Applying NCQA PPC-PCMH Standards to Primary Care and Behavioral Health

Applying NCQA PPC-PCMH Standards to Primary Care and Behavioral Health

Maria Ludwick, MPHHarold Pincus, MD

Agenda PCASG Quality Improvement Program

NCQA Patient Centered Medical Home Basics

Adaptation to PC - BH

Gaps in Implementation

Strategies to Fill the Gap

Note: This is a participatory session

Goals for the Primary Care Access and Stabilization Grant

o Increase access to care on a population basis

o Develop sustainable business entities

o Provide evidenced based, quality health care

o Develop an organized system of care

PCASG Quality Improvement Program

Interprets NoA requirement for a quality improvement program at the grantee level

Approved by CMS in June 2008

Outlines a uniform set of quality standards Minimum quality requirements Optional incentive payment program

Encourages maximum participation

Based on National Committee for Quality Assurance (NCQA) Physician Practice Connections – Patient Centered Medical Home

Why NCQA PPC-PCMH? Widely recognized for health care quality standards Received input from a variety of stakeholders e.g. professional

organizations, insurers, and patient advocacy groups

Standards emphasize use of systematic, patient-centered, coordinated care management processes

Reinforces partnerships between individual patients, and their personal physicians, and when appropriate, the family

Uses of registries, care coordination, information technology, and other means to assure patients have the right care when they need it

Standardized survey tool & methodology enables equitable distribution of PCASG funds

Encourages grantees to seek NCQA recognition

5% of PCASG grant funds available for QIP ($3.85M) 3 opportunities (March, June and Dec 09) ~$1.283M each payment Round One Awards Ranged from $67k-$135k

Three Payment Tiers Based on NCQA levels but less stringent Graduated tiers/Graduated payments

Half of an organization’s eligible service delivery sites must pass to obtain a specific tier

Optional Quality Incentive Payment (QIP)

NCQA Scoring PCASG Scoring Qualifying

Level Points Must Pass

(50%)

Qualifying Tier Points

Must Pass

(50%)

Payment Factor

Level 3 75 10 of 10 Tier 3 50 8 of 10 6x Level 2 50 10 of 10 Tier 2 25 5 of 10 3x Level 1 25 5 of 10 Tier 1 20 4 of 10 1x

PPC-Patient Centered Medical Home Basics Measures evaluate:

Use of systems Effectiveness in prevention Management of chronic illness and patient safety

Measures are “actionable” at practice level Measures are validated by relating them to

performance

Score is based on: Responses in Web-based Survey Tool Supporting documentation attached to Survey Tool Each element specifies type of documentation: Reports;

Documented processes; Records or files

Data Sources & Guidance Data sources and documentation are required

Each element indicate type of HIT required to perform functions

Basic – (HIT) Basic Paper-based or administrative electronic system

Intermediate – (HIT) Intermediate Electronic system for clinical functions

Advanced – (HIT) Advanced Electronic system for connectivity or interoperability

Practices can achieve a passing score on All Must Pass Elements with Basic Health Information Technology

9Physician Practice Connections and Patient-Centered Medical Home

PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and

patient communication**B. Uses data to show it meets its standards for

patient access and communication**

Pts

459

Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information

(mostly non-clinical data) B. Has clinical data system with clinical data in

searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting

tools to organize clinical information**E. Uses data to identify important diagnoses

and conditions in practice**F. Generates lists of patients and reminds patients

and clinicians of services needed (population management)

Pts

23364

321

Standard 3: Care ManagementA. Adopts and implements evidence-based

guidelines for three conditions **B. Generates reminders about preventive services for

clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,

assessing progress, addressing barriers E. Coordinates care//follow-up for patients who

receive care in inpatient and outpatient facilities

Pts

3

435520

Standard 4: Patient Self-Management Support A. Assesses language preference and other

communication barriersB. Actively supports patient self-management**

Pts

246

Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety

checksC. Has electronic prescription writer with cost

checks

Pts3328

Standard 6: Test Tracking A. Tracks tests and identifies abnormal

results systematically** B. Uses electronic systems to order and retrieve

tests and flag duplicate tests

Pts7

613

Standard 7: Referral Tracking A. Tracks referrals using paper-based or

electronic system**

PT44

Standard 8: Performance Reporting and Improvement

A. Measures clinical and/or service performance by physician or across the practice**

B. Survey of patients’ care experience C. Reports performance across the practice

or by physician **D. Sets goals and takes action to improve

performance E. Produces reports using standardized

measures F. Transmits reports with standardized measures

electronically to external entities

Pts3

33

32115

Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support

Pts1214

**Must Pass Elements

NCQA PPC – PCMH Requirements: Must pass criteria 1A – Written standards for patient access 1B – Data to show it meets access standards 2D – Use charting tools to organize clinical info 2E – Data to identify 3 important conditions 3A – EBG for 3 conditions – 2 to pass 4B – Supports patient self management 6A – Test tracking 7A – Referral tracking 8A – Measure performance 8C – Report performance

Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective

Prepared, ProactivePractice Team

Informed, Empowered Patient and Family

Productive InteractionsPatient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Improved Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity Health Care OrganizationResources and Policies

Chronic Disease Clinical Models

Hypertension Congestive heart failure (CHF)/Coronary

artery disease (CAD) Stroke COPD (Chronic Obstructive Pulmonary

Disease) DM (Disease Management) Asthma Multiple comorbidities Transitional care management

Depression Clinical Models

• Chronic (planned) care model – Wagner• Collaborative care – Katon• Partners in Care (AHRQ) – Wells• PROSPECT – Alexopoulous, Katz, Reynolds• Telephone care management – Simon, Hunkeler• IMPACT (Hartford) – Unutzer• RESPECT (MacArthur) – Dietrich• Quality Improvement for Depression (NIMH) – Rost,

Ford, Rubenstein• Child models – Campo, Asarnow, GLAD-PC• Other models for anxiety/PTSD

Clinical Model: Major ComponentsLeadership Accountability

Vision Resources

Practice design Patient registryProtocolsCare manager

Clinical information systems

Red flagsFeedback to provider on clinical progressSupport care manager

Decision support GuidelinesProvider trainingExpert/specialist consultationReferral pathways

Self management support

Patient preferences, cultural competencyInformation on depression, medications, skills

Community resources

Information on and for consumer groups and other servicesAccess to non-provider sources of care

Leadership

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

Component Key Principles Description

Leadership There must be a leadership team composed of organizational partners with overall program accountability for implementation across partnering organizations

A team of primary care, mental health, and senior administrative personnel that:

• Garners resources (personnel, space, financial)

• Incorporates and coordinates stakeholder interests

• Promotes adherence to treatment guidelines and protocols

• Sets target goals for key process measures and outcomes

• Encourages efforts at continuous quality improvement

Delivery System Design



Delivery System Design

The delivery system is available to implement all aspects of decision support. It consists of:•Access to guidelines and protocols•A depression patient registry•A care manager responsible for implementing coordinated care in conjunction with primary care providers and, when necessary, mental health specialists•A systematized approach to obtaining access to mental health specialists for referral, consultation, and feedback

1) Care manager, either on or off site, implements protocols for:

• Systematically identification of patients at elevated risk for depression

• Screening of patients at elevated risk for major depression using a structured assessment tool

• Stratification of treatment intensity by episode severity and patient preference

• Monitoring and promotion of adherence to guideline-based treatment(s) for depression

• Routing follow-up at intervals specific to a patient’s phase of depression treatment (acute, continuation, or maintenance)

2) Structure is in place to ensure facilitated access to mental health specialists

Clinical Information System



Clinical Information System

The clinical information system consists of tools to facilitate the roles of the primary care providers and care managers

Note: The clinical information system does not necessarily need to be interactive with other computer systems

• Enables the primary care physician and care manager to establish a registry to identify, manage, and track depressed patients

• Tracks key process and program measures (e.g. percent of patients who received a structured assessment for depression, percent of patients continuing pharmacotherapy after 3 months, percent of patients who achieved a 50% decrease in depression scores)

Decision Support



Decision Support Evidence-based depression treatment guidelines and care protocols are available to improve recognition and treatment of depression

1) There are evidence-based treatment guidelines and care protocols for:

• Systematically identifying patients at elevated risk for depression

• Case identification using a structured assessment tool

• Stratification of treatment intensity by severity

• Treatment by provider and care manager• Mental health specialist referral2) Staff are trained in using decision

support tools3) Materials receive periodic review and

updating4) Mental health specialists are readily

available for decision support and patient referral

Self-Management Support



Self-Management Support

Materials, tools, and processes are available to promote patient activation and self-care for depression

Self-management support consists of:•Shared decision making between patient and provider(s), taking into account patient preferences for treatment and family involvement•Culturally appropriate patient information available in a variety of formats (e.g. print, audio, and videotape)•Self-study materials including such self-care techniques as goal setting and problem solving, as well as promotion of adherence to pharmacotherapy•CM follow-up on a patient’s progress with advice and acquisition of skills described in self-study materials

Community ResourcesComponent Key Principles Description

Community Resources

Patient information and education about depression are available from organizations that are independent of providers and health plan

Patients and families are informed of nonprogram information and other resources designed to assist in their understanding of depression and the various treatments available from such entities as:•Local/national organizations•Clergy, employee assistance programs, and support groups

Functions of Care ManagersPatient-Focused Support •Develop and maintain rapport

•Help access psychosocial treatment (e.g. interpersonal therapy or problem-solving therapy)

Education/Self Management •Educate about illness, treatments, side effects•Communicate, customize, and maintain self-action plan for patient


Functions of Care ManagersFollow-up •Encourage adherence to medications and

education on their side effects •Facilitate and remind patient about telephone or personal visits•Facilitate communication and linkages with mental health specialist and primary care provider•Intervene in crisis

Clinical •Systematically monitor depressive symptoms, comorbidities, adherence •May provide psychosocial therapy or counseling (e.g. interpersonal therapy or problem-solving therapy)


Phases of Depression Treatment

Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.

Treatment Phases

RelapseRecurrence

Recovery

Acute Continuation Maintenance

Syndrome

Symptoms

Remission

Response

No Depression

Top Ten IssuesGeneral Health/Mental Health Relationships

1. Partnerships2. Formalize3. Accountability4. Referral5. Consultation/Evaluation6. Information Flow7. Money8. Quid Pro Quo9. Maintenance10. Generalize

Gaps (1) Participant comments

NCQA Reports

RESULTS FROM Round One NCQA Surveyed Sites

36 Sites Total 34 Primary Care 2 Behavioral Health

Where QIP Participants Did Well PPC1A: Access & Communication Processes e.g. Written Standards*

MUST PASS 4 POINTS

PPC2A: Patient Data e.g. Practice Management System or Registry*

Not MUST PASS

2 POINTS

PPC2E: Identify Important Conditions* MUST PASS 4 POINTS

PPC3A: Implement EBG* MUST PASS 3 POINTS

PPC3B: Guideline-based Reminders When Seeing Patient

Not MUST PASS

4 POINTS

PPC8A: Measures clinical and service performance*

MUST PASS 3 POINTS

TOTAL 20 POINTS

* PCASG Quality Minimum Requirement

Where QIP Participants Didn’t Do WellPPC2F: System for Population Management

Generates lists of patients needing appts or follow-up, reminders for follow, on particular meds, chronic condition

Not MUST PASS

3 POINTS

PPC3E: Continuity of Care Identifies patients receiving care in facilities; routinely sends

info to facilities; contacts patients after discharge

Not MUST PASS

5 POINTS

PPC4B: Actively Supports Self-Management: Readiness for change, language appropriate educational resources,

self-monitoring tools, support programs, written care plan

MUST PASS 4 POINTS

Where They Didn’t Do Well (cont)PPC6A: Test Tracking and Follow-up: Track lab and imaging tests until results return; flags overdue and

abnormal results; notify patients of abnormal results; paper based or electronic

MUST PASS 7 POINTS

PPC7A: Referral Tracking and Follow-upFor referral to specialist or consultant: origination: referring

clinician; reason for referral; status; insurance/preapproval

MUST PASS 4 POINTS

Where Results Were VariablePPC1B: Report on Access & Communication Visits with assigned physician; Response times; Same day

appointment access; Language services available

MUST PASS

5 POINTS

PPC2B & C: Has and Uses Clinical Data System (SEARCHABLE)

Age appropriate preventive services (immunizations, screening, counseling); Allergies; Vitals (BP, weight, BMI); Labs, imaging and path results

Not MUST PASS

3 POINTSeach

PPC2D: Charting Tools Problem lists, medications, structured templates

MUST PASS

6 POINTS

PPC3C: Care TeamNon-clinician provides reminders, standing orders, education, coordination

Not MUST PASS

3 POINTS

PPC3D: Care Management Care plans, treatment goals, assess progress

Not MUST PASS

5 POINTS

Behavioral Health Organizations Challenges & Successes

Successes Reporting on

Access & Communication

Charting Tools Care

Management

Challenges Clinical Data System for Population Management Self Management Support Test Tracking

Primary Care Organizations Challenges & Successes

Successes Processes for Access &

Communications Charting Tools

Challenges Reporting on Access & Communication Clinical Data Systems System for Population Management Care Management Continuity of Care Self Management Support Test Tracking

Gaps (2) Organizing care management

Tasks/Roles/People Incorporating self management Disease registries Referral tracking Communication/HIPAA Test tracking Guideline-based reminders Using data for QI Continuity of care Anticipation of needs

Care Management Functions Patient engagement/rapport Screening/Assessment Education/Planning Self management support Clinical monitoring/Tracking Reminders (patient/provider) Accessing resources/referrals Coordination/Continuity Problem solving/counseling/therapy

Top Ten IssuesGeneral Health/Mental Health Relationships

1. Partnerships2. Formalize3. Accountability4. Referral5. Consultation/Evaluation6. Information Flow7. Money8. Quid Pro Quo9. Maintenance10. Generalize

Documents

Applying NCQA PPC-PCMH Standards to Primary Care and Behavioral Health