Achieving NCQA Standards for the Patient-Centered Medical Home by wlx15873


									   Achieving NCQA Standards
    for the Patient-Centered
          Medical Home

       Eboni G Price, MD, MPH
 Chief Medical Officer, Tulane Community Health
Medical Director, Tulane Community Health Center

• Care coordination
• Patient-centered medical home
  – NCQA medical home recognition
• Medical home system of care
  – Role of electronic medical records
            Care Coordination
• Domains of care coordination
  – Among providers
    •   PCP & specialists
    •   PCP & emergency departments
    •   PCP & sources of diagnostic data
    •   PCP & hospital based physicians
    •   PCP & other parts of the health system
  – Between providers & patient/ family
    • Physicians
    • Hospitals
                                       Bodenheimer, NEJM, 2008
             Models of Improved
             Care Coordination
• Primary care “Teamlet”
  – Nonphysician coach coordinates care
• Referral agreements
  – Specific referral templates; subspecialist accountability
• Electronic consults
  – Reduces wait time for specialty appointments
  – Barriers: Loss of specialist income & liability concerns
• Integrated systems of care
  – Electronic medical record system
                                         Bodenheimer, NEJM, 2008
     Electronic Medical Records &
           Care Coordination
• Key functions of electronic medical record
  – Health information & data storage
  – Results management
  – Order entry & management
  – Decision support
  – Patient support
  – Population health management
  – Electronic communication connectivity
                                   Institute of Medicine, 2003
Patient-Centered Medical Home
• Patients have a relationship with a personal physician.
• A practice-based care team takes collective
  responsibility for the patient's ongoing care.
• Care team is responsible for providing and arranging all
  the patient's health care needs.
• Patients can expect care that is coordinated across care
  settings and disciplines.
• Quality is measured and improved as part of daily work
• Patients experience enhanced access and
• Practice uses EHRs, registries, and other clinical
  support systems.
                 Joint Principles of the Patient Centered Medical Home, 2007
Patient-Centered Medical Home
• Care delivered by physicians in PCMH:
  – Improved patient compliance
  – Better outcomes
  – Reduced mortality
  – Reduced health disparities
  – Fewer hospital admissions
  – Lower utilization
  – Lower costs

 Starfield, 2006; Commonwealth Fund, 2007; Paulus, Health Affairs, 2008
                     The Majority of Adults with a Medical Home
                          Always Get the Care They Need

 Percent of adults 18–64 reporting always
 getting care they need when they need it


                      55                                                           52*
   50                                                                                                            38*


                     Total                   Medical home                Regular source of             No regular source
                                                                       care, not a medical                   of care/ER

Note: Medical home includes having a regular provider or place of care, reporting no
difficulty contacting provider by phone or getting advice and medical care on weekends
or evenings, and always or often finding office visits well organized and running on time.
* Compared with medical home, differences remain statistically significant after adjusting for income or insurance.
Source: Commonwealth Fund 2006 Health Care Quality Survey.
      Patients with a Medical Home Report Better Coordination
           Between Their Regular Provider and Specialist

Percent of adults ages 18–64 who have
seen a specialist in past two years

                    Medical home                Regular source of care, not a medical home

                                    77                        80
           73                                                                          73
 75                                                                    65
                  58                         58


        Regular provider        Regular provider            After seeing            Regular provider
         helped decide           communicated            specialist, regular           helped you
          who to see             with specialist          provider seemed              understand
                                 about medical               up to date             information from
                                     history                                         specialist care

                       Source: Commonwealth Fund 2006 Health Care Quality Survey.
            NCQA Medical Home Recognition
Standard 1: Access and Communication                       Pts   Standard 5: Electronic Prescribing                    Pts
A. Has written standards for patient access and patient          A. Uses electronic system to write prescriptions      3
    communication**                                        4     B.  Has electronic prescription writer with safety
B.  Uses data to show it meets its standards for patient   5
    access and communication**                                   C. Has electronic prescription writer with cost
                                                           9         checks                                            2
Standard 2: Patient Tracking and Registry Functions        Pts                                                         8
A. Uses data system for basic patient information
    (mostly non-clinical data)                             2     Standard 6: Test Tracking                             Pts
B.  Has clinical data system with clinical data in               A. Tracks tests and identifies abnormal results       7
    searchable data fields                                 3         systematically**
C. Uses the clinical data system                           3     B.  Uses electronic systems to order and retrieve     6
D. Uses paper or electronic-based charting tools to                  tests and flag duplicate tests
    organize clinical information**                        6
E.  Uses data to identify important diagnoses and          4     Standard 7: Referral Tracking                         PT
    conditions in practice**                                     A. Tracks referrals using paper-based or electronic   4
F.  Generates lists of patients and reminds patients and   3         system**
    clinicians of services needed (population                                                                          4
    management)                                            21
                                                                 Standard 8: Performance Reporting & Improvement       Pts
Standard 3: Care Management                                Pts
A. Adopts and implements evidence-based guidelines         3     A.   Measures clinical and/or service performance     3
    for three conditions **                                           by physician or across the practice**
B.  Generates reminders about preventive services for      4     B.   Survey of patients’ care experience              3
    clinicians                                                   C.   Reports performance across the practice or by    3
C. Uses non-physician staff to manage patient care         3          physician **
D. Conducts care management, including care plans,         5     D.   Sets goals and takes action to improve           3
    assessing progress, addressing barriers                           performance
E.  Coordinates care//follow-up for patients who           5     E.   Produces reports using standardized measures     2
    receive care in inpatient and outpatient facilities          F.   Transmits reports with standardized measures     1
                                                           20         electronically to external entities
Standard 4: Patient Self-Management Support                Pts   Standard 9: Advanced Electronic Communications        Pts
A. Assesses language preference and other                  2     A. Availability of Interactive Website                1
    communication barriers                                 4     B.  Electronic Patient Identification                 2
B.  Actively supports patient self-management**                  C. Electronic Care Management Support                 1
                                                                                                **Must Pass Elements
                    NCQA Recognition Tiers

                      Level 3: 75+ Points; 10/10 Must Pass

              Level 2: 50-74 Points; 10/10 Must Pass

    Level 1: 25-49 Points; 5/10 Must Pass

                                                                 Increasing Complexity
                                                                 of Services

NCQA, National Committee on Quality Assurance              11
& From the American College of Physicians- Michael S. Barr, MD
             Tulane Community Health Center
                           at Covenant House –
                      from ice chest to medical home

     DeSalvo, J Urban Health, 2005; Howe, PreHospital and Disaster Medicine, 2008; Niyogi, AJMS, 2006
               History of Tulane Community
                      Health Center’s
                  Growth & Development
   Sept. 2005 to         Jan. 2006 to             Sept. 2006 to           July 2008
    Jan. 2006             Sept. 2006               June 2008             To Present

   Post-Disaster         Transitional          Fully Operational          Medical
      Phase                 Period             Primary Care Site           Home

Re-establish:            Re-establish:      Expand:                     Expand:
Rudimentary Healthcare   Continuity of care Core clinic staff           Medical home
Training Programs        Training Programs Healthcare services          & Quality
                                            Electronic medical record   Improvement
 Health information technology to improve
  access, quality & acceptability of care

• Electronic medical record, Docsynergy
  – Patient scheduling for follow up care
  – Reduce medication errors
  – Reduce errors in test ordering & tracking results
  – Reduce errors in referral tracking
  – Manage disease registries
  – Patient portal for medical records
               Access & Communication
                                                                                   MedUnison, L.L.C

• Scheduled Events for Patient:
   Start         End         Type          Status            Staffing               Created
04/04/2008   04/04/2008   Continuity--   Discharged   Christopher, Caroline   03/20/2008 12:47 PM
10:15 AM     10:45 AM     Established
04/14/2008   04/14/2008   Continuity--   Discharged   Christopher, Caroline   04/10/2008 10:13 AM
01:15 PM     01:45 PM     Established
05/20/2008   05/20/2008   Continuity--   Discharged   Christopher, Caroline   05/13/2008 12:28 PM
08:30 AM     08:45 AM     Established
07/24/2008   07/24/2008   Continuity--   Discharged   Christopher, Caroline   06/18/2008 11:40 AM
10:15 AM     10:45 AM     Established
07/28/2008   07/28/2008   Continuity--   Discharged   Christopher, Caroline   07/24/2008 10:39 AM
01:15 PM     01:45 PM     Established
09/26/2008   09/26/2008   Continuity--   Scheduled    Christopher, Caroline   08/28/2008 12:27 PM
10:15 AM     10:45 AM     Established
                  Patient Tracking &
                  Registry Functions                     MedUnison, L.L.C

• Searchable charting tools to organize clinical data
   – Demographics, appointment schedule
   – Problem, procedure & medication lists
   – Allergies, lab results, vital signs, clinic notes

• User defined reports for population disease
   – Identify common diagnoses and risk factors
   – Lacks clinical decision support tool to generate reminders
                Care Management Support
                                                                                  MedUnison, L.L.C

   • Clinical documentation management
        – standardized clinic note templates

Title                                       Type                   Availability         Creator

General Medical Visit - Psych New Eval      Encounter–Behavioral   System-wide           E. Price
General Medical Visit -- HTN/DM             Encounter-Medical      System-wide           E. Price
General Medical Visit--New Patient          Encounter-Medical      System-wide           E. Price
General Medical Visit--Well Woman           Encounter-Medical      System-wide           E. Price
Lab Call Coumadin Check                                            System-wide           E. Price
Lab Call Other Diagnostics                                         System-wide           E. Price
GAD 7 Generalized Anxiety Disorder Screen                          System-wide           E. Price
PC-PTSD Screen                                                     System-wide           E. Price
PHQ 9 Depression Screen                                            System-wide           E. Price
 Patient Self Management Support
                                                                MedUnison, L.L.C

Documenting Communication Needs: Language Preference

 Date/Time Taken Vital Sign      Value     Units   Entered by

 10/01/08 09:30   DBP            78        mmHg    Lewis, Cronwell
 10/01/08 09:30   PrefLang       English           Lewis, Cronwell
 10/01/08 09:30   Pulse          86        BPM     Lewis, Cronwell
 10/01/08 09:30   Respirations   18        BPM     Lewis, Cronwell
 10/01/08 09:30   SBP            140       mmHg    Lewis, Cronwell
 10/01/08 09:30   Temperature    96.9      F       Lewis, Cronwell
 10/01/08 09:30   Weight         149.8     lbs     Lewis, Cronwell
                 Electronic Prescribing
                                                                                                     MedUnison, L.L.C

                                      Tulane Community Health Center
                                             at Covenant House

                             Tulane Community Health Center at Covenant House
                                        611 North Rampart Street
                                         New Orleans, LA 70112
                                             Orleans county
                                          Phone: 504-988-3000
                                            Fax: 504-988-3001
  Patient:          XXXX XXXX                                                              Age: 35
                    TCH MR# xxxxx

  Allergies:        No Known Drug Allergies
                    No Known Environmental Allergies
                    No Known Food Allergies

                                      Ibuprofen [ibuprofen] tablet 800 mg oral
                              SIG 1: Take 1 tablet(s) oral Three times daily for 30 Days
                                                      PRN: pain

Dispense: Exactly 90 tablet(s), QS for 30 days (8/4/2008 - 9/2/2008)


Allow substitution for medically equivalent formulation: Yes

Date: 08/04/08 10:59

Electronically signed by: Eboni Price, MD, MPH

                                                 Signed and Printed

                                          Confidential Information
                                        Powered by DocSynergy(tm)
                          Test Tracking

Tulane Covenant House            User: Eboni Price             October 22, 2008


   •    Ordering & tracking status through eLabcorp
   •    Unidirectional interface with EMR for reporting results
   •    EMR flags all abnormal results
   •    Panic values sent to all EMR users
                                  Test Tracking                                                 MedUnison, L.L.C.

Lab Results Report                               Records Per Page:
Search Criteria: unsigned labs (default)

Result Set ID:                                            Date Range:

MR Number:
Patient Last:                                             Ordered By Last:

Patient Clinic:

Ordered By Clinic:

Limit Results To:       Electronically received           Unsigned       No ordering Provider

                                                Submit       Reset
Set ID   Patient                 Ordering Provider                           Result         Value         Date/Time
                   Gabor, Edith
8907                   Tulane Community Health Center at        Albumin, Serum (g/dL)     4.3 N
                       Covenant House
                   Gabor, Edith
                                                                Alkaline Phosphatase, S                10/23/08
8907                   Tulane Community Health Center at                                  55 N
                                                                     (IU/L)                                07:45
                       Covenant House
                   Gabor, Edith
8907                   Tulane Community Health Center at        ALT (SGPT) (IU/L)         16 N
                       Covenant House
                   Gabor, Edith
8907                   Tulane Community Health Center at        AST (SGOT) (IU/L)         21 N
                       Covenant House
            Referral Tracking


to refer?

                                MedUnison, L.L.C.

                          Referral Tracking
                                                                                              MedUnison, L.L.C.

Referral Subspecialty Clinics - 10/05/08 21:41 by Dr. Eboni G Price

Cosigners:             Sarah Reed (Assigned: 10/05/08 22:00 Cosigned: 10/06/08 09:20)
Date of referral: 10/05/2008

Location of clinic requested: MCLNO (University Hospital)
 2021 Perdido Street, New Orleans, LA, 70112
(504) 903-2815 or 903-3000

Clinic requested: Cardiology

Referring Clinic: Tulane Community Health Center at Covenant House
611 N. Rampart Street, New Orleans, LA 70112;
Clinic # 504-988-3000

Brief History: 2D echocardiogram for dyspnea on exertion evaluate for heart dysfunction, valvular dysfunction,
pulmonary hypertension

ICD9 code: 786.09

Next appointment in referring clinic: 10/27/2008 10:00 AM

Attending Physician/ Primary Provider: Eboni Price
        Performance Reporting &
              Improvement                                                 MedUnison, L.L.C.

User Defined Reports: Tulane Covenant House: Create New


Columns:       Patient Medical Record Number
               Patient Gender
               Patient Race
               Patient Age
               ICD Code
               Problem Created Date
               Creator Last First Name
Sort:          First sort column by:   Patient Medical Record Number
               Then sort column by:    Creator Last First Name
Filter:        Show items only when the following is true: ICD Code equals 250.00
Group By:

Paging:        100 records per page

                Save and Run Report          Save and Return to List
             Advanced Electronic

• Care management team communication
  – Send clinic notes for co-signature
  – EMR confidential email system
• Lack interactive web site for patients to
  – Request appointments, referrals, refills, test results
  – View & import medical record into personal health record
• Lacks electronic clinical decision support tool
  – cannot identify patients due for services
  – cannot e-mail reminders to such patients
        Electronic Medical Records &
              Care Coordination
• EMR system assets
   – Health information & data storage
   – Results management
   – User defined note templates for care management &
     reports for population health management
• EMR system limitations
   – Lacks interoperability
   – Lacks clinical decision support tools
   – Limited patient support tools
   – Limited electronic communication connectivity
         Medical Home System of Care
       ALL                                                                              EHR
                  MEDICAL HOME

       EHR                                                                         HOSPITAL
                                       Referral as
                                       Medically               Care
                                       Necessary            Coordination

                   SPECIALIZED                                                         Other
                                                                                Health care Providers
                MEDICAL HOME                                                             &
                Services for Individuals with                                    Extension Services
                 Complex Chronic Illnesses
                    or at the End of Life             EHR

                                                                     Adapted from the LHCRC, October 2006
       Steps to Developing
   Medical Home System of Care

• Encourage primary care clinics to adopt electronic
  medical records

   –   Affordability
   –   Ease of use & “one stop shop”
   –   Information technology support
   –   Team leader
         • Super user understands EMR assets & limitations
         • Leads staff training in EMR documentation
         • Promotes continuous quality improvement
       Steps to Developing
   Medical Home System of Care

• Require electronic medical record programmers
  to incorporate features compatible with NCQA or
  similar standards
  –   Searchable charting tools
  –   Comprehensive reporting tools
  –   Clinical decision support tools
  –   Comprehensive electronic prescription tools
  –   Patient portals to medical records
       Steps to Developing
   Medical Home System of Care

• Promote interoperability of electronic medical
  record systems to improve care coordination
  across different health systems
  – Test tracking
  – Referral tracking
  – Transition of care from hospital to medical home

• Karen DeSalvo, MD, MPH, MSc
• Katherine Roth
• Tulane Community Health Center Staff
  – At Covenant House
  – On the Road
  – New Orleans East

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