~ HIT Investment and Quality Outcomes~ The Patient-Centered Medical Home.

~ HIT Investment and Quality Outcomes~The Patient-Centered Medical Home

2~HIT Investment in the PCMH and Quality Outcomes~

National Committee for Quality AssuranceNCQA

Our Mission• To improve the quality of health care

Our Methods• MeasurementWe can’t improve what we don’t measure

• TransparencyWe show how we measure, so measurement will

be accepted

• Accountability Once we measure, we can expect and track

progress


Outcomes and PCMH

• Some Examples:– $10 PMPM reduction in total costs; total PMPM cost $488 for PCMH patients

vs. $498 for control patients (p=.076).– 16% reduction in hospital admissions (p<.001); 5.1 admissions per 1,000

patients per month in PCMH patients vs. 5.4 in controls. $14 PMPM reduction in inpatient hospital costs relative to controls. 29% reduction in emergency department use (p<.001); 27 emergency department visits per 1,000 patients per month in PCMH patients vs. 39 in controls. $4 PMPM reduction in emergency department costs relative to controls.

– Geisinger has estimated in unpublished reports an ROI of more than 2 to 1 for its investment in its PCMH model, and is spreading the ProvenHealth Navigator PCMH model throughout the Geisenger Health System.

• Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites.

Source: http://www.pcpcc.net/files/evidence_outcomes_in_pcmh_2010.pdf


PPC-PCMH & PCMH SITES BY STATE

ME

VT

RI

NJ

MD

MA

DE

NY

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PAOH

VAMO

HI

OK

GA

SC

TN

MT

KY

WV

AR

LA

AL

INIL

SD

ND

TX

ID

WY

UT

AK

CA

CT

NH

61-200 Sites

*As of 08/31/12

MS

21-60 Sites

0 Sites

1-20 Sites

201+ Sites4772 Sites

22565 Clinicians


PCMH 2011 Content and ScoringPCMH 1: Enhance Access and Continuity

A. Access During Office Hours**B. Access After HoursC. Electronic AccessD. Continuity (with provider)E. Medical Home ResponsibilitiesF. Culturally/Linguistically Appropriate

ServicesG. Practice Organization

Pts

4422224

20

PCMH 2: Identify and Manage Patient Populations

A. Patient Information B. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population

Management**

Pts

3445

16

PCMH 3: Plan and Manage Care

A. Implement Evidence-Based Guidelines B. Identify High-Risk PatientsC. Care Management**D. Medication ManagementE. Use Electronic Prescribing

Pts

43433

17

PCMH 4: Provide Self-Care and Community Resources

A. Support Self-Care Process**B. Provide Referrals to Community

Resources

Pts

63

9

PCMH 5: Track and Coordinate Care

A. Track Tests and Follow-UpB. Track Referrals and Follow-Up**C. Coordinate with Facilities/Care

Transitions

Pts

666

18

PCMH 6: Measure and Improve Performance

A. Measure PerformanceB. Measure Patient/Family ExperienceC. Implement Continuous Quality

Improvement** D. Demonstrate Continuous Quality

ImprovementE. Report PerformanceF. Report Data ExternallyG. Use Certified EHR Technology

Pts

44

4

332

20

Optional Patient Experiences Survey

**Must Pass Elements


Meaningful Use of Health Information Technology (HIT)

• NCQA emphasizes HIT because good primary care is information-intensive

• PCMH 2011 reinforces incentives to use HIT to improve quality

• Meaningful Use language is embedded, often verbatim, in PCMH 2011 evaluation standards

• Synergy/virtuous cycle: PCMH 2011 medical practices will be well prepared to qualify for meaningful use, and vice versa


NCQA’s PCMH* and Meaningful Use

~ Powerful Synergy ~

Patient-Centered Medical Homes Build on Meaningful Use

Foundation

* Based on Stage 1 Meaningful Use Requirements Update to Stage 2 planned


NCQA’s PCMH 2011 and Meaningful Use

PCMH closely aligned with Stage 1 MU• Electronic prescribing• Drug formulary, drug-drug, drug allergy checks • Maintaining an up-to date problem list of current

and active diagnoses and medications• Recording demographics on preferred language

gender (sex), race, ethnicity and date of birth• Recording and charting changes in vital signs• Recording smoking status• Reporting ambulatory quality measures • Implementing clinical decision support rules…

Plan similar alignment with Stage 2 MU


PCMH 1: Enhance Access and Continuity

Intent of Standard• Patient access to

routine/urgent care and clinical advice during/after hours that are culturally and linguistically appropriate

• Electronic access• Clinician selected by patient• Team-based care; trained

staff

Meaningful Use Criteria

Patients provided electronic:

• Copy of health information

• Clinical summary of visit

• Access to health information


PCMH 2: Identify/Manage Patient Populations

Intent of Standard• Collects demographic

and clinical data for population management

• Assess/document risks• Create lists; use for

point of care reminders

Meaningful Use Criteria• Language, gender (sex),

race, ethnicity, DOB• Problem list• Medication list• Medication allergy list• Vital signs• Growth chart (peds.)• Smoking status• Lists of patients with

specific conditions for QI, decrease disparities

• Follow-up reminders for care


PCMH 3: Plan and Manage Care

Intent of Standard• Identify patients with

specific conditions including high-risk or complex, behavioral health

• Care management – Manage care using

point-of-care reminders

– Pre-visit planning – Progress toward goals – Barriers to treatment

goals• Reconcile medications• E-prescribing

Meaningful Use Criteria• Clinical decision support• Medication reconciliation

with transitions of care• E-prescribing• Drug-drug, drug-allergy

checks• Transmit prescriptions

using EHR• Drug-formulary checks


PCMH 4: Provide Self-Care/Community Resources

Intent of Standard• Assess self-management

abilities• Document self-care plan• Provide educational tools

and resources• Counsel on healthy

behaviors• Assess/provide/arrange

for mental health/substance abuse treatment

• Provide community resources

Meaningful Use CriteriaPatient-specific education

materials


PCMH 5: Track and Coordinate CareIntent of Standard• Tracks, follows-up on and coordinates tests,

referrals and patient care in other

facilities• Orders, retrieves and

incorporates into patient records lab and imaging results

• Establish information exchange with facilities

• Follows up with discharged patients

• E-information exchange• E-summary of care

Meaningful Use Criteria• Incorporate lab/test

results• Exchange patient

information with other providers (meds/ allergies, tests)

• Provide summary care record for transitions and referrals


PCMH 6: Measure and Improve Performance

Intent of Standard• Practice uses

performance and patient experience data to continuously improve

• Track utilization measures

• Identifies vulnerable populations

• Report data to CMS, immunization registries, public health agencies

Meaningful Use CriteriaReport:• Ambulatory clinical

quality measures to CMS/state

• Immunization data to registries

• Syndromic surveillance data to public health agencies


Alignment: Health IT Meaningful Use & NCQA’s PCMH 2011Domain MU-only MU-PCMH Alignment PCMH-only

Protecting Privacy Protect EHRs/secure electronic messaging

Using Patient Information

Family History as structured data(Stage 2)

Record and chart vital signsRecord smoking statusImaging results/ info accessible through EHR Clinical lab-test results in EHR as structured dataGenerate lists of patients by conditions Surveillance data to public health agencies

Comprehensive Health Assessment (including family history)Use Data for Population ManagementPlan and Manage CareIdentify High-Risk PatientsCare ManagementMeasure Patient/Family Experience

Patient Education/Self Care

Clinical summaries to patients for each visitLet patients view online, download, transmit health information w/in 4 business days ID patients for preventive/follow-up reminders Use EHR to ID/provide patient-specific education

Support self-management/behavior change

Care Coordination Summary record for each transition or referralMed reconciliation from other provider/setting

Care teams coordinate carePopulation managementSupport self-mgmt/behavior changeReferrals to Community ResourcesReferral tracking & follow-upPerformance evaluation & QI

Medication Management

Electronic Rx & CPOE for meds, lab & radiology

Decision Support Use clinical decision support to improve performance on high-priority health condition

Disparities Record demographics as structured data Assess patients; racial/ethnic diversity Assess language needs Provide interpretation/bilingual services Printed materials patients’ languages

Reporting Report to Registries (Stage 2)

Report clinical quality measures to CMS Electronic data to immunization registries

Measure and Improve Performance

Enhance Access and Continuity

Same day appointmentsPhone/electronic adviceAfter-hours access

~ HIT Investment and Quality Outcomes~ The Patient-Centered Medical Home.

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