Overvie w Megan A. Housley, MBA Business Development Director - - PowerPoint PPT Presentation

Megan A. Housley, MBA Business Development Director Kentucky Regional Extension Center

Practice Transformation: Patient Centered Medical Home Overview

The Triple Aim

Population Health Per Capita Cost

TRIPLE AIM

Experience

• f Care

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
• f 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

• wn/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

Stage 2 Core MU Measures

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

• ffice visit within
• ne 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

• verdue results. (CRITICAL FACTOR)

2. Tracks imaging tests until results are available, flagging and following up on

• verdue 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

• f 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%

• f 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
• ffice 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

Stage 2 Menu MU Measures

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

• verdue results. (CRITICAL FACTOR)

2. Tracks imaging tests until results are available, flagging and following up on

• verdue 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
• ffice visit or specialty

appointment

• Between visits

Identifying Patients for Care Coordination

• Produced quarterly or monthly, pulls from claims data on
• ur 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
• ur physician practices who have been admitted, are in
• bservation 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
• ften 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

THANK YOU