Welcome to Facilitating Patient-Centered Medical Home (PCMH) Recognition: Standard 2. All materials 2012, National Committee for Quality Assurance

Transcription

1 Welcome to Facilitating Patient-Centered Medical Home (PCMH) Recognition: Standard All materials 2012, National Committee for Quality Assurance

2 Learning Objective Identify the measurement and documentation criteria for PCMH Standard 2 2

3 Discuss and Analyze the PCMH Recognition Requirements August 14,

4 2011 PCMH Content and Scoring Standard 1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team Standard 2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management** Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Medication Management E. Use Electronic Prescribing Pts Pts Pts Standard 4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources Standard 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions Standard 6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology Pts Pts Pts **Must Pass Elements 4

5 PCMH 2: Identify and Manage Intent of Standard Electronic systems have searchable fields for demographic and clinical data Patients receive documented comprehensive health assessments Electronic systems used to identify patients who need services Populations Meaningful Use Alignment Practice has searchable electronic system: Race/ethnicity/preferre d language Clinical information Practice uses electronic system for patient reminders 5

6 Elements PCMH 2: Identify and Manage Populations PCMH 2A: Patient Information PCMH 2B: Clinical Data PCMH 2C: Comprehensive Health Assessment PCMH 2D: Use Data for Population Management MUST PASS 6

7 PCMH 2A: Patient Information Practice uses a searchable electronic system and records data more than 50% of the time for the following: 1. Date of birth* 2. Gender* 3. Race* 4. Ethnicity* 5. Preferred language* 6. Telephone numbers 7. address * Core MU 7 includes factors Dates of previous clinical visits 9. Legal guardian/health care proxy 10.Primary caregiver 11.Advance directives (NA pediatric only practices) 12.Health insurance 7

8 PCMH 2A: Scoring and Documentation 3 Points Scoring 9-12 factors = 100% 7-8 factors = 75% 5-6 factors = 50% 3-4 factors = 25% 0-2 factors = 0% Documentation F1-12: Report from electronic system showing the percentage of all patients for each populated data field. The report contains each required data item to determine how many factors are consistently entered (numerator and denominator showing > 50%)for a sample of patients. 12 mo. (or 3 mo. of data) 8

9 PCMH 2A(1-5)/Core MU 7 - Demographics This certified system produced very graphic Meaningful Use reports that the were used to show practice level (all providers) results for a 12 month reporting period Demographic percentage for 1 year duration-2/6/2011-2/6/2012. Report covers all site providers. 9

10 PCMH 2A (1-5) - For a Solo Provider Practice This certified system produced another graphic presentation for the solo practice provider for a 3 month reporting period Jeffrey Doe, MD, PC 10

11 PCMH 2A, Factors 1 8, 12 An acceptable summary report with at least 3 months of data with numerators and denominators producing results over 50% for factors shown, explanation should indicate source of data as in a searchable system 11

12 PCMH 2A: Factors1-12 Example PCMH 2A, Items % of patients with documented items recorded as searchable data within the practice's EMR (denominator shown in first column) Report covers 12 months of data May 4, May 4, 2012 General Internal Medicine Associates Total Patient Count DOB Gender Race Ethnicity Lang Phone # Dates of Previous Visits Legal Guardian Primary Caregiver Adv Dir Insur Info # of PTS NA NA NA 9541 % 100% 100% 95% 95% 100% 98% 35% 100% NA NA NA 96% Correct Factor Responses Yes Yes Yes Yes Yes Yes No Yes No No No Yes Shows 8 of 12 items at >50% NA is not an option for factor 9 or 10 (Guardian, Care Giver) Adult practices are not eligible for NA for factor 11 (Advanced Directives) Practice scored at 75% (2.25 points for Element 2A) 12

13 PCMH 2B: Clinical Data Practice uses a searchable electronic system to record the following data: 1. Up-to-date problem list of active diagnoses for >80% of patients (Core MU 3) 2. Allergies, including medications and reactions for >80% of patients (Core MU 6) 3. Blood pressure with the date of update for >50% of patients >2 (or 3) years (Core MU 8) 4. Height for >50% of patients >2 years (Core MU 8) 5. Weight for >50% of patients >2 years (Core MU 8) 6. System calculates/displays BMI (NA for pediatrics) (Core MU 8) 7. System plots/displays growth charts (length/height, weight, head circumference (less than 2 years); BMI percentile (2-20 years) (Core MU 8) 8. Tobacco use status for patients 13 and older for >50% of patients (Core MU 9) 9. List of prescription medications with date of update for >80% of patients (Core MU 5) 13

14 PCMH 2B: Scoring and Documentation 4 Points Scoring 9 factors = 100% 7-8 factors = 75% 5-6 factors = 50% 3-4 factors = 25% 0-2 factors = 0% Documentation F1-5,8,9: Report showing percentage of patients for each data field F6-7: Screen shots demonstrating BMI/BMI percentile capability of electronic system Factors 6, 7, and 8 may response NA with explanation of patient age range 14

15 PCMH 2 B/MU Core Measures For Solo Practice Provider Factor 1 Factor 9 Factor 8 15

16 PCMH 2B: Practice Data 2 Primary Care Physicians 1/1/2012-3/31/012 Core MU Requirements (CO) #1 PCP #2 PCP Total % CO3 (factor 1) N % D CO5 (factor 9) N % D CO6 (factor 2) N % D CO8 (factors 3-7) N % D CO9 (factor 8) N % D

17 PCMH 2B 1 Date range 1 year 1/6/2011-1/6/2012 for following documents Problem List 17

18 PCMH 2B (2-5) Date range 1 year 1/6/2011-1/6/2012 for following documents. Report covers all providers. Allergy Vital Signs-Blood pressure, weight, height, pulse recorded for each visit 18

19 PCMH 2B Patients With Recorded Vital Signs (Combined factors 3 5 in MU report) PCP #1 255 PCP #2 19

20 PCMH 2B(Factor 8) Date range 1 year 1/6/2011-1/6/2012 for following documents. Report covers all providers. Smoking status 20

21 PCMH 2B(9) Date range 1 year 1/6/2011-1/6/2012 for following documents. Report covers all providers. Medication maintenance 21

22 PCMH 2C: Comprehensive Health Assessment Practice conducts and documents a health assessment: 1. Age and gender appropriate immunizations/screenings 2. Family/social/cultural characteristics 3. Communication needs 4. Medical history of patient and family 5. Advance care planning (N/A for pediatric practices) 6. Behaviors affecting health 7. Patient and family mental health/substance abuse, including maternal depression 8. Developmental screening using standardized tool (N/A for adult only practices) 9. Depression screening for teens/adults using standardized tool 22

23 PCMH 2C: Scoring and Documentation 4 Points Scoring 8-9 factors = 100% 6-7 factors = 75% 4-5 factors = 50% 2-3 factors = 25% 0-1 factors = 0% Documentation F1-9: Process to show how information collected or completed patient assessment (de-identified) 23

24 PCMH 2C6: Example Screening and Intervention Preventive Care Tobacco use Advised to quit Immunizations Screenings Condition-specific August 14,

25 PCMH 2C Factors 4 and 7 Example Family Medical and Mental Health History 25

26 PCMH 2D: Use Data for Population Management Practice uses patient data and evidence-based guidelines to generate lists and remind patients about needed services: 1. At least three different preventive care services** 2. At least three different chronic care services** 3. Patients not recently seen by the practice 4. Specific medications 26

27 PCMH 2D: Scoring and Documentation MUST PASS 5 Points Scoring 4 factors = 100% 3 factors = 75% 2 factors = 50% 1 factors = 25% 0 factors = 0% Documentation F1-4: Lists or summary reports of patients who need services within past 12 mo. (Health plan data okay if 75% of patient population) Must include at least three different immunizations/ screenings and three different acute/chronic care services F1-4: Materials demonstrating patient notification (letter, phone call script, screen shot of e-notice) 27

28 PCMH 2D Factor 1- List for Preventive Service 28

29 Immunizations PCMH 2D Factor 1- Overdue Immunization Outreach Patient Contact Phone Call Script for 3/15/12 List: Hi Mrs. Williams, this is Meagan from ABCD Pediatrics. I am calling to tell you that recently, the company that manufactures the Prevnar vaccine that prevents blood infections like pneumonia and meningitis improved the vaccine to include more protection against these infections and the CDC is recommending children between 2 and 5 get this booster to get the additional protection. I noticed that Jane was due for her Prevnar Booster and that we didn t have an appointment scheduled. Would this be a good time to schedule her appointment? Post Cards: The front desk staff assigned to the Well Child Visit Scheduling Process also tracks those patients identified as needing Immunizations. Staff members address Is your child fully protected? postcards and send them out. 29

30 PCMH 2D Factor 2 Patients Needing Chronic Care Service Patients having abnormal BMI who need a follow-up plan. 30

31 PCMH 2D Factor 2 Outreach for Chronic Care Service 31

32 PCMH 2D Factor 4: Identify and Contact Patients on Specific Medication Report run for patients prescribed a medication that was recalled May Staff contacted them by phone about the recall. Parameters: Drugs: Lo/Ovral (28) mg-mcg Tabs Date Range: 05/07/ /07/2012 Patient Name Phone Number Patient # Issue Date Total Days Days Left Date of Call 210 5/08/12 3 5/09/12 0 5/09/ /09/ /09/ /09/12 1 5/09/12 4 5/09/12 32

33 PCMH 2D Factor 4: Example Identifying Patients on Specific Medication August 14,

34 PCMH 2D Factor 4: Specific Medication Outreach (Script) Hi Mrs. Williams, this is Meagan from ABCD General Internal Medicine Associates. I am calling to tell you that recently, the company that manufactures Lo/Ovral has announced a recall. Our system indicated that you have been prescribed this medication and we wanted to inform you of the recall. Our nurse is available to speak with you to answer questions and recommend other medication options. Is now a good time? 34

35 Questions? August 14,