Transforming Practices Through

Patient-Centered Medical Home (PCMH)

Overview of the NCQA PCMH 2017 Standards

June 27, 2018

AgendaTime Topic Lead

8:00 - 8:25 AM Welcome, Introductions and Icebreaker Karen & Christina

8:25 - 9:25 AM Overview & Highlights of PCMH 2017- What’s New w/PCMH 2017- Concepts & Scoring- Accelerated Renewal Process- Annual Reporting- Prevalidation- QPASS- Recommended Timelines for Recognition

Karen & Christina

9:25 - 10:10 AM PCMH 2017 Clinical Content & Reports Review- FAQ Document – Demonstration of Centricity Forms- Reports Spreadsheet –Available PCMH reports Review

Christina

10:10-10:20 AM BREAK

10:20-11:15 AM Group Activity- Group activities to introduce attendees to a few of the new criteria

Christina

11:15-11:45 AM Panel Discussion- Best practices/lessons learned from PCMH recognized Health

Centers

Your Fellow Colleagues!

11:45-12:00 PM Q&A- Any further questions?- Available PCMH resources- Future steps as a PCMH cohort

Karen & Christina

Continuing Education Disclosures

Commercial Support – None

Speaker or planner conflicts of interest – None

For CME and CNE credit or an Attendance Certificate -

Full session attendance and

completion of an on-line evaluation is required.

Link to the evaluation is on the AllianceChicago Conference App

Thank you!

Welcome & Introductions

Welcome & Introductions

• Name

• Health Center

• PCMH Recognition Status

Getting to Know You...

1) Find one person with the same color chip and share one PCMH challenge your organization faces (3 minutes).

2) Find one person with the same color chip and share one PCMH success story from your organization (3 minutes).

3) Find one person with the same color chip and share a story about a favorite journey you've taken in your life (3 minutes).

Overview & Highlights of PCMH 2017

Why Patient-Centered Medical Home?

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

• Helps to drive important reforms in healthcare delivery

• PCMHs save money

• Mitigates health disparities

• Improves patient outcomes

And......

Click to add text

HRSA Grant Awards

PCMH 2017 Highlights

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

PCMH 2017 Standards Format

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

PCMH 2017 Standards

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

PCMH 2017 Standards

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

PCMH 2017 Standards

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Recognition: No More Levels

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Scoring

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Redesign: Why?

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Standards: 2014 v 2017

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Standards Redesign: 3 Parts

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Sustaining Recognition

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

2017 Distinction Modules

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

Prevalidation

• NCQA prevalidated Health IT solutions have successfully demonstrated that their technology solution has functionality that supports or meets one or more criteria in the PCMH standards

• GE Centricity is a prevalidated HIT vendor!

• Evaluation can result in approved fully met criteria and partially met criteria that are transferable to eligible client practices submitting for recognition and acknowledgment of practice support functionality

Content reproduced with permission from theIntroduction to PCMH 2017: FoundationalConcepts of the Medical Home by the NationalCommittee for Quality Assurance (NCQA).©2017 by the National Committee for QualityAssurance

PrevalidationHow to obtain prevalidation:

• Contact the AllianceChicago (Karen or Christina) to obtain:

• Letter of Product Implementation from GE/your vendor, indicating which prevalidated tool(s)/modules approved for transfer credit have been implemented at the practice

• Vendor’s Prevalidation Letter of Credit Approval

• Upload the Letter of Product Implementation to QPASS and submit for review/approval from NCQA

Accelerated Renewal Process

• Practices will be able to attest to meeting certain criteria without providing the full evidence required (no demonstration of documentation and/or evidence)

• Qualifications

• PCMH 2011 Level 1, 2, or 3 recognized practices

• PCMH 2014 Level 1 or 2 recognized practices

Annual Reporting

• Practices will attest that they have continued to adopt the PCMH principles and maintained recognition using the PCMH Annual Questionnaire

• Qualifications

• PCMH 2014 Level 3 recognized practices

• PCMH 2017 recognized practices

Q-PASS

• ISS Survey Tool > Quality Performance Assessment Support System (Q-PASS)

• Web-based platform to submit required evidence and documentation to NCQA during the Transformation Phase & Succeed Phase (annual reporting)

• Q-PASS lets you manage multiple organizations, practices, clinicians and recognitions through a SINGLE portal.

Q-PASS

Quick demo:

https://qpass.ncqa.org/

- How to set up an account

- How to access the organization dashboard

- Where/how to submit evidence

- How to link evidence

QPASS – How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- How/where to submit evidence

QPASS - How/where to submit evidence

QPASS- How/where to submit evidence

QPASS- Accelerated Renewal: How to attest for a criteria

QPASS- How to submit for a virtual check-in

QPASS- How to submit for a virtual check-in

Recommended Timelines – No Prior Recognition

Modify any

evidence that did

not pass & continue

preparation for 3rd

virtual review

Modify any

evidence that did

not pass & continue

preparation for 2nd

virtual review

Schedule &

complete 1st virtual

check-in call

Schedule &

complete 2nd virtual

check-in callSecond& complete

3rd/final check-in

call

Review the 2017

S&G and the

PCMH Progress

Log

Submit NOI to

HRSA if needed

QPASS – Set up

account and enroll

site(s)

Initial intro call with

NCQA Rep

Qrt 1 Qrt 2 Qrt 3 Qrt 4

Recommended Timelines – Accelerated Renewal Process

Modify any

evidence that did

not pass & continue

preparation for 3rd

virtual review

Modify any

evidence that did

not pass & continue

preparation for 2nd

virtual review

Schedule &

complete 1st virtual

check-in 2-3

months after the

initial intro callSchedule &

complete 2nd virtual

check-in call 2-3

months after the

2nd check-in call

Schedule &

complete 3rd/final

check-in call 2-3

months after the 3rd

check-in call

Review the 2017

S&G, Accelerated

Renewal Process,

& PCMH Progress

Log

Submit NOI to

HRSA if needed

QPASS – Set up

account and enroll

site(s)

Initial intro call with

NCQA Rep

Qrt 1 Qrt 2 Qrt 3 Qrt 4

Recommended Timelines – Annual ReportingComplete Annual Survey Questionnaire in QPASS-

Note: Reporting date, or the date the evaluation must be

submitted is 30 days before the end of the practice’s

current recognition

Review the 2017

S&G, Annual

Reporting PDF, &

PCMH Progress

Log

Submit NOI to HRSA

if needed

QPASS – Create

organizations and

enroll site(s) at the

minimum 90 days

before the end of the

practice’s current

recognition

Initial intro call with

NCQA Rep

Month 1 Month 2 Month 3 End of current recognition

PCMH 2017 Clinical Content & Reports Review

Helpful Documentation

• The following can help you start or maintain PCMH Recognition:

▪ Alliance NCQA PCMH 2017 Progress Log

▪ Alliance FAQ: PCMH 2017 Content

▪ Alliance High, Medium, Low Priority Reports Log

Helpful Documentation• Alliance Progress Log

• Located on Loop.alliancechicago.org > Resources > PCMH

• Useful for PCMH teams to review the type of documentation required, location in the content, NCQA 2014 alignment, and responsible party

PCMH 2017 Clinical Content

• Alliance FAQ: PCMH Content

• Located on loop.alliancechicago.org > Resources > PCMH

• Helps to inform you of new and revised content for PMCH

• Can be a good training document for staff

PCMH 2017 Clinical Content• Alliance PCMH 2017 Flowsheet

• Initial Intake

• Adult Chief Complaint / History of Present Illness

• Care Management Plan

• Care Team

• Self-Management Goals

• Quality of Care Checklist

• Pre-Visit Preparation

• Team Huddle

• Phone Note

• PC-PTSD

• Adult ADHD

• Referral Order

• Pre-visit Prep

• Assessment and Plan

• PRAPARE

• Patient History

• Well Child Care

• Adult HM & Ed

• Preventative Care

• GAD

• AUDIT

• DAST

• HEEADSSS

PCMH 2017 Clinical Content – Let's take a closer look

• PCMH 2017 Flowsheet

• Initial Intake

• Care Management Plan

• PRAPARE

PCMH 2017 Reporting

• Alliance PCMH Reporting Log and Status

• Located on loop.alliancechicago.org > Resources > PCMH

• Lists High, Medium, Low Priority Reports & Status / Delivery Schedule

10 Minute Break

Group Activities: Let's get familiar with the 2017 standards and guidelines!

Group Activities

• Find a table with other folks outside your organization

• You're going to review challenging criteria and discuss how you would meet it

• What documented process, evidence of implementation, or patient examples would we need?

Group Activities

Team Based Care

• TC 06 (Core) Individual Patient Care Meetings/Communication: Has regular patient care team meetings or a structured communication process focused on individual patient care. (10 minutes, 5 minutes report-out)

Knowing & Managing Your Patients

• KM 02 (Core) Comprehensive Health Assessment: Comprehensive health assessment includes (all items required): (10 minutes, 5 minutes report-out)

• Medical history of patient and family.• Family/social/cultural characteristics.• Communication needs.• Behaviors affecting health.• Social functioning.• Social determinants of health.• Developmental screening using a standardized tool (NA for practices with no pediatric population under 30 months of age)• Advance care planning (NA for pediatric practices).

Group Activities Continued

Care Coordination and Care Transitions

• CC 14 (Core): Identifying Unplanned Hospital and ED Visits: Systematically identifies patients with unplanned hospital admissions and emergency department visits.

• CC 15 (Core): Sharing Clinical Information: Shares clinical information with admitting hospitals and emergency departments.

• CC 16 (Core): Post-Hospital / ED Visit Follow-up: Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit. (10 minutes, 5 minutes report-out)

Hear from the Experts!

Best Practices/Lessons Learned

• Developing your PCMH Team

• How to overcome challenges/barriers during the PCMH transformation journey

• How to successfully engage providers and staff to transform into a PCMH

Next Steps & Attendee Feedback

• How can the AllianceChicago best support you in your future PCMH transformation?

• PCMH Workshops/Webinars – Deep dive of the PCMH 2017 Standards & Guidelines

• Monthly/Quarterly Committee Calls

Q & A

Thank you!

Karen Iversen, MPH, PCMH-CCEkiversen@alliancechicago.org

Christina Kim, MPH, PCMH-CCEckim@alliancechicago.org