View
219
Download
2
Category
Preview:
Citation preview
Megan A. Housley, MBA
Business Development Director
Kentucky Regional Extension Center
Practice Transformation: Patient Centered
Medical Home
Overview
Policy Framework For Achieving Triple
Aim
Quality & Efficiency
Care Delivery & Innovation
Provider Feedback & Measurement
Payment Reform
HIT Foundation: Meaningful Use of EHRs and HIE
A journey of a thousand miles begins with a single step…
Meaningful Use
Care Delivery Innovation (PCMH)
Payment Innovation
Health IT & HIE + Quality Improvement
What is Patient-Centered Medical Home?
PCMH is a model that provides specific standards
for transforming the organization and delivery of
primary care to be more:
Comprehensive Patient-Centered Coordinated Accessible Safe
What is Patient-Centered Medical Home?
Other Common PCMH Descriptors:
…a vision of healthcare as it should be
…a framework for organizing systems of care at both the micro (practice) and macro (society) level
…a model to test, improve, and validate
…part of the healthcare reform agenda
political construct that includes new ways of organizing and financing care, while attempting to remain true to the proven value of primary care
Other Common PCMH Descriptors
Patient Centered Medical Home Extreme Makeover
• Uncoordinated care
• Over-loaded schedule
• Physician & practice-centric
• Arbitrary quality improvement projects
• Lack of clear leadership & support
• Team-based approach
• Open access
• Patient engagement & empanelment
• Data directed quality improvement efforts
• Engaged leadership
PCMH: Extreme Makeover
Five Functions of a PCMH
1. Comprehensive Care
2. Patient-Centered
3. Coordinated Care
4. Accessible Services
5. Quality and Safety
5 Functions of PCMH
PCMH Benefits • Long-term partnerships, not hurried visits
• Care that is coordinated among providers
• Better access
• Shared decision-making
• Lower costs
• Fewer EH visits/hospitalizations
• Practices get paid for doing the right things
• More satisfied providers and patients
PCMH Benefits
• Primary Care • Specialty Care • Inpatient Care • Emergency Care • Urgent Care • Laboratory Services • Physical Therapy /
Rehabilitation • Mental Health • Home Health Services • Pharmacy • Durable Medical
Equipment • Social Work • Community Support
Agencies
Even Bigger Picture: Medical Neighborhood
PCMH
Sub-Specialty Procedural Practice
Sub-Specialty PCMH/ Medical Home Neighbor
Hospital
Pharmacy
Lab
Patient Centered Medical Neighborhood
HIT
HIT
HIT
HIT
HIT
HIT
HIT
Patient-Centered Medical Neighborhood
How Do We Get There? • Meaningful Use
• Primary Care-PCMH Recognition
• Care Coordination Agreements
– Define type of interaction
– Responsibility for elements of care
• Expectations for HIE
• Population Health Management focus (work with ACO/Medical System with this focus)
So How Do We Get There?
• Many PCMH recognition programs
• National Committee for Quality Assurance (NCQA)
– Private, non-profit health care quality organization offering clinical & practice process programs
– “Gold Standard” for Primary Care Transformation
– By far the most widely used method for Medical Home Recognition (Each month 150+ practices apply)
– Partnering with Department of Defense, Department of Health & Human Services, state programs and insurance companies
How To Achieve PCMH Recognition
NCQA PCMH Recognition
• For outpatient primary care
• Practice-site level
• NCQA defines practice as a clinician or clinicians practicing together at a single geographic location
• Recognizes PCPs at the site, including NPs and Pas who can be designated as a personal clinical with their own panel of patients
• 3-year Recognition period
• Practice may add/remove clinicians
NCQA PCMH Recognition
Who Is Eligible?
• Clinicians with intention of serving as the personal, primary care clinician
• Physicians, NPs and Pas
who practice in Internal Medicine, Family Medicine, or Pediatrics
• Must have license as MD,
DO, NP or PA
Who Is Eligible?
6 NCQA PCMH Standards
Standard 1: Enhance Access and Continuity of Care
Standard 2: Identify and Manage Patient Populations
Standard 3: Plan and Manage Care
Standard 4: Self-Care Support & Community Resources
Standard 5: Track and Coordinate Care
Standard 6: Measure and Improve Performance
6 NCQA PCMH Standards
NCQA PCSP Recognition
• For non-primary care specialists
• Practice-site level
• Recognizes clinicians at
the site, including NPs and PAs with own/shared patient panel
• 3-year Recognition period
• May be multi-site and/or multi-specialty
• May add/remove clinicians
NCQA PCSP Recognition
Who Is Eligible?
• Clinicians who typically receive referrals from PCPs and other non-primary care specialists including :
– MDs, DOs, – NPs/PAs with own/shared
patient panel – CNMs
– Behavioral health specialists: Psychologists, licensed clinical social workers, marriage and family counselors
Who Is Eligible?
6 NCQA PCSP Standards
Standard 1: Track and Coordinate Referrals
Standard 2: Provide Access and Communication
Standard 3: Identify and Coordinate Patient Populations
Standard 4: Plan and Manage Care
Standard 5: Track and Coordinate Care
Standard 6: Measure and Improve Performance
6 NCQA PCSP Standards
Meaningful Use Overlap
• PCMH reinforces the use of HIT through the involvement of an EHR, registries, and HIEs
• MU practices well-prepared for PCMH
• MU language embedded in PCMH Standards
Meaningful Use Overlap
Phone: (859) 323-3090 Email: Kyrec@uky.edu
Follow us on Twitter: @KentuckyREC
Like us on Facebook: facebook.com/EHRResource
Follow us on LinkedIn: linkedin.com/company/kentucky-rec
Check out our website: www.kentuckyrec.com
Connect with Kentucky REC!
Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director
Northeast KY Regional Health Information Organization
www.nekyrhio.org
NCQA Program Setup
Standards • Six Standards Outline Program
Elements • Six Must Pass
Factors • Must meet
50% AND ALL Critical Factors
2014 NCQA Standards
• Patient – Centered Access PCMH 1
• Team – Based Care PCMH 2
• Population Health Management PCMH 3
• Care Management and Support PCMH 4
• Care Coordination and Care Transition PCMH 5 • Performance Measurement and Quality
Improvement PCMH 6
Sample Element
Element D: Use Data for Population Management
P C M H 3 : P o p u l a t i o n H e a l t h M a n a g e m e n t
At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including:
1) At least two different preventive care services 2) At least two different immunizations 3) At least three different chronic or acute care services 4) Patient not recently seen by the practice 5) Medication monitoring or alert
100%
The practice meets 4-5
factors
75%
The practice meets 3 factors
50%
The practice meets 2 factors
25%
The practice meets 1 factor
0%
The practice meets 0 factors
5 Points 3.75 Points 2.5 Points 0 Points 0 Points
Stag
e 2
Co
re M
U M
easu
res 1) CPOE
2) eRX
3) Demographics
4) Vital Signs
5) Smoking Status
6) Clinical Decision Support
7) View, Download and Transmit
8) Clinical Summaries
9) Privacy and Security
10) Lab-test Results
11) List of Patients
12) Patient Reminders
13) Patient Education
14) Medication Reconciliation
15) Summary of Care/Transitions of Care
16) Immunization Registry
17) Secure Electronic Messaging
MU Core Measure 1
CPOE - 60% Medications - 30% Lab - 30% Radiology
PCMH 4: Care Management and Support
1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies
2. Enters electronic medication orders in the medical record for more that 60 percent of medications
3. Performs patient-specific checks for drug-drug and drug-allergy interactions 4. Alerts prescribers to generic alternatives
Element D: Use Electronic Prescribing 3.0 Points
PCMH 5: Care Coordination and Care Transitions
1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot
screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient record 8. More that 30 %of the radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured
fields in medical record. 10. More than 10% of scans and test that result in an image are accessible electronically.
Element A: Test Tracking and Follow-Up 6.0 Points
MU Core Measure 2
eRX - 50% Generate and transmit prescriptions electronically
PCMH 4: Care Management and Support
1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies
2. Enters electronic medication orders in the medical record for more that 60 percent of medications
3. Performs patient-specific checks for drug-drug and drug-allergy interactions
4. Alerts prescribers to generic alternatives
Element D: Use Electronic Prescribing 3.0 Points
100%
The practice meets 4 factors
75%
The practice meets 3 factors
50%
The practice meets 2 factors
25%
The practice meets 1 factor
0%
The practice meets 0 factors
3 Points 2.25 Points 1.5 Points .75 Points 0 Points
MU Core Measure 3
Record Demographics - 80% -Language -Sex -Race -Ethnicity -DoB
PCMH 3: Population Health Management
Practice records as structured data for more that 80% of patients the following: 1. Date of Birth 2. Sex 3. Race 4. Ethnicity 5. Preferred Language 6. Telephone numbers 7. E-mail address 8. Occupation 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives 13. Health insurance information 14. Name and contact information of other health care professionals involved in patients care.
Element A: Patient Information 3.0 Points
100%
The practice meets 10-14
factors
75%
The practice meets 8-9
factors
50%
The practice meets 5-7
factors
25%
The practice meets 3-4
factor
0%
The practice meets 0-2
factors
3 Points 2.25 Points 1.5 Points .75 Points 0 Points
MU Core Measure 4
Record Vitals - 80% -Height/length -Weight -Blood Pressure -BMI -Display growth chart
PCMH 3: Population Health Management
The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of
patients 2. Allergies, including medication allergies and adverse reactions for more than
80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and
up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of
patients 9. List of prescription medications with date of updates for more than 80% of
patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible
professional for more than 30 % of patient with at least one office visit.
Element B: Clinical Data 4.0 Points
MU Core Measure 5
Record Smoking Status - 80% -Patients age 13 and up
PCMH 3: Population Health Management
The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of
patients 2. Allergies, including medication allergies and adverse reactions for more than
80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and
up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of
patients 9. List of prescription medications with date of updates for more than 80% of
patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible
professional for more than 30 % of patient with at least one office visit.
Element B: Clinical Data 4.0 Points
MU Core Measure 6
-Implement 5 Clinical Decision Support Rules
-Enable drug-drug and drug to allergy interaction checks
PCMH 4: Care Management and Support
1. More that 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies
2. Enters electronic medication orders in the medical record for more that 60 percent of medications
3. Performs patient-specific checks for drug-drug and drug-allergy interactions
4. Alerts prescribers to generic alternatives
Element D: Use Electronic Prescribing 3.0 Points
100%
The practice meets 4 factors
75%
The practice meets 3 factors
50%
The practice meets 2 factors
25%
The practice meets 1 factor
0%
The practice meets 0 factors
3 Points 2.25 Points 1.5 Points .75 Points 0 Points
MU Core Measure 7
Provide patients ability to View, Download and Transmit their ePHI - 50% available - 5% viewed
PCMH 1: Patient-Centered Access
The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health
information within four business days of when the information is available to the practice.
2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party.
3. Clinical summaries are provided within 1 business day for more than 50% of office visits.
4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and
test results.
Element C: Electronic Access 2.0 Points
MU Core Measure 8
Provide clinical summaries to patients for each office visit within one business day -50%
PCMH 1: Patient-Centered Access
The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health
information within four business days of when the information is available to the practice.
2. More than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party.
3. Clinical summaries are provided within 1 business day for more than 50% of office visits.
4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and
test results.
Element C: Electronic Access 2.0 Points
MU Core Measure 9
Protect electronic health information (Privacy and Security)
PCMH 6: Performance Measurement and Quality Improvement
1. The practice uses an EHR system that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis and implement updates as necessary.
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization
registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Element G: Use Certified EHR Technology 0.0 Points
MU Core Measure 10
Incorporate clinical lab-test results into EHR as structured data. - 55%
PCMH 5: Care Coordination and Care Transitions
1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the
clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test
results. 6. Follows up with the inpatient facility about newborn hearing and newborn
blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient
record 8. More that 30 %of the radiology orders are electronically recorded in the
patient record 9. Electronically incorporates more than 55% of all clinical lab test results into
structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible
electronically.
Element A: Test Tracking and Follow-Up 6.0 Points
MU Core Measure 11
Generate lists of patients by specific condition
PCMH 3: Population Health Management (MUST PASS)
At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers of needed care based on patient information. 1. At least two different preventive care services 2. At least two different immunizations 3. At least three different chronic or acute care services 4. Patients not recently seen by the practice 5. Medication monitoring or alert.
Element D: Use data for Population Management 5.0 Points
MU Core Measure 12
Send reminders to patients for preventive/follow-up care - 10 %
PCMH 6: Performance Measurement and Quality Improvement
1. The practice uses an EHR system that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis and implement updates as necessary.
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization
registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Element G: Use Certified EHR Technology 0.0 Points
MU Core Measure 13
Identify and provide patient specific education resources to patient - 10%
PCMH 4: Care Management and Support
The practice has, and demonstrates us of, materials to support patients and families/caregivers in self-management and shared decision making. 1. Uses an EHR to identify patient-specific education resources and provide
them to more than 10% of patients. 2. Provides educational materials and resources to patients. 3. Provides self-management tools to record self-care results. 4. Adopts shared decision making aids. 5. Offers or refers patients to structured health education programs, such as
group classes or peer support. 6. Maintains a current resource list of five topics or key community service areas
of importance to the patient population including services offered outside the practice and its affiliates.
7. Assesses usefulness of identified community resources.
Element E: Support Self-Care and Shared Decision Making 5.0 Points
MU Core Measure 14
Perform Medication Reconciliation as relevant - 50%
PCMH 4: Care Management and Support
The practice has a process for managing medications, and systematically implements the process in the following ways. 1. Reviews and reconciles medications for more than 50% of patients received
from care transitions. (CRITICAL FACTOR) 2. Reviews and reconciles medications with patients/families for more than 80%
of care transitions. 3. Provides information about new prescriptions to more than 80% of
patients/families/caregivers. 4. Assesses understanding of medications for more than 50% of
patients/families/caregivers, and dates the assessment. 5. Assesses response to medications and barriers to adherence for more than
50% of patients, and dates the assessment. 6. Documents over-the-counter medications, herbal therapies and supplements
for more than 50% of patients, and dates updates.
Element C: Medication Management 4.00 Points
MU Core Measure 15
Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document – 50% b) Provide summary of care document electronically – 10% c) Provide summary of care document to another provider on different EHR - Once
PCMH 5: Care Coordination and Care Transitions (MUST PASS)
The practice: 1. Considers available performance information on consultants/specialists when
making referral recommendations. 2. Maintains formal and information agreements with a subset of specialists
based on established criteria 3. Maintains agreements with behavioral healthcare providers. 4. Integrates behavioral healthcare providers within the practice site. 5. Gives the consultant or specialist the clinical question, the required timing
and the type of referral. 6. Gives the consultant or specialist pertinent demographic and clinical data,
including test results and the current care plan. 7. Has the capacity for electronic exchange of key clinical information and
provides an electronic summary of care record to another provider for more than 50% of referrals.
8. Tracks referrals until the consultant or specialist's report is available, flagging and following up on overdue reports. (CRITICAL FACTOR)
9. Documents co-management arrangements in the patients medical record 10. Asks patients/families about self-referrals and requesting reports from
clinicians.
Element B: Coordinate Care Transitions 6.00 Points
MU Core Measure 15
Provide Summary of Care record for transitions in care or referrals: a) Provide summary of care document – 50% b) Provide summary of care document electronically – 10% c) Provide summary of care document to another provider on different EHR - Once
PCMH 5: Care Coordination and Care Transitions
The practice: 1. Proactively identifies patients with unplanned hospital admissions and
emergency department visits. 2. Shares clinical information with admitting hospitals and emergency
departments. 3. Consistently obtains patient discharge summaries from the hospital and other
facilities 4. Proactively contacts patients/families for appropriate follow-up care within an
appropriate period following a hospital admission or emergency department visit.
5. Exchanges patient information with the hospital during a patient’s hospitalization.
6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.
7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.
Element C: Coordinate Care Transitions 6.00 Points
MU Core Measure 16
Submit electronic data to state Immunization Registry
PCMH 6: Performance Measurement and Quality Improvement
1. The practice uses an EHR system that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis and implement updates as necessary.
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization
registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Element G: Use Certified EHR Technology 0.0 Points
MU Core Measure 17
Use Secure Electronic Messaging to communicate with Patients - 5%
PCMH 1: Patient-Centered Access
The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system. 1. More than 50% of patients have online access to their health information
within four business days of when the information is available to the practice. 2. More than 5% of patients view, and are provided the capability to download,
their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day for more than 50% of
office visits. 4. A secure message was sent to more than 5% of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test
results.
Element C: Electronic Access 2.0 Points
Stag
e 2
Men
u M
U M
easu
res 1) Syndromic Surveillance
2) Electronic Notes
3) Imaging Results
4) Family Health History
5) Cancer Registry
6) Specialized Registry
MU Menu Measure 1
Submit Syndromic Surveillance data to public health agency
PCMH 6: Performance Measurement and Quality Improvement
1. The practice uses an EHR system that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis and implement updates as necessary.
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization
registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Element G: Use Certified EHR Technology 0.0 Points
MU Menu Measure 2
Record Electronic Notes in patient records - 30%
PCMH 3: Population Health Management
The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of
patients 2. Allergies, including medication allergies and adverse reactions for more than
80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and
up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of
patients 9. List of prescription medications with date of updates for more than 80% of
patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible
professional for more than 30 % of patient with at least one office visit.
Element B: Clinical Data 4.0 Points
MU Menu Measure 3
Imaging Results are available in the EHR system - 10%
PCMH 5: Care Coordination and Care Transitions
1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the
clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test
results. 6. Follows up with the inpatient facility about newborn hearing and newborn
blood-spot screening (N/A for adults). 7. More that 30% of laboratory orders are electronically recorded in the patient
record 8. More that 30 %of the radiology orders are electronically recorded in the
patient record 9. Electronically incorporates more than 55% of all clinical lab test results into
structured fields in medical record. 10. More than 10% of scans and test that result in an image are accessible
electronically.
Element A: Test Tracking and Follow-Up 6.0 Points
MU Menu Measure 4
Record Family Health History as structured data - 20%
PCMH 3: Population Health Management
The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured data. 1. An up-to-date problem list with current and active diagnoses for 80% of
patients 2. Allergies, including medication allergies and adverse reactions for more than
80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 and
up. 4. Height/length for more than 80% of patients 5. Weight for more than 80% of patients 6. System calculates and displays BMI 7. System plots and displays growth charts 8. Status of tobacco use for patients 13 years and older for more than 80% of
patients 9. List of prescription medications with date of updates for more than 80% of
patients 10.More than 20% of patients have family history recorded as structured data 11.At least one electronic progress note created, edited and signed by an eligible
professional for more than 30 % of patient with at least one office visit.
Element B: Clinical Data 4.0 Points
MU Menu Measure 5
Capability to identify and report cancer cases to public health cancer registry
MU Menu Measure 6
Capability to identify and report specific cases to public health specialized registry
PCMH 6: Performance Measurement and Quality Improvement
1. The practice uses an EHR system that has been certified and issued a CMS certification ID.
2. The practice conducts a security risk analysis and implement updates as necessary.
3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
5. The practice demonstrates the capability to identify and report specific cases to a specialized registry electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency. 7. The practice demonstrates the capability to submit data to immunization
registries or immunization information systems electronically. 8. The practice has access to a health information exchange. 9. The practice has bidirectional exchange with a health information exchange. 10.The practice generates lists of patients, and based on their preferred method of
communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care.
Element G: Use Certified EHR Technology 0.0 Points
Care Coordination Within a Patient Centered Medical Home Practice
Angie Ross, RnCC
Catholic Health Partners
Planned and Purposeful Care
Pre-visit
visit
post visit
Between visits
Risk-based out
reach
• Identify high risk population
• Pre-visit planning
• During patient’s office visit
• Following patient’s office visit or specialty appointment
• Between visits
Identifying Patients for Care Coordination
•Produced quarterly or monthly, pulls from claims data on our population health patients in our physician practices that are based on historical claims history Practice Risk Report
•Produced daily, pulls from Meditech and lists all patients in our physician practices who have been admitted, are in observation or are at the ER by hospital Daily Census
•Produced “real time”, from Explorys and lists all patients by practice who have A1C greater than 8 as well as patient’s next visit to the practice
A1C greater than 8 Report
•During office visit, recognizing patient in need of further clinical support and management of care beyond the physician’s office
Input from Physician and Physician Staff
Initial Assessment
• Initial Evaluation – Living situation – Type of support – Mental status – Self care deficits – Durable medical
equipment – Financial assessment – Health literacy – Anticipated needs – Fall risk assessment
Develop Care Plan Patient input
Physician input
Assist with goal setting
Ongoing Workflow
• Follow up monthly calls/visits, or can be as often as several times a week based on patient needs such as: – Active medication adjustments-weekly calls for 3-4
weeks, then decreased to biweekly
– Post hospitalization initial call within 24-72 hours follow up weekly for 4 weeks
– New referrals or tests ordered facilitate scheduling; follow up post appointment to facilitate getting consult or results in patient chart
Care Coordination: Pre Visit
• Pre-visit
– Review needs prior to visit; ie are labs, retinal exam, podiatrist visit ect. due
– Communicate to physician what is due. Make sure patient knows if need to be fasting
– Was patient referred to another provider since last visit-if so, was appointment made and are visit results in the chart
Care Coordination: Office Visit
Update physician on patient goals, progress toward goals, barriers, social issues effecting treatment plan, compliance issues, patient concerns
Participate in setting and explaining plan/orders/goals
Let patient know when to expect next follow up
Care Coordination: Post Visit
• Follow up calls-frequency based on individual needs
• Face to face visits either in office or at patient’s home
• Continued education/support
Care Coordination: Patient Outcome
Goals set during initial visit:
• Weight less than 400 lbs.
• HgbA1C less than 7
• Will walk 3 times a week for 3-5 minute increments Initial Current
WEIGHT 432 lbs 408 lbs
A1C 10.3 8.5
LDL 76 75
TG’S 314 231
CHOL 142 130
Key Takeaways
• Care coordination is a key part of our success in a value-based delivery system and will help ensure an overall better experience and outcome for our patients
• Care coordination is a vital asset to our practices to ensure our eyes are on the patient during, after, and between visits with PCP and specialty
• Care coordination is vital within our practices to support and implement patient centered medical home standards
Recommended