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Training Webinar #7DavidHalpern, MD, MPHMarch 7,2012
Patient-Centered Medical HomeNCQA’s PCMH 2011 Standards
Legal Disclaimer
© Copyright 2011 North Carolina Community Care Networks, Inc.  All rights reserved. The content set forth herein is made available on an “as is” basis without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure NCQA recognition as patient-centered medical homes.  All other uses of or modifications to the content set forth herein without the prior express written approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with the permission of the respective copyright owners in each case.
Acknowledgements
Let’s Review
What Is The Record Review Workbook?Standard 4 – Self-Care Support & Community ResourcesPCMH4A: Support Self-Care Process –MUST PASSPCMH4B: Provide Referrals to Community Resources
Let’s Track Our Progress
Standard 1 – Enhance Access/ContinuityStandard 2 – Identify/Manage PopulationsStandard 3 – Plan/Manage CareStandard 4 – Self-Care Support/ResourcesStandard 5 – Track/Coordinate CareStandard 6 – Measure/Improve Performance
Today’s Agenda
Standard 3–Plan & Manage CarePCMH3A:Implement Evidence-Based GuidelinesPCMH3B:Identify High-Risk PatientsPCMH3C:Care Management-MUSTPASSPCMH3D:Medication ManagementPCMH3E:Use Electronic Prescribing
PCMH 3A:ImplementEvidence-BasedGuidelines
Practice implements guidelines through point of care reminders for patients with:Thefirst importantcondition*Thesecond important conditionThethird condition, related to unhealthy behaviors or mental health or substanceabuse* Meaningful Use Requirement
4PointsScoring3factors = 100%2factors (including factor 3) =50%1factor = 25%0factors = 0%DataSources:Identificationof 3conditions; (theseare not screening or a single preventive serviceprocess)Nameand source of guidelinesDemonstrationof how guidelines are implemented
PCMH 3A:ImplementEvidence-BasedGuidelines
Examples of eligible conditions include: COPD, hypertension,hyperlipidemia, HIV/AIDS, asthma, diabetes, or congestive heart failure.One of the 3 conditions (Factor 3) must be related to unhealthy behavior (e.g. obesity, smoking), substance abuse (e.g. illicit drug use, prescription drug addiction, alcoholism), or a mental health condition (e.g. depression, anxiety, bipolar disorder, ADHD, dementia).
PCMH 3A:Choose Conditions
PCMH 3A:Provide Justification
PCMH 3A:SelectEvidence-BasedGuidelines
PCMH 3A:SelectEvidence-BasedGuidelines
PCMH 3A:SelectEvidence-BasedGuidelines
You mustadoptANDimplementthe guidelinesGuidelines can be implemented by embedding them into the EMR or using paper-based supporting documentation (flow sheets or templates used to document treatment plans or patient progress)
PCMH 3A:ImplementEvidence-Based Guidelines
Diabetes Management Flow Sheet
PCMH 3A:ImplementEvidence-Based Guidelines
PCMH 3A:ImplementEvidence-Based Guidelines
PCMH 3A:ImplementEvidence-Based Guidelines
The practice does the following to identify high-risk patients:Establishescriteria and a process to identify high-risk or complex patientsDeterminesthe percentage of high-risk patients in the population
PCMH 3B:IdentifyHigh-Risk Patients
3 PointsScoring2 factors = 100%1 factor = 25%0 factors = 0%Data Sources:Process to identify patientsReport showing number and percentage of high-risk patients
PCMH 3B:IdentifyHigh-Risk Patients
The practice should have specificcriteriaand aprocessfor identifying complex or high-risk patients who need care planning and management services.This may be based on (alone or in combination):High resource use (e.g. visits, medications, treatments, other cost measures)Frequent visits for urgent or emergent careFrequent hospitalizationsMultiplecomorbidities(including mental health)Non-adherence with prescribed treatments/medsTerminal illness (palliative care/hospice involvement)Barriers to care (e.g. lack of social/financial support)Advanced age and frailtyMultiple risk factors (smoking, family history, obesity, etc)
PCMH 3B:Explanation of Factor 1
The practice may identify patients through a billing or practice management system, through the EMR, through key staff members, or through profiles from health plan (as long as these encompass 75% or more of patients)The factor requires a report that shows a number and percentage of patients identified as high risk, meaning you need to show a numerator (# of high risk patients) and denominator (total # of patients)
PCMH 3B:Explanation of Factor2
The patients you use for the review in3Cand3Dare those who have one of the 3 conditions listed in3A, or are designated “high-risk” as described in3BYou should only use visits that are “relevant” (i.e. related to the chronic condition in question or a combination of the factors which make them “high risk”)NCQA doesNOTexpect you to care manageevery patientin your practice.
PCMH 3C &3D:REMEMBER!
Care team performs the following for at least75%ofpatients fromElements3Aand3B:Conductspre-visit preparationsCollaborateswith patient to develop care plan, including treatment goalsGivespatient written care planAssessesand addresses barriers to treatment goalsGivespatient clinical summary at relevant visitsIdentifiespatients who need more care management supportFollowsup with patients who have not kept important appointments
PCMH 3C:Care Management
MUST PASS4PointsScoring6-7factors = 100%5 factors = 75%3-4factors=50%1-2 factors= 25%0factors = 0%Data Sources:Reportfrom electronic system or submission of Record Review Workbook
PCMH 3C:Care Management
PCMH 3C:Record Review Workbook
PCMH 3C:Example – Factor 1
PCMH 3C:Example – Factor 3
PCMH 3C:Example – Factor 4
PCMH 3C:Example – Factor 7
Practice manages medications in the following ways:Reviewsand reconciles medications for more than50%ofcaretransitions*- CRITICALFACTORReviewsand reconciles medications for more than80%ofcare transitionsProvidesinformation about new prescriptions to more than80%ofpatientsAssesspatient understanding of medications for more than50%ofpatientsAssessespatient response to medication and barriers to adherence for more than50%ofpatientsDocumentsOTCs, herbal/supplements, for more than50%ofpatients, with date ofupdate* Meaningful Use Requirement
PCMH 3D:Medication Management
3PointsScoring5-6factors (including factor 1) = 100%3-4factors (including factor 1) = 75%2factors (including factor 1) = 50%Factor 1 =25%0factors or does not meet Factor1 =0%DataSources:Report from electronic system or submission of Record Review Workbook
PCMH 3D:Medication Management
PCMH 3D:Record Review Workbook
PCMH 3D:Example – Factor 2
PCMH 3D:Example – Factor 2 & 6
PCMH 3D:Example – Factor 2
Practice uses e-prescribing system with the following capabilities:Generatesand transmits at least40%ofprescriptions to pharmacies*Generatesat least75%of eligibleprescriptions*Integrateswith patient medical recordsPerformspatient-specific checks for drug-drug and drug-allergyinteractions*Alertsprescribers to generic alternativesAlertsprescribers to formularystatus**Meaningful Use Requirement
PCMH 3E:Use Electronic Prescribing
3PointsScoring5-6factors (including factor 2) =100%4 factors =(including factor 2)= 75%2-3 factors =(including factor 2)= 50%1 factor =25%0factors = 0%DataSources:Reports showing percent of electronic prescriptions written andtransmitted,and demonstrating the system’s capabilities
PCMH 3E:Use Electronic Prescribing
PCMH 3E:Example – Factors 1 & 2
EXPLANATIONJanuary to March 2009 prescribing method is documented in the table.Certain prescriptions (Schedule II) must be printed on special paperprescription pads in our state.96% of prescriptions were generated from our electronic medical record.
PCMH 3E:Example – Factors 1 & 2
PCMH 3E:Example – Factors 3 & 4
Drug-Allergy Interaction
PCMH 3E:Example – Factor 4
PCMH 3E:Example – Factors 3, 5, 6
PCMH 3E:Example – Factors 3, 5, 6
Capturing A Screenshot
Press the Print Screen key on your keyboard. It may be labeled [PrtScn].Open a word processing program like Microsoft Word.Go to the Edit tab and choose Paste (or press control V).Optional: Use your image editor's crop tool to crop out unnecessary portions of the screen shot.Annotate the image by typing above or below.Go to the File tab and choose Save As.Navigate to the folder where you want to save the image.Type a file name for the image.Click the Save button.
Screenshot Demo
Community Care PCMH Team
DavidHalpern, MD, MPHCommunity Care of North Carolina (CCNC)R.W. “Chip” Watkins, MD, MPH, FAAFPCommunity Care of North Carolina (CCNC)BrentHazelett, MPANorth Carolina Academy of Family Physicians (NCAFP)Elizabeth Walker Kasper, MSPHNorth Carolina Healthcare Quality Alliance (NCHQA)
Questions?
Feel free to contact me:DavidHalpern, MD, MPH(215) 498-4648dhalpern@n3cn.org

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