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NCQA’s Patient Centered Medical Home (PCMH)
Program
Mina Harkins, MBA, MT(ASCP)Assistant Vice President, Recognition Programs
February 5, 2011
2Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
A Strategy for Quality Improvement
Address these challenges
1. Eliminating harm
2. Eradicating disparities
3. Reducing disease burden
4. Removing waste
…by acting on these priorities.1. Engage patients and families in
managing health, making decisions
2. Improve the health of the population
3. Improve safety, reliability4. Ensure patients receive
coordinated care within and across organizations, settings and levels of care
5. Guarantee appropriate, compassionate care for patients with life-limiting illnesses
6. Eliminate overuse while ensuring the delivery of appropriate careSource: National Priorities and Goals:
Aligning Our Efforts to Transform America’s Healthcare, 2008
3Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PPC-PCMH Recognition• NCQA has the most widely-adopted evaluation model• States/practices can get on board with a system that
has a strong track record, Federal initiatives are expanding to military and FQHCs
• 1500 sites recognized, over 8,000 clinicians• NCQA provides goals and guidelines for practice
transformation based on evidence – Practices decide how best to reach goals based on
their size, location, area conditions• Gives physicians a roadmap to improve quality with
systematic approach to preventive and chronic care delivery
• Focuses on evidence-based requirements to improve quality and reduced costs
4Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
NUMBER OF PPC-PCMH SITES BY STATE
ME
VT
RI
NJ
MD
MA
DE
NY
WA
OR
AZ
NV
WI
NM
NE
MN
KS
FL
CO
IA
NC
MI
PAOH
VAMO
HI
OK
GA
SC
TN
MT
KY
WV
AR
LA
AL
INIL
SD
ND
TX
ID
WY
UT
AK
CA
CT
NH
61-200 Sites
As of 12/31/10
MS
21-60 Sites
0 Sites
1-20 Sites
201+ Sites1498 PPC-PCMH SITES
5Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
0102030405060708090100110120130140150160170180190200210220230240250260270280290300310320330340350360370380390400410420
AK AL AR AZ CA CO CT DC FL GA HI IA ID IL IN KY LAMAMDMEMIMNMOMS NC NE NH NJ NMNV NYOHOKOR PA RI SC TN TX VA VTWAWIWV
Nu
mb
er o
f Pra
ctic
es
State
PPC-PCMH RECOGNIZED PRACTICES BY STATE(As of 12/31/10)
PPC-PCMH Level 3 PPC-PCMH Level 2 PPC-PCMH Level 1
6Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PPC-PCMH Practices*
* As of 12/31/10
1-2 3-7 8-9 10-19
20-50
50+ Total
Level 1
260 217 26 41 9 0 553
Level 2
21 30 4 2 0 0 57
Level 3
295 388 81 89 34 1 888
Total 576 635 111 132 43 1 1498
NUMBER OF PHYSICIANS IN RECOGNIZED PRACTICES
7Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Evaluation of PPC-PCMH Demonstrations: Driving
Quality and Cost Savings• Outcomes for seven medical home
demonstrations – Reduce hospitalization rates (6-19%)– Reduce ER visits (0-29%)– Increase savings per patient ($71-$640)
• Four common features in demonstrations– Dedicated care managers – Expanded access to clinicians– Data-driven analytic tools– Use of incentives
Elements or uses of NCQA’s
PCMH evaluation
Source: Fields, et al. 2010
8Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 2011: Evolution• Raise expectations through scoring
and new requirements; maintain a pathway for those just beginning to transform
• Streamline requirements/documentation with greater focus on areas with strongest link to desired outcomes
• Move toward performance reporting/benchmarking for clinical and patient experience measures
• Embed and report HIT Meaningful Use
9Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
What is different about the PCMH 2011 standards?
• Enhances patient-centeredness• Emphasizes language, culturally sensitive
aspects• Integrates behaviors affecting health,
substance abuse, mental health and risk factor assessment and management
• Enhances applicability to pediatric practices• Aligns with CMS Meaningful Use requirements• Emphasizes relationship with/expectations of
subspecialists• Enhances evaluation of patient experience• Underscores the importance of system cost-
savings• Enhances use of clinical performance measure
results
10Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 2011 Alignment with Measures of
Meaningful Use• E-prescribing – medication list, allergies• Patient tracking/registry – demographics,
diagnoses, vital signs, smoking, population management, insurance
• Care management – reminders for follow-up care, decision support, Rx reconciliation
• Electronic capability – e-health information to patient, visit summary, e-access to health information, provider information exchange
• Performance reporting/improvement
11Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Comparison of PPC-PCMH and PCMH 2011
PPC-PCMH (9 standards/30 elements)
1. Access and Communication– Processes – Results
2. Patient Tracking and Registry Function
3. Care Management– Continuity Between Settings
4. Self-Management Support5. Electronic Prescribing6. Test Tracking7. Referral Tracking8. Performance Reporting and
Improvement– Measure Performance– Measure Patient/Family
Experience
9. Advance Electronic Communication
PCMH 2011 (6 standards/27 elements)
1. Access/Continuity – Access/Continuity – Medical Home Responsibilities– CLAS– Practice Team
2. Identify/Manage Patient Populations
3. Plan/Manage Care– Care Management (Incl. Behavioral
Health – Identify High Risk Patients– Medication Management/E-
Prescribing
4. Self-Care and Community Referrals
5. Track/Coordinate Care– Test/Referral Tracking and Follow-
Up– Facilities
6. Performance Measurement/Quality Improvement– Measures of Performance– Patient Experience
12Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 2011 Overview (6 standards/27 elements)
1. Enhance Access and Continuity A. Access During Office HoursB. Access After HoursC. Electronic AccessD. Continuity (with provider)E. Medical Home ResponsibilitiesF. Culturally/Linguistically Appropriate
ServicesG. Practice Organization
2. Identify/Manage Patient PopulationsA. Patient Information B. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population Management
3. Plan/Manage CareA. Implement Evidence-Based Guidelines B. Identify High-Risk PatientsC. Manage CareD. Manage MedicationsE. Electronic Prescribing
4. Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources
5. Track/Coordinate CareA. Test Tracking and Follow-UpB. Referral Tracking and Follow-UpC. Coordinate with Facilities/Care
Transitions
6. Measure and Improve Performance A. Measures of PerformanceB. Patient/Family FeedbackC. Implements Continuous Quality
Improvement D. Demonstrates Continuous Quality
ImprovementE. Report PerformanceF. Report Data Externally
Optional Patient Experiences Survey
13Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
ScoringTotal 100 Points
Level Points Required Must Pass
1 ≥ 35 6 Must Pass
2 ≥ 60 6 Must Pass
3 ≥ 85 6 Must Pass
Recognition requires achieving all 6 must pass elements with a ≥50% score
14Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Must Pass ElementsRationale for Must Pass Elements • Identifies critical concepts of PCMH• Helps focus Level 1 practices on most important
aspects of PCMH• Guides practices in PCMH evolution and continuous
quality improvement• Standardizes “Recognition”
Must Pass Elements• 1A: Access During Office Hours• 2D: Use Data for Population Management• 3C: Manage Care• 4A: Self-Care Process• 5B: Referral Tracking and Follow-Up• 6C: Implement Continuous Quality Improvement
15Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 1: Enhance Access and Continuity
Standard• Access
– During/after office hours – Appointments and advice
• Electronic access • Continuity of care with
clinician/care team• Information to patients
about medical home• Culturally and
linguistically appropriate services (CLAS)
• Specific staff roles, responsibilities, training
Meaningful Use CriteriaPatients provided
electronic: • Copy of health
information• Clinical summary of visit• Access to health
information
16Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 2: Identify and Manage Populations
Standard• Collects demographic and
clinical data• Searchable data:
diagnoses, advance directives, immunizations, screenings, BMI, medications
• Assess/document risks• Create lists; use for point
of care reminders
Meaningful Use Criteria
• Language, gender, race, ethnicity, DOB
• Problem list• Medication list• Medication allergy list• Vital signs• Growth chart (peds.)• Smoking status• Lists of patients with
specific conditions for QI, decrease disparities
• Follow-up reminders for care
17Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 3: Plan and Manage Care
Standard• Identify patients with
specific conditions including high-risk or complex, behavioral health
• Care management – Pre-visit planning – Progress toward goals – Barriers to treatment
goals• Reconcile medications• E-prescribing
Meaningful Use Criteria• Clinical decision support• Medication reconciliation
with transitions of care• E-prescribing• Drug-drug, drug-allergy
checks• Transmit prescriptions
using EHR• Drug-formulary checks
18Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 4: Provide Self-Care Support and Community Resources
Standard• Assess self-management
abilities• Document self-care plan;
provide tools and resources
• Counsel on healthy behaviors
• Assess/provide/arrange for mental health/substance abuse treatment
• Provide community resources
Meaningful Use CriteriaPatient-specific education
materials
19Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 5: Track and Coordinate Care
Standard• Track lab/imaging results;
notify patients• Integrate results into
medical record• Track referrals• Coordinate with facilities
– Hospitalized patients and ER
– Establish information exchange with facilities
– Follow up with discharged patients
Meaningful Use Criteria• Incorporate lab/test
results• Exchange patient
information with other providers (meds/ allergies, tests)
• Provide summary care record for transitions and referrals
20Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
PCMH 6: Measure and Improve Performance
Standard• Measure performance
(preventive/chronic/acute care clinical measures)
• Track utilization measures
• Patient experience survey - identifies vulnerable populations
• Continuous quality Improvement
• Report performance– Clinical measures
Meaningful Use CriteriaReport:• Ambulatory clinical
quality measures to CMS/ state
• Immunization data to registries
• Syndromic surveillance data to public health agencies
21Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Emphasize Patient-Centered Care
Increasing patient-centeredness
PCMH 1: Enhance Access and Continuity• Provide continuity of care with the same provider• Provide information to the patient about medical
home• Provide access to care during and after office
hours• Provide patient materials and services meeting
the language needs of patients PCMH 4: Provide Self-Care and Community Support • Provide resources to support patient/family self-
managementPCMH 6: Measure and Improve Performance• Involve patients/families in quality improvement• Obtain performance data for key vulnerable
populations
22Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Focus on Behavioral Health
Incorporating attention to behaviors affecting health, mental health and substance abuse
• PCMH 1: Enhance Access and Continuity– Comprehensive assessment includes depression screening,
behaviors affecting health and patient and family mental health and substance abuse
• PCMH 3: Plan and Manage Care– One of three clinically important conditions identified by the
practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition
– Practice must plan and manage care for the selected condition• PCMH 4: Provide Self-Care and Community Resources
– Self-care support includes educational and community resources and adopting healthy behaviors
• PCMH 5: Track and Coordinate Care– Tracks referrals and coordinates care with mental health and
substance abuse services• PCMH 6: Measure and Improve Performance
– Preventive measures include depression screening
23Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Focus on Pediatrics
• Goal for PCMH 2011 to enhance applicability to pediatric practices
• AAP participated on the PCMH Advisory Committee• Throughout the Standards
– “Families” has been incorporated where appropriate – “NA for pediatric practices” has been used where appropriate – Pediatric examples and explanations have been added– References to Bright Futures have been included
• PCMH 1: Enhance Access and Continuity – Explanation addresses unique pediatric issues, such as teen privacy
and guardianship• PCMH 2: Identify and Manage Patient Populations
– Includes pediatric clinical data and age appropriate screenings• PCMH 3: Plan and Manage Care
– Explanation specifies relevant pediatric clinical conditions, including well-child care and children/youth with special health care needs
• PCMH 4: Provide Self-Care and Community Support – Population specific referrals include parenting and respite care
24Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Focus on Patient Experience
Increasing the emphasis on patient feedback
PCMH 6: Measure and Improve Performance • Expanded the survey categories (access,
communication, coordination, self-management support, whole person orientation, comprehensiveness, shared decision-making) and the requirements for the practice.
• Use of patient survey results for quality improvement• Involve patients/families in quality improvement• Optional Recognition for reporting results using a
standardized Patient Experiences survey & methodology
25Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
The Case for Patient-Centered Medical Home Recognition
• Gives physicians a roadmap to improve quality with systematic approach to preventive and chronic care delivery
• Focuses on evidence-based requirements to improve quality and reduced costs
• Considers capabilities of small and large practices, without sacrificing quality
• Program is built on what is shown to improve care and can be copied or replicated
26Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
The Case for Patient-Centered Medical Home Recognition
• Requires electronic information when necessary– electronic systems alone are not
sufficient
• Incentivizes investment in quality infrastructure and processes
• Complements evaluation of clinical effectiveness, patient experiences and efficiency
27Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Patient PerspectivePCMH Practices
Focus Group Findings• PCMH patients emerge as highly satisfied with their
current PCP practices, and deem “continuity of care” as related rationale (with one participant using the term).
28Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Patient PerspectiveNon-PCMH Practices
Focus Group Findings• Conversely, a majority of General Population Patients
emerge overall with less satisfaction. (A few General Population Patients who have long-standing PCP relationships emerge as satisfied and convey practices similar to care coordination practices described by PCMH Patients).
29Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
Benefits of PCMH• Clinician Burnout
– 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline
• Total Cost– 29 percent fewer emergency visits and 6 percent
fewer hospitalizations.– Estimated total savings of $10.3 per patient per
month• Patient Experience
– Improved access, coordination, goal-setting• Quality
– Improved HEDIS results
Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs 29:5 (2010): 835-843.
30Achieving NCQA Recognition as a Patient-Centered Medical Home
RI Statewide Learning Collaborative February 5, 2011
NCQA Contact Information
Contact NCQA Customer Support to:• Order FREE Information/Application Packets• Purchase ISS Tool• 1-888-275-7585
Visit NCQA Web Site to:• View Frequently Asked Questions• View Recognition Programs Training Schedule• www.ncqa.org/medicalhome.aspx
Send Questions to: [email protected]