing alternative types of clinical encounters. P/R

4. Availability of appointments. P/R

5. Monitoring no-show rates. P/R

6. Acting on identified opportunities to improve access. P/R

Pricing and ApplicationThe cost of applying for NCQA PCMH Recognition varies depending on practice characteristics, and pricing is provided here. To initiate the application process, you must first purchase an ISS Survey Tool, which includes all information needed to prepare and submit materials for an NCQA survey. The Survey Tool must be completed and submitted to NCQA. The survey tool allows for you to document your practice’s medical home features. The Survey Tool also contains the Record Review Workbook and Quality Improvement Worksheet.Before submitting your recognition application, you must pay your application fee based on the pricing found in the link above. Practices must submit payment via the Recognition Program Payment Portal. The portal will generate a payment application for the practice to submit payment via credit card or e-check prior to submitting their application. It also includes instructions for mailing in a paper check.NCQA reviews your application and notifies you in 1-5 business days that your application is linked to your Survey Tool.

COMPLETING APPLICATIONFactor Overlap Crosswalk As we’ve noted, many factors and elements closely align with, or must be completed in conjunction with or subsequent to another factor/element. As such, we do not recommend a practice attempts to achieve each standard, element and factor in a sequential order. We created a crosswalk to show where factors and elements overlap. This crosswalk is meant to assist practices in developing their timeline, and also in determining their strategic plan for completion – aligned factors/elements should

be worked on by the same owner, or owners that consult with each other in order to prevent duplication of efforts or working at cross purposes. The Factor Overlap Crosswalk can be accessed here.

Documentation LibraryThe Documentation Library contains examples of documentation that meets NCQA requirements for each element/factor. The examples provided should not be considered the “final word”, as other types of documentation may be acceptable. The examples were gathered from NCQA training materials and practices that received recognition. The documentation library can be accessed here.

Document Preparation ResourcesWe learned through our work with practices that document preparation is extremely important. We regularly encouraged practices to refer to NCQA’s resources on documentation preparation. The most important point to keep in mind about documentation is that NCQA reviewers are not familiar with your practice, its electronic health record or terminology/acronyms, nor are they clinicians so may not be able to interpret the documentation you have provided. Clearly label everything to “tell the story” of what you are providing. NCQA’s document preparation tips can be accessed here.

Internal Documentation ChecklistsWhether utilizing the technical assistance of a certified consultant or not, it is helpful to have another team member review a documentation example before it is submitted. This task serves two purposes: 1) it promotes accountability and accuracy since more than one team member is aware of and understands what has been submitted; and 2) it saves technical assistance resources, which can be costly, for tasks that are harder for the PCMH team to complete on their own. By reviewing the documentation prepared by another PCMH team member, the reviewer often develops a greater

understanding of NCQA requirements and is better able to prepare their own documentation that meets standards. Additionally, it ensures that documents developed by one team member are not contradictory or redundant with documents developed by another team member. For this reason, we recommend that at least two team members are responsible for the development and submission of documentation, and that they each review each other’s documentation examples. We created checklists for each factor to assist in this review and provide a standardized process. These checklists can also be used during the creation of documentation. The internal documentation checklists can be accessed here.