Candace Chitty RN, MBA, CPHQ, PCMH-CCE 5_NCQA PCMH... · 2017 NCQA PCMH Webinar Series, Standard Five: Care Coordination and Care Transitions 5/9/2018 1 1 Candace Chitty RN, MBA,

2017 NCQA PCMH Webinar Series, Standard Five: Care Coordination and Care Transitions

5/9/2018

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Candace ChittyRN, MBA, CPHQ, PCMH-CCE

6 PCMH Concepts within the standards

1. Team-Based Care and Practice Organization (TC).

2. Knowing and Managing Your Patients (KM).

3. Patient-Centered Access and Continuity (AC).4. Care Management and Support (CM).5. Care Coordination and Care Transitions (CC).

6. Performance Measurement and Quality Improvement (QI).

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The practice systematically tracks tests, referrals and care transitions to achieve high quality coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

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Three competencies 5 Core Criteria (CC 01, 04, 14, 15, 16) 16 Elective Criteria (CC 02, 03, 05, 06, 07, 08,

09, 10, 11, 12, 13, 17, 18, 19, 20, 21)

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Competency A: CC 01- 03 The practice effectively tracks and manages

laboratory and imaging tests important to patient care and informs patients of the results.

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CC-01 is a Core Criteria (aligns with 2014 PCMH 5A Factors 1-5).The practice systematically manages lab and imaging tests byA. Tracking lab tests until results are available, flagging and following up on overdue results.

B. Tracking imaging tests until results are available, flagging and following up on overdue results.

C. Flagging abnormal lab results, bringing them to the attention of the clinician.

D. Flagging abnormal image results, bringing them to the attention of the clinician.

E. Notifying patients/families/caregivers of normal lab and image results.

F. Notifying patients/families/caregivers of abnormal lab and image results.

Evidence: Shared (Documented process only)

Documented Process: Describes a systematic process for staff to follow to track, report, and notify patients of lab and image testing

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Evidence of Implementation: Examples showing how the process is met including patient notification (reports, logs, examples of electronic tracking system, letters, documented phone encounters, etc)

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CC-02 is an elective criteria (aligns with 2014 PCMH 5A Factor 6).

1 creditThe practice follows up with the inpatient facility about newborn hearing and blood-spot screening.


Documented Process: Describes the process for staff to follow up with hospitals to obtain hearing and blood-spot screening results.

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Evidence of Implementation: Examples of follow up completed.

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CC-03 is an elective criteria and is New for 2017.

2 creditsThe practice uses clinical protocols to determine when imaging and lab tests are necessary.

Evidence: Shared

Evidence of Implementation: Examples of clinical protocols used that are based on evidence-based guidelines and/or evidence of implementation of clinical decision supports to ensure that protocols are used.

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Competency B: CC 04 - 13 The practice provides important information

in referrals to specialists and tracking referrals until the report is received.

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CC-04 is a Core Criteria (aligns with 2014 PCMH 5B Factors 5,6, and 8).The practice systematically manages referral by:A. Giving the consultant or specialist the clinical question, the required timing and the type of

referral.

B. Giving the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan.

C. Tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue results.


Documented Process: Describes a systematic process for staff to follow to track and follow-up on specialist/consultant referrals. The tracking process includes the date when the referral was initiated and the timing indicated for receiving the report with documentation of staff efforts.

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Evidence of Implementation: Examples of systematic referral tracking and follow up (reports, logs, examples of electronic tracking system, etc)

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2 creditsThe practice uses clinical protocols to determine when a referral to a specialist is necessary.

Evidence:

Evidence of Implementation: Examples of clinical protocols used that are based on evidence-based guidelines and/or evidence of implementation of clinical decision supports to ensure that protocols are used.

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1 creditThe practice identifies the specialists/specialty types frequently used by the practice.

Evidence:

Evidence of Implementation: Examples high volume specialist/specialty types the practice refers to. (list, report, etc)

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CC-07 is an elective criteria (aligns with 2014 PCMH 5B Factor 1).

2 creditsThe practice considers available performance information on consultants/specialists when making referrals.

Evidence: Shared

Data Source: Lists the data source used such as Health Grades, CMS, etc.

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Examples of the information provided from the data sources used. NOTE: Information gathered in CC-11 may be useful in this assessment of consultants/specialists.

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1 creditThe practice works with nonbehavioral healthcare specialists to whom the patient frequently refers to set expectations for information sharing and patient care.

Evidence: Shared

Documented Process: Describes the process for establishing formal or informal relationships with nonbehavioral healthcare specialists.

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Agreement between practice and nonbehavioral healthcare specialist that establishes expectations for the exchange of information (e.g., frequency, timeliness, content).

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2 creditsThe practice works with behavioral healthcare specialists to whom the patient frequently refers to set expectations for information sharing and patient care.

Evidence: Shared

Agreement between practice and behavioral healthcare specialist that establishes expectations for the exchange of information (e.g., frequency, timeliness, content).

OR

Documented Process: Describes the process for establishing formal or informal relationships with behavioral healthcare specialists, and

Evidence of Implementation: demonstrates across patients in a report, log, or electronic tracking system of behavioral health services. A notification demonstrating legal inability to receive a report that includes confirmation of a BH visit occurred meets the requirement.

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2 creditsThe practice integrates behavioral healthcare providers into the care delivery system of the practice site.


Documented Process: Describes the process for behavioral health integration.

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Evidence of Implementation: Examples of patient materials, referrals, workflows showing shared accountability and collaborative treatment and workflow strategies.

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1 creditThe practice monitors the timeliness and quality of the referral response.


Documented Process: Describes the process for monitoring and the defines the timely on patient need.

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Report: Data collected to report referral responses in comparison to the practice’s timeliness standard(s) and evaluates whether the response was timely and provided appropriate information about the patient’s diagnosis and treatment plan. (chart audit, report, etc).

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CC-12 is an elective criteria (aligned with 2014 PCMH 5B Factor 9).

1 creditThe practice documents co-management arrangements in the patient’s medical record.

Evidence:

Evidence of Implementation: Three examples of co-management arrangements that includes sharing changes in the treatment plan and patient health status, in addition to entering information in the medical record within an agreed upon time frame.

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2 creditsThe practice engages with patients regarding cost implications of treatment options.


Documented Process: Describes how the practice engages patients. For example, adding a financial question to the clinical intake screening (do you have trouble affording the care or prescriptions prescribed, etc).

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Evidence of Implementation: Example(s) of discussions about cost implications and how used to recommend less expensive treatment options, if appropriate.

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Competency C: CC 14 - 21 The practice connects with health care

facilities to support patient safety throughout care transitions.

The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.

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CC-14 is a core criteria (aligned with 2014 PCMH 5C Factor 1).The practice systematically identifies patients with unplanned hospital admissions and emergency department visits.


Documented Process: Describes how the practice identifies patients. The process musts state how often monitoring takes place.

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Report with the proportion of local admissions and ED visits (reported separately) to facilities where practices have an established notification exchange mechanism.

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CC-15 is a core criteria (aligned with 2014 PCMH 5C Factor 2).

The practice shares clinical information with admitting hospitals and emergency departments.


Documented Process: Describes how the practice shares information.

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Evidence of Implementation: Three examples.

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CC-16 is a core criteria (aligned with 2014 PCMH 5C Factor 4).

The practice contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit.


Documented Process: Describes how the practice conducts the follow-up process post discharge and includes established time frames for follow-up to occur.

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Evidence of Implementation: Log documented systematic follow-up was completed.

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1 credit

The practice has the systematic ability to coordinate with acute care settings after office hours through access to current patient information.


Documented Process: Describes how the practice coordinates with acute care facilities when a patient is seen after the office is closed.

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Evidence of Implementation: At least one example of coordination with the facility.

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CC-18 is an elective criteria (aligns with 2014 PCMH 5C Factor 5)

1 credit

The practice exchanges information with the hospital during a patient’s hospitalization.


Documented Process: Describes how the practice facilitates exchange of information (portal, calls, etc).

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Evidence of Implementation: Three examples of the data exchange during a patient’s hospitalization.

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CC-19 is an elective criteria (aligns with 2014 PCMH 5C Factor 3)

1 credit

The practice implements a process to consistently obtain patient discharge summaries from the hospital and other facilities.

Evidence: Shared (Documented process only)Documented Process: Describes how the practice obtains discharge summaries in a consistent manner.

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Evidence of Implementation: Three examples of obtaining DC summaries or demonstrates participation in the local admission, discharge, transfer (ADT) system.

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CC-20 is an elective criteria (aligns with 2014 PCMH 2A Factor 4)

1 credit

The practice collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., pediatric to adult care).

Evidence: Evidence of Implementation: Example of written care plan. For family medicine practices that do not transition the practice should example how it educates patients and families about ways in which their care experience may change. Sensitivity to privacy concerns should be incorporated into messaging.

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CC-21 is an elective criteria (aligns with 2014 PCMH 5B Factor 7 and 5C Factor 7)

3 credits maximum

The practice demonstrates electronic exchange of information with external facilities, agencies and registries. May select one or more.A. Regional health information organization or other HIE source that enhances the

practice’s ability to manage complex patients (1 credit)

B. Immunization registries or immunization information systems (1 credit)

C. Summary of care record to another provider or care facility for care transitions (1 credit)

Evidence: Evidence of Implementation: Example of electronic exchange(s).

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Concept 6: Performance Measurement and Quality

Improvement (QI)

Wednesday, May 23 2018 from 1PM – 2PM Central

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Documents

Candace Chitty RN, MBA, CPHQ, PCMH-CCE 5_NCQA PCMH... · 2017 NCQA PCMH Webinar Series, Standard Five: Care Coordination and Care Transitions 5/9/2018 1 1 Candace Chitty RN, MBA,