HITEQ Highlights:

Tools and Tips for NCQA Patient Centered

Medical Home 2017

September 27, 2018

Intro to HITEQ

The HITEQ Center is a HRSA-funded National Cooperative

Agreement that collaborates with HRSA partners including

Health Center Controlled Networks, Primary Care Associations

and other National Cooperative Agreements to support health

centers in full optimization of their EHR/Health IT systems.

HITEQ identifies and disseminates resources for using health

information technology (IT) to improve quality and health

outcomes. HITEQ includes:

• A searchable web-based health IT knowledgebase with

resources, toolkits, training, and a calendar of related events

• Workshops and webinars on health IT and QI topics

• Technical assistance and responsive teams of experts to

work with health centers on specific challenges or needs

email us at hiteqinfo@jsi.com!

Agenda

• Introduction

• Review of updates of the NCQA PCMH

• Discussion of structure of 2017 Standards

• Demonstration of PCMH tracking and

assessment tools

• Review of health center assets and practices

that support PCMH recognition

Learning Objectives

• Describe the general structure of PCMH

2017 and its basic requirements

• Identify 2-3 existing Health IT tools or

policies that support PCMH 2017

recognition

• Access documents to begin the PCMH 2017

process

Jillian Maccini, MBA, PMP, PCMH CCEHITEQ Knowledge Base Lead

HITEQ Quality Improvement Lead

Health Center Supporter | Overall Data Lover

Patient Centered Medical Home

Updated in 2017

• As you likely know, the PCMH program was

revamped in 2017.

– Continuous practice transformation

– Flexible and personalized with new virtual review

process

– Emphasizes comprehensive, integrated care

– New evidence options

– Increased alignment with existing initiatives

Why are we talking about this?

• As focus on value based payment increases, so

does the impetus for structured processes that

facilitate whole person care and population

health management, as well as quality

improvement.

Good news: You’re already doing much of this,

and this is what is needed for PCMH!

First Steps

• Contact HRSA, submit NOI through EHB

• Create Q-PASS account

– Complete NCQA Eligibility/ Readiness Survey

– Claim/ create/ add organization

• Contact EHR/ health IT vendor for pre-

validation credit and ONC certification.

• Use education and self-assessment tools

HRSA’s Accreditation and Patient-Centered Medical Home (PCMH) Initiative

National Patient-Centered Medical Home (PCMH) Recognition in Health Centers

(75% as of July 1, 2018)

Source: HRSA Accreditation and Patient-Centered Medical Home Report, 2018

Interested health centers must notify HRSA of their intent to participate by submitting a Notice of Intent (NOI) in the HRSA EHB. In the EHB, go to the Grant Folder and click the ‘HRSA Accreditation/PCMH Initiative’ link.

https://grants.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx

Accessing Q-PASS

• Q-PASS: Quality Performance Assessment

Support System- qpass.ncqa.org

You’ll

need this!

Start

Here!

Q-PASS

New Organizations

• Search for your org., just to be sure!

• Create

organization

in Q-PASS

• Provide address,

phone, Tax ID, etc.

• Save organization

• Need the following: Site information, including NPI; Each clinician’s

information including NPI & boards/ specialties; Authorized

signatory for agreements; Payment information

Q-PASS Continued

Existing Organizations• Must be an

authorized user, then go to ‘My Organizations’ tab

• If you need to ‘claim’ your organization, contact NQCA

R

Let EHR do (some of) the work!

• You may get auto-credit for a number of

criteria based on your EHR or Health IT tools.

– Pre-Validation- Up to 75 criteria may be fully met or

partially met by pre-validation

• Obtain the NCQA-issued Prevalidation Summary

Approval Table, NCQA Letter of Product Autocredit

Approval as well as a Letter of Product

Implementation from the vendor

– ONC Certified EHR Criteria TC05

Pre-Validation

• Once Prevalidation Summary Approval Table, NCQA Letter

of Product Autocredit Approval, as well as a Letter of

Product Implementation are received from the vendor, it

should be submitted through Q-PASS; NCQA

Representative will confirm and then all auto-credit criteria

documented will be counted as “Met”.

Clinicians

Clinicians qualifying for PCMH: Hold current, unrestricted MD, DO, APRN, or PA license.

• Physicians, APRNs (including NPs) and PAs who practice internal medicine, family

medicine or pediatrics, serving as the personal clinician for their patients.

– These clinicians will be identified individually with the recognized practice.

• • Physician-led practices applying with identified APRNs or PAs:

– Patients may choose the APRN or PA as their primary care clinician, or

– ARPNs or PAs share a panel of patients as a primary care team with the

physician.

• Note: Clinicians who are part of the practice but are not personal clinicians (e.g.,

behavioral health clinicians, dentists, OB/GYNs) are not identified individually, but their

work on behalf of patients can be used to demonstrate the practice meets PCMH

criteria.

Clinicians who don’t qualify: Non-primary

care specialty clinicians, and APRNs and PAs

who do not have a panel of patients

(as they are not a ‘personal clinician’).

Organizations

• Recognition is at the geographic site level, one recognition per address.

• Practice: One or more clinicians (including all eligible primary care

clinicians) who practice together and provide patient care at a single

geographic location and must include all eligible primary care clinicians at

the site. “Practicing together” means that all the clinicians in a practice:

– Follow the same procedures and protocols.

– Have access to (as appropriate) and share medical records (paper and

electronic) for all patients treated at the practice site.

– Electronic and paper-based systems and procedures support clinical and

administrative functions (e.g., scheduling, treating patients, ordering services,

prescribing, maintaining medical records and follow-up).

• Multi-site group: Three or more primary care practice sites using the same

systems and processes, including shared electronic medical record system/

EHR. Multi-site allows corporate information to be entered only once, and

for some specified evidence to be shared (such as documented processes

and demonstration of capability), submitted once for all sites or site groups.

Recognition Process

3 Virtual Check-Ins in 12 months with NCQA Rep.Once transformation is well underway, it’s time to begin meeting

with your NCQA representative. You’ll submit documentation and

note criteria that will be demonstrated. NQCA representative will

provide feedback as needed, and determine whether each

criteria is met.

Documentation/ Evidence

• 2017 offers the option of demonstrating evidence during

virtual check-in.

• Some evidence can be shared across sites, where

specified.

• All PHI should be removed before adding to Q-PASS

Documented Process: Written policies

and procedures (e.g., protocols,

practice guidelines, agreements or

other documents describing actual

processes or forms). Must include date

of implementation and provide

practice staff with instructions for

following policies and procedures.

Evidence of Implementation:

• Reports

• Patient Records

• Materials

• Examples

• Screenshots

• Virtual

demonstration

• eCQM

• Transfer credit (from

pre-validation)

• Surveys (patient

satisfaction)

• Data entered directly

into Q-PASS

Structure

6 Concepts

Each Concept has 2-6 Competencies

Each Competency has

Core and Elective Criteria

Must meet

all 40 core

criteria.

Must achieve 25 credits*,

of 60 elective criteria, in

5 of 6 competencies.

*Some elective criteria are worth more than one credit.

Concepts

Team Based Care +

Practice Org.

(TC)

Provide continuity of care, communicate roles and responsibilities of the medical home to patients/ families/ caregivers, and organize and trains staff to work to the top of their license and provide effective team-based care.

Knowing + Managing

Your Patients

(KM)

Capture and analyze information about the patients and community being served and use the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.

Patient-Centered Access + Continuity

(AC)

The PCMH model requires continuity of care. Patients/ families/ caregivers have round the clock access to clinical advice and care is facilitated by their designated clinician/ care team and supported by access to their medical record. The practice considered the needs and preferences of the patient population when establishing and updating standards for access.

Care Management

+ Support

(CM)

Identify patient needs at the individual and population levels to effectively plan, manage, and coordinate patient care in partnership with patients/ families/ caregivers. Emphasis is placed on supporting patients at highest risk.

Care Coord. + Care

Transition

(CC)

Systematically track tests, referrals, and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Performance Measurement

+ Quality Improvement

(QI)

Establish a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/ families/ caregivers in quality improvement activities.

Team Based Care + Practice Org.

Are you… participating in Meaningful Use? Convening staff in a cross functional QI team? Sharing Medical Home information with patients (perhaps along with patient portal or consent information)?

Knowing + Managing Your Patients

R

Are you… doing depression screening? SBIRT? Oral health risk assessment?

Using PRAPARE? Leveraging population health management tools (i2i, Azara) or

reports to identify care gaps and disparities?

Knowing + Managing Your Patients Cont.

Are you… consistently doing med rec? Using CDS tools in your EHR?

Involved in community collective impact or asset mapping?

Providing patients resource lists or referral to community resources?

Patient-Centered Access + Continuity

Are you… gathering social determinants and monitoring outcomes,

or otherwise assessing equity? Effectively leveraging your patient

portal? Using telehealth/ telemedicine?

Care Management and Support

Are you… Risk stratifying? Implementing Care Coordination?

Chronic Disease Self Management programs? Using patient

engagement tools?

Care Coordination + Care Transitions

Are you… using referral coordinators? integrating BH in primary care?

Part of an RHIO or HIE? Systematically receiving ADT information? Using

state immunization information systems or registries?

Performance Measurement + Quality Improvement

Are you… Participating in Learning Collaboratives or ongoing QI projects? Do you use dashboards, data visualizations?

PCMH Self Assessment Tool

• Excel-based tool

• Allows you to

track core and

elective criteria

met

• Use as planning

document

PCMH AirTable Tracking Tool

• Excel-based tool

• Allows you to track core and elective criteria met

• Use as planning document

Demonstration of Tools

Comments, Questions, and

Discussion

Q&APlease ask your questions in the chat box.

HITEQ Center

• In addition the Health IT QI tools and guide discussed, HITEQ has several other resource sets on health center priority topics.

• For additional information see http://hiteqcenter.org or contact HITEQ at hiteqinfo@jsi.com.

• If you are interested in hosting a workshop or training with your health centers around these tools, please reach out to us!

Reach out: hiteqinfo@jsi.com

http://hiteqcenter.org/Resources/tabid/90/Default.aspxhttp://hiteqcenter.org/mailto:hiteqinfo@jsi.comhttp://hiteqcenter.org/Contact/WorkshopRequest/tabid/153/Default.aspxhttp://hiteqcenter.org/Services/TrainingRequest/tabid/133/Default.aspx

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S.

Department of Health and Human Services (HHS) under grant number U30CS29366 titled Training and Technical

Assistance National Cooperative Agreements (NCAs) for grant amount $500,000. This information or content

and conclusions are those of the author and should not be construed as the official position or policy of, nor

should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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