We wrap up our PCMH series with a deep dive into Standard 5-Care Coordination and Care Transitions and Standard 6- Performance Measurement and Quality Improvement. How are you handling referrals and transitions of care today? Do you need to make changes to optimize the process? We’ll review care coordination elements and factors as well as the performance improvement standards, elements, and associated factors in this webinar to complete your practice’s PCMH transformation!

1. PCMH: PART 4
CARE COORDINATION AND PERFORMANCE
IMPROVEMENT AND QUALITY IMPROVEMENT PROGRAMS
JUNE 24, 2016

2. Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
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3. Presenter
Christy Erickson, MSN, PMP, PCMH CCE
Director, Clinical Transformation
Over 10 years of Healthcare IT & Clinical
Informatics experience
Over 25 years of Nursing & Nurse
Practitioner experience

4. Agenda
• PCMH Overview
• Standard 5- Care Coordination and Care
Transitions
• Standard 6- Performance Measurement and
Quality Improvement
• Brief review of changes between 2011 and 2014
standards
• MU Alignment of Standards

5. This just in……….MACRA
• MACRA- The Medicare Access and CHIP Reauthorization
Act of 2015- WEDNESDAY, 4/27/16 ruling released
– Changes payment for Medicare beneficiaries FFS program
replacing sustainable growth rate (SGR) formula
• 2 Paths
– MIPS
• Quality (PQRS) (50%)
• Advancing Care Information (MU) (25%)
• Clinical Practice Improvement Activities (15%)
• Resource Use Measures (VM) (10%)
– APM’S
• CPC Plus
• ACO’s (MSSP, Next Generation ACO Model)
• Comprehensive End Stage Renal Disease Care Model
• Oncology Care Program

6. What is PCMH?
• Patient Centered Medical Home
• Primary Care Program
• Emphasizes care coordination/management and team
based care
• Triple aim

7. NCQA Roadmap – Download Standards
Scoring Levels
Level 1= 35-59 points
Level 2= 60-84 points
Level 3= 85-100 points
* MUST PASS Elements

8. PCMH 5: Care Coordination and Care
Transitions
• Element A: Test Tracking
and Follow-Up
• Element B: Referral
Tracking and Follow-Up
• Element C: Coordinate
Care Transitions
18
POINTS

9. Element 5A: Test Tracking and Follow-Up
1. Tracks lab tests until results are available, flagging and following up on overdue
results.
2. Tracks imaging tests until results are available, flagging and following up on
overdue results.
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
7. More than 30 percent of laboratory orders are electronically recorded in the
patient record. +
8. More than 30 percent of radiology orders are electronically recorded in the
patient record. +
9. Electronically incorporates more than 55 percent of all clinical lab test results into
structured fields in medical record. +
10. More than 10 percent of scans and tests that result in an image are accessible
electronically +
+ Stage 2 Core Meaningful Use Requirement
Critical Factor

10. Meaningful Use Alignment
5A-Test Tracking and Follow-Up
NCQA Requirements Modified Stage 2 Ruling NCQA Response
Electronically incorporates
more than 55 percent of all
clinical lab test results into
structured fields in medical
record.
Removed as MU Measure NCQA maintaining requirement
but will accept an example of
capability in lieu of a report
More than 10 percent of scans
and tests that result in an
image are accessible
electronically
Removed as MU Measure NCQA maintaining requirement
but will accept an example of
capability in lieu of a report

11. Element 5A: Scoring
6.0 points
• 8-10 factors (including factors 1 and 2) = 100%
• 6-7 factors (including factors 1 and 2) = 75%
• 4-5 factors (including factors 1 and 2) = 50%
• 3 factors (including factors 1 and 2) = 25%
• 0-2 factors (doesn’t meet factors 1 and 2) = 0%

12. Element 5A Factor 1-10: Documentation
PCMH 5A1-6
• Process/Policy
• Date
• Practice Name
• Define process
• tracking labs and imaging studies
• overdue labs and imaging studies
• abnormal labs and imaging studies
• patient notification
• newborn hearing and screening tests
• Define timeline and frequency of lab/imaging results monitoring
• Report or Log or Examples
• For each factor
• Across patients

13. Element 5A Factor 1-10: Documentation
PCMH 5A7-10
• Report
• 3 months of recent data
• Numerator
• Denominator

14. PCMH 5A1-2, 3-5

15. Element 5A2: Overdue Order Tracking

16. Element 5A3: Abnormal Results Tracking

17. Element 5A5: Sample Lab Notification to Patient

18. Element 5A7-8: CPOE Labs/Imaging

19. Element 5B: Referral Tracking and Follow-Up
1. Considers available performance information on consultants/specialists
when making referral recommendations.
2. Maintains formal and informal 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 percent of referrals. +
8. Tracks referrals until the consultant or specialist’s report is available,
flagging and following up on overdue reports.
9. Documents co-management arrangements in the patient’s medical
record.
10.Asks patients/families about self-referrals and requesting reports from
clinicians.
+ Stage 2 Core MU Requirement
Critical Factor
MUST PASS

20. Meaningful Use Alignment
5B-Referral Tracking and Follow-Up
NCQA Requirements Modified Stage 2 Ruling NCQA Response
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 percent of referrals
Health Information
Exchange with a lower
threshold of “more than
10%” (includes an
exclusion)
NCQA will accept a report
demonstrating a more than 10
percent threshold

21. Element 5B: Scoring
6.0 points
• 9-10 factors (including factor 8) = 100%
• 7-8 factors (including factor 8) = 75%
• 4-6 factors (including factor 8) = 50%
• 2-3 factors (including factor 8) = 25%
• 0-1 factors (doesn’t meet factor 8) = 0%
Must meet at least 4 factors (including
Factor 8) to pass this Must-Pass Element

22. Element 5B: Documentation
• PCMH 5B1-3
• Examples
• PCMH 5B4
• Examples/Materials
• PCMH 5-6, 8, 10
Process/Policy
• Date
• Practice Name
• Define process
• Clinical question
• Supporting documentation
• Tracking of referrals, timeframe, roles/responsibilities
• Intake process- query of referrals since last visit
Report or Log or Examples
• For each factor (report 5 days)

23. Element 5B: Documentation
• PCMH 7
Screen Shot and
Report
• 3 months of recent data
• Numerator
• Denominator
• PCMH 9
• 3 Examples

24. PCMH 5B1

25. PCMH 5B2: Sample Agreement

26. PCMH 5B4: Behavioral Health
http://www.milbank.org/uploads/documents/10430EvolvingCare/
10430EvolvingCare.html#PracticeModel2
Coordinated Co-Located Integrated
Minimal collaboration-
separate facilities and
systems, communicate
sporadically
Basic collaboration-
mental health services
on site, different
systems
Close collaboration-
fully integrated, part of
same team, same
facility/systems
Basic collaboration-
separate facilities and
systems, periodic
communication
Close collaboration-
partially integrated,
some systems in
common (EHR,
Scheduling), close
proximity for face-to-
face
Close collaboration-
mental health services
are integrated to some
degree with primary
care services

27. PCMH 5B5-6: Examples following process

28. PCMH 5B8: Referral Tracking

29. Element 5C: Coordinate Care Transitions
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. +
+ Stage 2 Core MU Requirement

30. Meaningful Use Alignment
5C-Coordinate Care Transitions
NCQA Requirements Modified Stage 2 Ruling NCQA Response
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.
PCMH 5C aligns with
Objective 5: Health
Information with a lower
threshold of “more than
10%” (includes an
exclusion)
NCQA will accept a report
demonstrating a more than 10
percent threshold.

31. Element 5C: Scoring
6.0 points
• 7 factors = 100%
• 5-6 factors = 75%
• 3-4 factors = 50%
• 1-2 factors = 25%
• 0 factors = 0%

32. Element 5C: Documentation
• PCMH 5C1
Process
• Date
• Practice Name
• Define process for identifying patients who’ve been in the
ER/hospitalized.
• Reporting/Log of patients who’ve been hospitalized
• PCMH 5C2
Process
• Date
• Practice Name
• Define process for providing hospitals and ER’s clinical information
• 3 de-identified data examples of patient information sent to
hospital/ER

33. Element 5C: Documentation
• PCMH 5C3
Process
• Date
• Practice Name
• Define process for obtaining hospital discharge summaries
• 3 examples of discharge summaries
• PCMH 5C4
Process
• Date
• Practice Name
• Define process for providing patient care follow up post admission
and ER visit.
• 3 de-identified examples of patient follow up post discharge

34. Element 5C: Documentation
• PCMH 5C5
Process
• Date
• Practice Name
• Define process for two way communication with hospitals
• Example of two-way communication
• PCMH 5C6
Process
• Date
• Practice Name
• Define process for obtaining proper consent for release of
information
• PCMH 5C7
Report-3 months
• Numerator/Denominator
• Or Example showing capability

35. PCMH 5C1-4: Sample Process

36. PCMH 5C3: Sample De-Identified
Discharge Data

37. PCMH 6: Performance Measurement and
Quality Improvement
• Element A: Measure Clinical Quality
Performance
• Element B: Measure Resource Use and
Care Coordination
• Element C: Measure Patient/Family
Experience
• Element D: Implement Continuous Quality
Improvement
• Element E: Demonstrate Continuous
Quality Improvement
• Element F: Report Performance
• Element G: Use Certified EHR
Technology
20
POINTS

38. Element 6A: Measure Clinical Quality Performance
At least annually
1. At least two immunization measures.
2. At least two other preventive care measures.
3. At least three chronic or acute care clinical
measures.
4. Performance data stratified for vulnerable
populations (to assess disparities in care).
+ Stage 2 Core MU Requirement

39. Element 6A: Scoring
3.0 points
• 4 factors = 100%
• 3 factors = 75%
• 2 factors = 50%
• 1 factors = 25%
• 0 factors = 0%

40. Element 6A1-4: Documentation
• For each measure
• Period of measurement
• Number of patients represented by data
• Rate (percentage) based on
numerator/denominator

41. PCMH6A: Report Sample

42. Element 6B: Measure Resource Use and Care
Coordination
1. At least two measures related to
care coordination.
2. At least two utilization measures
affecting health care costs.

43. Element 6B: Scoring
3.0 points
• 2 factors = 100%
• 1 factors = 50%
• 0 factors = 0%

44. Element 6B1-2: Documentation
Report
• Showing practice performance results
• Initial submission: Data <1 year old

45. PCMH 6B1 Documentation

46. Element 6C: Measure Patient/Family
Experience
1. The practice conducts a survey (using any instrument) to evaluate
patient/family experiences on at least three of the following categories:
– Access.
– Communication.
– Coordination.
– Whole person care/self-management support.
2. The practice uses the PCMH version of the CAHPS Clinician & Group
Survey Tool.
3. The practice obtains feedback on experiences of vulnerable patient
groups.
4. The practice obtains feedback from patients/families through qualitative
means.

47. Element 6C: Scoring
4.0 points
• 4 factors = 100%
• 3 factors = 75%
• 2 factors = 50%
• 1 factor = 25%
• 0 factors = 0%

48. Element 6C: Documentation
PCMH 6C1-4
• Report with summarized results of patient
feedback
• If going for NCQA Distinction must provide a
report

49. Element 6C: Sample Patient Survey Data

50. Element 6D: Implement Continuous Quality
Improvement
MUST PASS
1. Set goals and analyze at least three clinical quality
measures from Element A.
2. Act to improve at least three clinical quality measures from
Element A.
3. Set goals and analyze at least one measure from Element
B.
4. Act to improve at least one measure from Element B.
5. Set goals and analyze at least one patient experience
measure from Element C.
6. Act to improve at least one patient experience measure from
Element C.
7. Set goals and address at least one identified disparity in
care/service for identified vulnerable populations.

51. Element 6D: Scoring
4.0 points
• 7 factors = 100%
• 6 factors = 75%
• 5 factors = 50%
• 1-4 factors = 25%
• 0 factors = 0%
Must meet at 5 factors to pass this
Must-Pass Element

52. Element 6D: Documentation
• PCMH 6D1-7 Report
• Showing how each measure met
OR
• PCMH Quality Measurement and Improvement
Worksheet

53. Element 6D: Quality Measurement and
Improvement Worksheet

54. Element 6D:
Quality Measurement

55. Element 6E: Demonstrate Continuous Quality
Improvement
1. Measuring the effectiveness of the actions it takes
to improve the measures selected in Element D.
2. Achieving improved performance on at least two
clinical quality measures.
3. Achieving improved performance on one
utilization or care coordination measure.
4. Achieving improved performance on at least one
patient experience measure.

56. Element 6E: Scoring
3.0 points
•4 factors = 100%
• 3 factors = 75%
• 2 factors = 50%
• 1 factors = 25%
• 0 factors = 0%

57. Element 6E: Documentation
• PCMH 6E1-4 Report
• Showing how each measure met
OR
• PCMH Quality Measurement and Improvement
Worksheet

58. Element 6E: Tracking Improvement Over Time

59. Element 6F: Report Performance
1. Individual clinician performance results with
the practice.
2. Practice-level performance results with the
practice.
3. Individual clinician or practice-level
performance results publicly.
4. Individual clinician or practice-level
performance results with patients.

60. Element 6F: Scoring
3.0 points
• 3-4 factors = 100%
• 2 factors = 75%
• 1 factors = 50%
• No scoring option= 25%
• 0 factors = 0%

61. Element 6F: Documentation
• PCMH 6F1 Report of clinician results
• Provided to clinicians and practice staff and explain how
results shared with group
• PCMH 6F2 Report of practice results
• Explain how results shared with group
• PCMH 6F3-4- Report
• Example of how report is shared with patients
and public

62. Element 6F: Reports

63. Element 6F: Reports

64. Element 6G: Use of Certified EHR Technology
1. The practice uses an EHR system (or modules) that has been certified and issued a
CMS certification ID.
2. The practice conducts a security risk analysis of its EHR system (or modules),
implements security updates as necessary and corrects identified security
deficiencies. +
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 (other than a cancer registry) electronically.
6. The practice reports clinical quality measures to Medicare or Medicaid agency, as
required for Meaningful Use.
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 percent of
patients/families/caregivers about needed preventive/follow-up care.+
+ Stage 2 Core MU Requirement

65. Element 6G: Scoring
0 points
No Scoring option

66. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2011-
pcmh-2014-crosswalk
Standard 5
5A6: Follows up with the inpatient facility about newborn hearing and newborn blood-spot
screening
5B1: Considers available performance information on consultants/specialists when making
referral recommendations
5B2: Maintains formal and informal agreements with a subset of specialists based on
established criteria
5B3: Maintains agreements with behavioral healthcare providers
5B4: Integrates behavioral healthcare providers within the practice site
5B8: Tracks referrals until the consultant or specialist’s report is available, flagging and
following up on overdue reports
5B9: Documents co-management
5C4: Proactively contacts patients/families for appropriate follow-up care within an
appropriate period following a hospital admission or emergency department visit
5C5: Exchanges patient information with the hospital during a patient’s hospitalization
5C6: Obtains proper consent for release of information and has a process for secure
exchange of information and for coordination of care with community partners
Cross Walk 2011-2014

67. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-
2011-pcmh-2014-crosswalk
Standard 6
6A1: At least two immunization measures
6A2: At least two other preventive care measures
6A3: At least three chronic or acute care clinical measures
6B1: At least two measures related to care coordination
6B2: At least two measures affecting health care costs
6E1: Measuring the effectiveness of the actions it takes to improve the
measures selected in Element D
6E2: Achieving improved performance on at least two clinical quality
measures
6E3: Achieving improved performance on one utilization or care
coordination measure
6E4: Achieving improved performance on at least one patient
experience measure
Cross Walk 2011-2014

68. Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
• Gap Analysis/Audit
• Identify areas requiring work
• Process/Policy
• Organizational change
• Reports, Samples
• Focus on areas that are quick wins
first
Next Steps- Tips/Tricks

69. Gap Analysis Sample

70. Gap Analysis Sample

71. Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
References
http://store.ncqa.org/index.php/recognition/patient-centered-medical-home-pcmh.html
http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8.%20PCMH%20Recognition%20
2014_Appendix%206_Summary%20of%20Updates%20to%20PCMH%202014%2003.28.2016
%20FINAL.pdf?ver=2016-04-01-142019-047
http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-
pcmh/pcmh-2011-pcmh-2014-crosswalk

72. Confidential © 2015 Galen Healthcare Solutions
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THANK YOU

73. Confidential © 2015 Galen Healthcare Solutions
SOLVING FOR TODAY. PREPARING FOR TOMORROW.
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