Patient-Centered Medical Home

Physician Practice Connections –

Patient-Centered Medical Home

(PPC-PCMH)

NCQA Certification Workbook

Special Thanks to AmericanAcademy of Family Physicians (AAFP), Medical Group Management Association (MGMA) and Richard J. Barron, MD for selflessly sharing materials with us.

Special thanks, acknowledgement, and appreciationfor their contributions also go to:

The PCMH Team at HealthTeamWorks:

Natl Ctr for Medical Home Implementation and the American Academy of Pediatrics:

Institute for HealthCare Improvement:

Diabetes Initiative:

Primary Care Development Corporation:

Improving Chronic Illness Care:

Gateway Community Health Center:

Robert C. Byrd Center for Rural Health at Marshall University:

Mid-State Health – NH:

NC Academy of Family Physicians:

The PCMH Team at CCNC:

Created by:-

Zula Solomon, MBA – PCMH Quality Improvement Coach

Deb Barnett, RN, MS, FNP – Family Medicine Residency PCMH Project Manager

R. Scott Hammond, M.D. -- Primary Care Consultants, Inc.

Adapted and expanded by:-

R.W. Watkins, MD, MPH, FAAFP – Community Care of North Carolina

Table of Contents

Organizational Steps

Definitions

Abbreviations

PPC-PCMH STANDARDS AND SCORING

PPC 1: Access and Communication ( 9 Points)

PPC 2: Patient tracking and Registry Functions ( 21 Points)

PPC 3: Care Management ( 20 Points )

PPC 4: Patient Self- Management Support ( 6 Points )

PPC 5: Electronic Prescribing ( 8 Points )

PPC 6: Test Tracking ( 13 Points )

PPC 7: Referral Tracking ( 4 Points )

PPC 8: Performance Reporting and Improvement ( 15 Points )

PPC 9: Advanced Electronic Communications ( 4 Points)

Questions and Answers______59

Organizational Steps

1. Build your team

a.Establish regular meeting time

b.Delegate roles and responsibility (who will be the project manager?)

1. Establish planning time

a.Identify practice champion and block non-clinic time for the provider(s) to do the work

1. Understand what it means to be a medical home.

a.What are the joint principles?

b.Who is NCQA and what are the standards and guidelines for PPC-PCMH?

c.What is the Chronic Care Model?

1. Establish Aim and milestones

a.Create a time table

b.Identify a project manager who will hold the team accountable to meeting goals and milestones?

1. Read the workbook
2. Do the work

Definitions:

Allergies: Adverse reactions to substances.

Business associate: A person or organization that on behalf of a covered entity (health plan, health care clearinghouse or health care provider) or organized health care arrangement, which includes a covered entity, performs, or assists in the performance of, but not in the capacity of a workforce member, functions or activities involving the use or disclosure of individually identifiable health information from the covered entity or organized health care arrangement.

Clinical visit data: A record of patient activity at the practice.

Clinically important condition:A chronic or recurring condition that a practice sees most frequently, such as otitis media, asthma, diabetes or congestive heart failure. The most frequently seen single-episode conditions may also be clinically important conditions such as colds or urinary tract infections.

Contact information: Patient location facts that may include telephone number, e-mail address, payor ID and emergency contact information.

Demographic information:Information that includes at least ethnicity, gender, marital status, date of birth, type of work, hours of work and preferred language.

Diagnoses: Problem list of conditions, injuries or other health issues.

Documented process:Written statements describing the practice's procedures. The statements may include protocols or other documents that describe actual processes or blank forms the practice uses in work flow such as referral forms, checklists and flow sheets.

Emergency admissions:Any unscheduled medical or behavioral health care event that results in either an emergency room visit or hospital admission.

Evidence-based:Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion.

Evidence-based guidelines:Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion. See PRACTICE GUIDELINES.

Example:One document, report or prepared material that serves as a model for those used by the practice.

Factor:An item within an element that is scored. For example, an element may require the organization to demonstrate that a specific document includes four items. Each item is a factor.

Materials:Prepared material that the practice provides to patients, including clinical guidelines and self-management and educational resources such as brochures, Web sites, videos and pamphlets.

Multi-Site Group:Multiple practice sites of a larger organization that provide standardized systems across the practice. In this case, NCQA reviews some elements once and applies the results to all practice sites in the Multi-Site Group.

Must Pass elements:Designated elements that a practice must pass at a 50% or greater score to achieve Recognition.

Population management:The assessment of all patients in a practice to identify groups of patients who require specific services.

Practice:[Appears with in Interactive Survey System] One physician or a group of physicians at a single geographic location who practice together. Practicing together means that, for all the physicians in a practice:
1) The single site is the location of practice for at least the majority of their clinical time;
2) The non-physician staff follow the same procedures and protocols;
3) Medical records, whether paper or electronic, for all patients treated at the practice site are available to and shared by all physicians as appropriate;
4) The same systems--electronic (computers) and paper-based--and procedures support both clinical and administrative functions: scheduling time, treating patients, ordering services, prescribing, keeping medical records and follow-up.

Practice guidelines:Systematically developed descriptive tools or standardized specifications for care to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Practice guidelines are typically developed through a formal process and are based on authoritative sources that include clinical literature and expert consensus. Practice guidelines may also be called PRACTICE PARAMETERS, TREATMENT PROTOCOLS or CLINICAL GUIDELINES.

Preventive health data:A patient's status regarding receipt of preventive screenings, immunizations and counseling appropriate for the patient's age and gender.

Records or files: Actual patient files or registry entries that document an action taken. The files are a source for estimating the extent of performance against an element. There are two ways to measure this performance: 1) a query of electronic files yielding a count, and 2) the sample selection process provided by NCQA--instructions for choosing a sample and a log for reviewing records are in the Record Review Workbook.

Registry: A searchable list of patient data that the practice actively uses to assist in patient care.

Reports:Aggregated data showing evidence of action; may include manual and computerized reports.

Risk factors: Behaviors, habits, age, family history or other factors that may increase the likelihood of poor health outcomes.

Sample:A statistically valid representation of the whole.

Treatment plan:A written action plan based on assessment data that identifies the individual or patient's clinical needs, the strategy for providing services to meet those needs, the treatment goals and objectives.

Practice is done working on Element

Practice is focusing on this Element

Practice is choosing not to work on this Element

Abbreviations

Acronym / Acronym
AAFP / American Academy of Family Physicians / RIA/E / Rapid Improvement Activity/Event
ABFP / American Board of Family Physicians / RMD / Reach My Doctor
ABIM / American Board of Internal Medicine / RMHP / Rocky Mountain Health Plan
ABMS / American Board of Medical Societies / TRIA / Tobacco Rapid Improvement Activity
ABP / American Board of Pediatrics
ACP / American College of Physicians
AHRQ / Agency for Healthcare Research and Quality
AMA / American Medical Association
AQA / Ambulatory Quality Alliance
CAFP / Colorado Academy of Family Physicians
CCGC / Colorado Clinical Guidelines Collaborative
CCM / Chronic Care Model
CCNC / Community Care of North Carolina
CMS / Colorado Medical Society
CMS / Centers for Medicare and Medicaid Services
EHR / Electronic Health Record
EMR / Electronic Medical Record
EPIC / Enhancing Practice, Improving Care
FPM / Family Practice Management
HIT / Health Information Technology
ICIC / Improving Chronic Illness Care
IHI / Institute for Healthcare Improvement
IOM / Institute of Medicine
IPIP / Improving Performance in Practice
ISS / Interactive Survey System
NCAFP / North Carolina Academy of Family Physicians
NCQA / National Committee for Quality Assurance
NICHQ / National Initiative for Children’s Health Care Quality
NIH / National Institute of Health
NQF / National Quality Forum
PBM / Pharmacy Benefit Management company
PCM / Planned Care Model
PDSA / Plan Do Study Act
PHR / Personal Health Record
PPC / Physician Practice Connections
PPC-PCMH / Physician Practice Connections─Patient-Centered Medical Home
QI / Quality Improvement

PPC-PCMH STANDARDS AND SCORING

PCMH Elements by HIT Type
Basic / Intermediate / Advanced
PPC 1 A - B / PPC 2 B, C, F / PPC 6 B
PPC 2 A, D, E / PPC 5 A - C / PPC 8 F
PPC 3 A - E / PPC 8 E
PPC 4 A - B / PPC 9 A - C
PPC 6 A
PPC 7 A
PPC 8 A - D
Practice can achieve a passing score on all Must Pass Elements with Basic Health Information Technology
Possible Status / Number of Points / Must Pass Elements at 50% Scoring Level
Recognized – Level III / 75- 100 / 10 out of 10
Recognized – Level II / 50-75 / 10 out of 10
Recognized – Level I / 25- 50 / 5 out of 10
Not Recognized / 0 - 25 / 0 out of 10

Of the 30 elements in PPC-PCMH, 10 are Must Pass, that is, elements that a practice Must Pass at 50% or greater score to achieve Recognition. Practices that achieve less than 5 Must Pass elements receive a Not Recognized status. If there is a difference in Level achieved for the number of points and the Must Pass elements, the practice will be awarded the lesser level. For example, if a practice has 65 points but passes only 7 Must Pass Elements, the practice will achieve Level 1 Recognition.

PPC 1 / Must Pass / Actions for Point Person / Staff responsible / Ready for NCQA / The person assigned to do the final review / Standard Complete / NCQA document linked / Points Completed / Points Pending / Upload completed / Total Points
Element A / x / Yes No / Yes No / Yes No
Element B / x / Yes No / Yes No / Yes No
PPC 2
Element A / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
Element C / Yes No / Yes No / Yes No
Element D / x / Yes No / Yes No / Yes No
Element E / x / Yes No / Yes No / Yes No
Element F / Yes No / Yes No / Yes No
PPC 3
Element A / x / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
Element C / Yes No / Yes No / Yes No
Element D / Yes No / Yes No / Yes No
Element E / Yes No / Yes No / Yes No
PPC 4
Element A / Yes No / Yes No / Yes No
Element B / x / Yes No / Yes No / Yes No
PPC 5
Element A / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
Element C / Yes No / Yes No / Yes No
PPC 6
Element A / x / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
PPC 7
Element A / x / Yes No / Yes No / Yes No
PPC 8
Element A / x / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
Element C / x / Yes No / Yes No / Yes No
Element D / Yes No / Yes No / Yes No
Element E / Yes No / Yes No / Yes No
Element F / Yes No / Yes No / Yes No
PPC 9
Element A / Yes No / Yes No / Yes No
Element B / Yes No / Yes No / Yes No
Element C / Yes No / Yes No / Yes No

PPC 1: Access and Communication 9 Points

Intent
The practice provides patient access during and after regular business hours, and communicates with patients effectively.
Element 1A: What are your written policies for access and communication to your patients?
Element 1B: Proof that shows your practice uses polices from 1A for patient access and communication.
Who will manage this standard?
NCQA’s Example Sheet:- Standard1 examples from NCQA
PPC 1 / Must Pass / Actions for Point Person / Staff responsible / Ready for NCQA / The person assigned to do the final review / Standard Complete / NCQA document linked / Points Completed / Points Pending / Upload completed / Total Points
A / x / Not started
In process
Done
Not working on this / Yes / Yes
B / x / Not started
In process
Done
Not working on this / Yes / Yes
Notes:
Element 1A: Access and Communication Processes / Must Pass / 4 Points
The practice establishes in writing standards for the following processes to support patient access:
/ / / Do we have these factors in writing? / Tools/ Resources needed / Process
Owner / Due Date

1. Scheduling each patient with a personal clinician for continuity of care

/ Yes
No / Written policy for scheduling patients with a requested provider.

1. Coordinating visits with multiple clinicians and/or diagnostic tests during one trip

/ Yes
No / Written procedures for staff for making appointments/ scheduling patient visit so that it is one trip to get the services they need.

1. Determining through triage how soon a patient needs to be seen

/ Yes
No / Written policy for triage on what needs to been seen urgently.

1. Maintaining the capacity to schedule patients the same day they call

/ Yes
No / Measuring capacity tool

1. Scheduling same day appointments based on practice's triage of patients' conditions

/ Yes
No / Procedures

1. Scheduling same day appointments based on patient's/family's requests

/ Yes
No / Open Access Article

1. Providing telephone advice on clinical issues during office hours by physician, nurse or other clinician within a specified time

/ Yes
No

1. Providing urgent phone response within a specific time, with clinician support available 24 hours a day, 7 days a week

/ Yes
No / Policy on returning urgent calls
What is your afterhour’s coverage? Sending to ER doesn’t meet standard.

1. Providing secure e-mail consultations with physician or other clinician on clinical issues, answering within a specified time

/ Yes
No / Policy on checking e-mail
If using, website for appt, rx refill, test results, etc… what is your policy?
Tool: RMD if your EMR doesn’t have this functionality

1. Providing an interactive practice Web site

/ Yes
No / If using, website for appt, rx refill, test results, etc… what is your policy?
Tool: RMD if your EMR doesn’t have this functionality

1. Making language services available for patients with limited English proficiency

/ Yes
No
PPC 4A asks similar communication question. / You don’t have to have policy on this factor. You just have to make a notation in the Support Test/Notes Box.
What percent of your practice have limited English proficiency?
Do you have bilingual staff?
Resources: Language lines (AT&T, Sprint..)

1. Identifying health insurance resources for patients/families without insurance.

/ Yes
No / What is the nearest CHC? Safety net clinic?
What the phone number for Medicaid/ Medicare?
Examples / Data source: Written procedures for staff for appointments, triage and patient communication; log or schedule to demonstrate capacity (Item 3).
Tools/ Resources /

1. Policies and Procedures (chapter 3)
2. MGMA’s - Operating Policies and Procedures: Manual for Medical Practices by Elizabeth Woodcock.

(MGMA Member $135, Joint MGMA-ACMPE member , MGMA affiliate $162.00 , Non-member $211.00)

• Practice Access Policies (examples) – (click_here)

1. Measuring Demand and Capacity

What Works, Effective Tools & Case Studies To Improve Clinical Office Practice by Sue Houck. HealthPress Publishing, 2004, chapters 3 and 7.

• Same Day Appt Tally Sheet (Word doc) (click_here)
• Same Day Appt Spreadsheet (Excel doc) (click_here)
• Open Access (Same Day Appts) Introduction (click_here)
• Open Access Preparation (click_here)
• Open Access Implementation (Instructions and Insights) (click_here)

/

Murray MD, Mark. Same Day Appointment: Exploding the Access Paradigm. FPM 2000 (click here)

• IHI’s Demand and Capacity Diagnostic Tool (click here)
• IHI.org - Shortening Waiting Times: Six Principles for Improved Access (click here)
• Access Workbook (click here)

1. Health Insurance Resources of Patients/ Families without insurance
2. Community Health Centers/ Safety Net Clinics –
3. Community Resources Toolkit (

1. Language Resources
2. NC Professional Interpreters Association -
3. AT&T’s Language Line ( )
4. HealthTranslations.com ( )

1. RMD – Activation of all of the RMD features (click here)

1. Practice Examples:

PCMH 1A1 ( PCMH1A1.pdf) – Scheduling Policy
PCMH 1A2 ( Lakeside Practice\PPC1A-2-One Stop Shop - Referral Policy.pdf) – Coordinating Care
PCMH 1A3,5 ( Lakeside Practice\PPC1A-3,5 Triage Policy.pdf) - Triage Policy
PCMH 1A4 ( PCMH1A4.pdf) – Advanced Access
PCMH 1A1,4,6 ( Lakeside Practice\PPC1A-1,4,6 Open Access Policy.pdf) – Open Access
PCMH 1A7 ( Lakeside Practice\PPC1A-7-Phone Note Policy.pdf) – Phone Policy
PCMH 1A8 ( Lakeside Practice\PPC1A-8 On-Call Policy.pdf) – On call Policy
PCMH 1A10, 11 ( PCMH1A,10,11) – Language and Web-based Services
PCMH 1A11 ( Lakeside Practice\PPC1A-11-Guide to Interpreter Service.pdf) – Interpreter Service
PCMH1A12 ( Lakeside Practice\PPC1A-12 Patient Advocacy Policy.pdf) – Patient Advocacy Policy
PCMH1A12 (Lakeside Practice\PPC1A-12-Financial Assistance Policy.pdf ) – Financial Assistance
Percentage / Min. score to pass / Our Score
100% / Practice has written processes for 9 -12 items
75% / Practice has written processes for 7 - 8 items
50% / Practice has written processes for 4 - 6 items / X
25% / Practice has written processes for 2 – 3 items
0% / Practice has written processes for 0 - 1 items
Further Examples/Notes:
Telephone/Email Response Policy (click here )
Scheduling, Same Day Appts, Triage, Care Coordination Policy (click here )
Access and communication Policy (click here )
Care Coordination between PCP and Specialist Policy (click here )
Practice Access and Communication Policies 2 ( click here)
Patient Portal Policies (click here ) or (click here)
Element 1B: Access and Communication Results / Must Pass / 5 Points
The practice's data shows that it meets access and communication standards in 1A:
/ / / What needs to happen? / Tools/ Resources / Process
Owner / Due Date

1. Visits with assigned personal clinician for each patient

/ Not started In process Done Linked /

• Patient Feedback Card

1. Appointments scheduled to meet the standards in Items 2-6 in 1A

/ Not started In process Done Linked /

• Excel Pt. Feedback Tracking sheet
• Logs

1. Response times to meet standards for timely response to telephone requests

/ Not started In process Done Linked /

• Patient Feedback Card

1. Response times to meet its standards for timely response to e-mail and interactive Web requests

/ Not started In process Done Linked /

• can exclude patient that don’t have email

1. Language services for patients with limited English proficiency.

/ Not started In process Done Linked /

• can mark NA if language services aren’t required

Examples / Tracking reports, either paper or screen shots, showing records for a period of appointments with personal clinicians, average wait for appointments, average time for returning telephone calls and emails.

• Visits with assigned physician
• Timely response to phone, e-mail and Internet requests
• Language services if the practice’s population requires it

Tools/ Resources /

1. Patient Satisfaction Survey

Patient Feedback Card (click here) & Excel Tracking Sheet (click here) For a more in-depth survey (click here )
For making sure patients are being seen in a timely manner use the Patient Cycle Tool (click here )

1. Logs

• 3rdnext available appointment, no show, telephone response time, # of same day appointments available, fill rate, ..etc (click here)Also see below for more examples.
• Open Access information -
• Supply Demand worksheet - click here For an example ( click here)

1. Reports from “How’s your Health”

1. Article:- Getting the most of your phone system (click here)

1. Panel Size How Many Patients Can a Provider Handle (click here)

Percentage / Min. score to pass / Our Score
100% / Practice data meets 5 items
75% / Practice data meets 4 items
50% / Practice data meets 3 items / X
25% / Practice data meets 2 items
0% / Practice data meets 0-1 items
Practice Examples/Notes:
PCMH 1B1 – Personal Physician (..\Practice Examples\Lakeside FP\PPC1B-1-LO Personal Clinician.pdf )
( ..\Practice Examples\Elizabeth FP\1B_1_Elizabeth[1].pdf)
PCMH 1B2 – Same Day Log (..\Practice Examples\Lakeside FP\PPC1B-2 Same Day Log LO.pdf )
( ..\Practice Examples\Lakeside FP\PPC1B-2-LO-Minimized-Trips.pdf)
(..\Practice Examples\Lakeside FP\PPC1B-2-LO-Same Day Appointment Scheduled.pdf )
(..\Practice Examples\Elizabeth FP\1B_2_Elizabeth_Family.pdf )
PCMH 1B3 – Phone Turn-Around Time ( ..\Practice Examples\Lakeside FP\PPC1B-3 LO Phone Note.pdf)
(..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log LO.pdf )
(..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log Summary.pdf )
(..\Practice Examples\Elizabeth FP\1B_3_Elizabeth.pdf )
PCMH 1B5 – Language Services (..\Practice Examples\Lakeside FP\PPC1B-5-LO-Language Services.pdf )
(..\Practice Examples\Elizabeth FP\1B_5_Elizabeth[1].pdf )
( LanguageServicesPolicy)

PPC 2: Patient tracking and Registry Functions21 Points