pcmh: recognition to impact€¦ · pcmh: recognition to impact 3.1.16 prepared by: shannon...

PCMH: Recognition to Impact3.1.16

Prepared by: Shannon Nielson, MHA, PCMH‐CCEPrepared for: OACHC 2016 Annual Conference

Centerprise, Inc

www.centerpriseinc.com

Objectives

• Defining a Patient Centered Medical Home • Translating PCMH Concepts to a Population Health Strategy• Expected Outcomes from Recognition• Understanding the key changes from 2011 to 2014 NCQA Application


PCMH‐What is it?

• “A way of organizing primary care that emphasizes care coordination and communication to transform primary care into ‘what patients want it to be’.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care (NCQA)– Theoretical – Task Based Practice– Internal Practice Process

CTP Definition of a PCMH: “A series of processes and tasks that can result in an unspecified improvement in your patient’s health”


PCMH‐What it shouldmean to you• A way of organizing primary care that practices accessibility, coordination, effective processes that transform primary care into what the populationneeds. Medical homes will lead to higher quality and lower costs, and willimprove a population’s health and provider’s experience of care (as defined by Centerprise, Inc)– Practical– Longitudinal Efficiency– Population Focused

CTP: “Your PCMH recognition demonstrates you have the core capability to put into effect efficient and effective processes that will result in a specified impact on the health of a population when in practice and sustainable”.

Transformation of Capability to Sustainable Practice


Process

ITRoles Experience

Outcomes

Cost

Recognition to Purpose


PCMH Concept: Application to Meaning

1A3. Availability of Appointments• What appointment types do you have?• How long does a patient have to wait

for each appointment type?• Are you meeting internal standards?

Appropriate Availability of Appointments

• How do you know if you have the right appointment types for your population?

• Do you have the appropriate appointment types for your population?

• Do you have the appropriate appointment availability to meet the needs of your population?


PCMH Concept: Strategy

1A3: Availability of Appointments• 3NA Report• Schedule Template• Internal protocols determined by

historical data• Templated same day access

Appropriate Availability of Appointments

• Measure inappropriate utilization of appointment types

• Monitor appointment requests by population

• Understand provider specific patient population needs and demands


PCMH Concept: Process to Impact

1A3: Availability of Appointments1A3: Appropriate Availability of Appointments• Why is 3NA for ER/Hospital F/U > 7 days?

– Provider specific high utilization?– Disease specific high utilization?– Care Coordination activities?– Appropriate vs. inappropriate utilization

• What is the true demand for New Patients versus availability?

– Why did you define at 14 days?– What is the new patient demand?– What is the demand from managed care enrollment

lists?• Does access within 7 days show better

outcomes?– Decrease in hospital readmission/ED Utilization?– Care Coordination engagement


PCMH Concept: Application to Meaning4E: Support Self Care and Shared Decision Making

• Do you have at least 3 educational materials in your office?

• Do you have at least 3 self management tools in your office?

• Do you have at least 3 shared decision making aids in your office?

• Do you refer patients to peer support or health education?

4E: Support Self Care and Shared Decision Making to engage patients resulting in improved outcomes• Are the educational materials in my office

relevant to the needs of my population?• Are the self management tools in my office

relevant to the needs of my population?• Are the shared decision making aids relevant

to the needs of my population?• Do the tools mirror my organization’s evidence

based guidelines?• Do I refer my patients to effective peer support

or health education resources?• Do I provide tools that are easy to understand?• Do my patients utilize the tools that I give

them?


PCMH Concept: Strategy4E: Support Self‐Care and Shared Decision Making

• Tools• Educational Materials• Shared Decision Making• Effective Community Resource

referrals

4E: Support Self‐Care and Shared Decision Making to engage patients resulting in improved outcomes

• Care Team assessment of tools needed by relevant population

• Tracking of populations with tool implementation

• Re‐assessment of tools and population for relevance


PCMH Concept: Process to Impact 4E: Support Self‐Care and Shared Decision Making

4e: Support Self Care and Shared Decision Making to engage patients resulting to improved outcomes

New BMI Plan


PCMH Concept: Application to Meaning3D3: At least 3 different chronic or acute care services

• A list of patients in need of 3 different services

• An actual patient letter or script AND documentation of the call

• Explanation of service

3D3: At least 3 different chronic or acute care services to improve access to care for existing patients and assigned patients

• What services are relevant to my patient population?

• Are missed services leading to poor health outcomes?

• Do I have all the information I need to know if they have missed a service?

• What services are in demand for my assigned patient population?


PCMH Concept: Strategy3D3:At least 3 different chronic or acute care services

• Evidence Based Guidelines• EMR/PHM/Patient Portal• Automated outreach


• Population stratification• EMR documentation• Managed Care enrollment lists• Available access• Opportunity for education


PCMH Concept: Process to Impact3D3: At least 3 different chronic or acute care services

• Providing quality care through service reminders

• Improving access to care for patients• Intermittent


• Continuous access to services• Improved health outcomes for existing

patients• Improved access to primary care for

assigned population• Decreased cost, improved outcomes,

improved patient experience and improved provider experience


You know you have done PCMH right when…

• You are having to adjust schedules regularly to meet the change in demand

• Your patients contribute to the conversation• Provider orders (labs, imaging, referrals etc…) are effective• You understand and monitor the risk of your patients‐‐‐and can illustrate an impact

• Your patient knows who their “Care team” actually is • Your data tells a story‐‐‐ a good one


NCQA PCMH 2011 to 2014


Key Conceptual Changes

2011• Data• Inform the patient• Requirements• Clinical • Process

2014• Meaningful Data• Engage the patient• Practical• Clinical and utilization• Purpose


Conceptual Changes: Examples

2011• Access: Same Day; 3NA • Provide educational tools and self‐

management plan• Reason for referral and clinical

information in tracking log• Clinical and Patient Satisfaction data• NA

2014• Access: Same Day; 3NA aligned with

internal standards• Utilize shared decision making tools• Logs OR demonstrating electronic

capability and providing information to specialists

• Clinical, Patient Satisfaction and CC/Utilization data

• Data on specialists you refer to


Key Application Changes

• Alignment with Modified MU Stage 2 rule• Corporate elements • Care Management Audit• Team Based Care Standard• Population Health Management


Key Application Changes: Standard 1‐Access

• Availability of all appointment types in alignment with practice standards

• After hours and during hours call logs combined• Access data and improvement work• No show data; appointment statistics• Alternative types of clinical encounters


Key Application: Standard 2‐ Team Based Care

• Moved from 1G (2011) to Standard 2 (2014)• Orient new patients• Medical Home Responsibilities‐expanded• Operations Meetings• Involving patients in QI activities (Standard 6‐2011)• Care team structure


Key Application Changes: Standard 3‐PHM• Comprehensive Health Assessment‐documentation changes‐now part of the RRWB or Report

• Health literacy• Outreach services includes Immunizations‐separate from preventive• Evidence Based Decision Support

– Mental Health or Substance use disorder– Chronic Medical Condition– An Acute Condition– A Condition Related to Unhealthy Behaviors– Well Child or Acute Cae– Overuse/Appropriateness Issues


Key Application Changes: Standard 4‐Care Management and Support

• Patient populations for Care Management Registry– Behavioral Health Conditions– High Cost/High Utilization– Poorly Controlled or Complex Conditions– Social Determinants of Health– Referrals by Outside Organization

• Lifestyle Goals• Understanding of medications• Care Management factors are fewer but don’t forget about 3C!!!• Shared Decision Making aids• Usefulness of community resources


Key Application Changes: Standard 5‐Care Coordination and Care Transitions

• Documentation for all tracking: Logs or OTHER capability• Performance information on specialists• Agreements with providers• Consent for release of information


Key Application Changes: Standard 6‐Performance Measurement and Quality Improvement

• Immunization measures separate from preventive measures (2)

• Resource use and Care Coordination measures (2 each)• Improvement:

– 2 clinical– 1 utilization/care coordination– 1 pt. experience


How you should approach PCMH

2014

• Data• Inform the patient• Requirements• Clinical • Process

• Meaningful Data• Engage the patient• Practical• Clinical and utilization• Purpose

• Information• Integrate the patient• Efficient • Clinical, Utilization, Cost

• Process, Purpose and Impact


2011 Pop Health

Where to begin your PCMH to PHM journey: 2A2‐Monitoring the percentage of patient visits with selected clinician or team

NCQA PCMH 2014 Requirement• %age of visits with patient’s PCP

Relevance to remaining application requirements and successful PHM• What is your provider panel size?• What is the capacity of each provider

today?• What are your care teams?• How are you utilizing your providers to

optimize access?• Is over utilization leading to fewer

empaneled visits?• Consistent care leads to improved patient

satisfaction• How can we use our managed care lists?


Questions


pcmh: recognition to impact€¦ · pcmh: recognition to impact 3.1.16 prepared by: shannon...

Documents