The document outlines the principles, benefits, and standards of the Patient-Centered Medical Home (PCMH) model, including the 2011 NCQA standards for practice transformation. Key elements such as enhanced access, coordinated care, and patient engagement are emphasized, along with a framework for self-assessment and preparation for PCMH recognition. It also details the steps practices should take to achieve and sustain this recognition, including timelines, action planning, and necessary resources.

1. Patient Centered Health Home
Overview and Preparation
February 2013
Dawn Gentsch, MPH, MCHES
PCHH Practice Transformation Facilitator
Great Basin Primary Care Association

2. Objectives for Webinar
• Overview of the principles and benefits of patient
centered medical home (PCMH) recognition.
• Understand the basic elements of the PCMH
standards, self-assessment and survey application
process for the National Committee for Quality
Assurance 2011 standards.
• Identify the next steps for your primary care
practice regarding the PCMH transformation
journey.

6. Principles for the Patient-Centered
Medical Home
• Personal physician/clinician
• Team-based care
• Whole person orientation
• Enhanced access (with continuity)
• Coordinated & integrated care
• Quality & safety prioritized
• Payment for the value provided

7. Medical Home: What it Looks Like
• A health care setting that provides patients with:
– well-organized & on-time visits
– enhanced access with their own provider & care team for continuity (same
day appointment availability, 24/7 telephone access, alternatives to the 1:1
visit)
– proactive care management (evidence-based clinical care, panel
management, reminder systems, registries)
– care coordination across settings (assistance with referrals, tracking for
tests & referrals; care during transitions)
– patient activation, engagement & participation in decisions on care
(patient centered  customer driven)
– connections to community resources to extend resources for care
– focus on health outcomes & goals for improvement
– use of Health IT as tool to support the achievement of advanced primary
care practice

12. Medical Home: Aligned with (Chronic) Care Model
Health System:
Community Health Care Organization
Resources Self- Decision Delivery Clinical
and Management Support System Information
Policies Support Design Systems
Informed, Prepared,
Activated Productive Proactive
Patient Interactions Practice Team
Functional and Clinical Outcomes

13. From Purpose To Practice: A Continuing Journey
Of Commitment
• PCMH focus is a continuation of the purpose-
driven journey of FQHCs
• Opportunity: continue our work to transform
practice to the highest levels of performance and
to obtain recognition for this achievement
• Recognition as a medical home is increasingly
associated with opportunities for enhanced
payment for the value created.

14. Suma Nair, MS, RD; Director Office of Quality and Data HRSA BPHC
810 ‘12-’13
grant
KyPCA Applied PCMH Webinar #1 01.16.13

15. NCQA 2011 Standards
• NCQA released its latest standards, PCMH 2011
in January 2011
• The new standards direct practices to organize
care according to patients’ preferences and
needs, and reinforce federal “meaningful use”
incentives for primary care practices to adopt
health information technology
– Meaningful use criteria (all 25) are in the standards
– Creates virtuous cycle for PCMH & MU

16. 2011 NCQA PCMH Standards
1. Enhance Access and Continuity
2. Identify and Manage Patient
Populations
3. Plan and Manage Care
4. Provide Support for Self-Care
5. Track and Coordinate Care
6. Measure and Improve Performance

17. 2011 NCQA PCMH Structure & Relationships
Reflect core principles of
primary care.
PCMH Joint Principles Evaluate practice’s ability to
function as a PCMH
Scored component
of standards
Provide details for
performance
expectations
6 Standards
Scored items for each
28 Elements (6 MPE) element
They reflect specific
capabilities for PCMH
147 Factors (8 CF)
Documentation is developed to demonstrate the capability as described by Factors

18. NCQA 2011 – Standards & Intent
• Access and Continuity: Provide team-based care with access and
advice during and after hours and patient/family information
about medical home
• Identify and Manage Patient Populations: Acquire and use data
for care of the practice’s population
• Plan and Manage Care: Use evidence-based guidelines for
preventive, acute and chronic care management for chronic,
frequent and behavior-based conditions, including medication
management
• Self-Care: Support patient and family in self-care with
information, tools and community resources
• Track and Coordinate Care: Track and coordinate tests, referrals
and transitions of care
• Performance Measurement and Quality Improvement: Use
performance and patient experience data for continuous quality
improvement

20. Important Parts of the
Structure
• Must Pass Elements
• Critical Factors
• Meaningful Use
• Documentation

24. Critical Factors -- central to capability being assessed;
important impact on scoring
• 1A1: Provide same day appointments [MPE]
• 1B3: Provide timely clinical advice by phone after hours
• 1G2: Have regular team meetings and communication processes
• 3A3: 3rd important condition for MH/SA or unhealthy behavior
• 3D1: Review & reconcile medications with patients/families for more
than 50% of care transitions**
• 3E2: Generate at least 75% of eligible prescriptions electronically*
• 4A3: Develop & document self-management plans and goals in
collaboration w/ at least 50% of patients/families** [MPE]
• 5A1: Track labs until results are available, flagging and following-up on
overdue results
• 5A2: Track imaging tests until results are available, flagging and
following-up on overdue results
NOTE: items in blue are must pass elements
* and ** are meaningful use items (3D1, 3E2, 4A3)

25. Anatomy of a Standard
Standard Name, Points &
Intent
Element Name, Points,
Description of Performance
Expectation
Factor: Scored item in an
Element
NOTE: * and ** indicate MU
criteria
Scoring Description
Explanation: Additional info on
what NCQA is looking for
Documentation Examples
Source: NCQA See pg 19 of NCQA Standards & Guidelines,
March 28, 2011 for definitions

41. Element 6B: relates to MPE 6C
Source: NCQA

43. Recognition & Transformation
“Recognition… is only the beginning of a journey for continuous
improvement and cultural transformation.
NCQA’s rigorous standards challenge a practice to examine nearly
every aspect of its operations. The evolution to a PCMH is a
serious undertaking — one that rewards patients with more
coordinated, focused and safer care, and rewards providers
with greater satisfaction in practicing medicine.”
- Marjie Harbrecht, MD
CEO, HealthTeamWorks, Colorado

44. RRWB is the Supplemental Worksheet
Click here
Click here

45. The Chart Review Using the
Record Review Workbook
• 2011 Elements PCMH 3C, 3D, 4A
− Require medical record abstraction of data
− Need % of patients for each factor based on
numerator and denominator
• Two methods to collect and submit patient data
– Method #1 - report from the electronic system
– Method #2 – Record Review Workbook
• Excel workbook in the Survey Tool
• Tool to identify sample of patients and abstract data

46. PCMH 3C: Care Management
Entering NOT USED in row 1
“grays” out the column for all
entries
Response Options
 Yes
 No
 Not Used
 Not applicable

47. Questions - PCMH Standards
Which PCMH standard is of greatest interest to
you, where will your clinic start?
What QI goal do you think you will start with?

48. NCQA PCMH 2011 Self-Assessment

49. PCMH-A

50. PCMH-A Background & Context
• Developed to measure a site’s progress
towards achieving the 8 Change Concepts
• Self-administered assessment
• Aids in the identification of improvement
opportunities
• Stimulates conversations with other sites to
learn, share, & transform
• Serves as a standardized measure of progress

51. PCHH Timeline General Planning

53. Decide/Plan
Assess 3
2
Take Action
4
Understand
1
The setting
for a Support &
BIG Idea
5 Sustain

54. Next Steps (Homework)
• Review the requirements for each standard,
element and factor
– What does the practice already do?
– What does the practice need to create?
– Are there elements the practice clearly does not
have in place but does not wish to implement in
the near-term?
• Complete the NCQA PCMH Baseline Self
Assessment tool in excel
– Complete the PCMH-A
• Complete a gaps analysis
– Timeline and work plan

55. Steps in the Process – You have
(will need to) taken!
• Form the Lead Team
• Get Ready
• Assess IT Requirements
• Know Your Deadlines
• Set Your Goals and Timeline for Recognition
• Order Interactive Survey System and On-Line
Application from NCQA
• Determine Eligibility for the Multi-site Survey Option
• Complete Your Survey
• Prepare & Submit Survey (you know when!)
• Receive Recognition Decision from NCQA (TBD)

56. Develop Your Action Plan
• Identify resources available for this project
• Refine the timeframe
• Identify roles and tasks for each of your team members
• Include key activities to facilitate the process:
– System to organize documentation
– Attend NCQA training courses, other courses
– Multi-Site network and survey or single sites
• Develop a schedule for completing your submission
using ISS
• Be as specific as possible
– Key deliverables and set completion deadlines
– Active verbs: identify, develop, review, draft, complete,
convene

57. GBPCA Website
• PCMH Resources
– Readiness Tools
– Planning/Preparation
– Standards/Guidelines
– Training
– Research, evidence-based
www.gbpca.org

58. Contact Information – TA and Coaching
through GBPCA
Dawn Gentsch, MPH, MCHES
Great Basin Primary Care Association
PCMH Practice Transformation Facilitator
dgentsch@gbpca.org
515.360.1731