The Long and Winding Road

to PCMH

PresentersLaurel Domanski Diaz, MNO, Director of

Business OperationsDan Gauntner, CNP, Director of Clinical

OperationsMarianella Napolitano, RN, MBA, Clinical

Quality Coordinator

ObjectivesIdentify all of the workflows needed to

implement PCMHDeep dive into NFP PCMH applicationIdentify the challenge areas within the

applicationDescribe how to overcome the challenges

presented due to limited ability to produce needed data

NFP BackgroundA Federally Qualified Community Health Center

founded in 1980Last year served 13,400 patients on the near

west side of ClevelandNCQA recognized as PCMH Level 3 under 2011

standards17 Providers on staff--7 Family Practice MDs, 6

Family Practice CNPs, 3 Certified Nurse Midwives

Focus on the medically underservedServe a large Hispanic population

What is a Care Team?A Care Team has been defined as: A panel of

patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

Our Care Team CompositionThree Providers—combination of Family MDs,

Family CNPs, one team’s providers consists of 3 Certified Nurse Midwives

One to two RNsOne to two Patient AdvocatesMedical Assistant for each ProviderFront Office representative at each team

meeting

Care Team Implementation Activities Developing new procedures around scheduling, registering patients &

directing phone calls to teams. Conducting activities around team formation, structure and ongoing activities. Organizing providers and support staff into integrated care teams Redesigning of Nursing staff structure to provide individual nurses to care

teams. Adding a Patient Advocate to each team, vital role in the PCMH model Extended Team Support includes:

On-site Clinical Pharmacist CareSource RN Wellness Coordinator Refugee Health Services Medication Assistance Program Diabetes Education

The PCMH Team & Application PlanIdentify the PCMH Application TeamIdentify Key Application FacilitatorsDelegation of different areas of application to relevant personNeed to have a variety of people on team, clinical and non-

clinicalOrganization of application and documentsTackle each section, utilizing organization’s resources as

neededWeekly working sessions, day long sessions as submission

time approached

Survey & Intake – What we needed to createInventory of Policies and Procedures, update the manual with

EMR implementation, focused on PCMH relevant documents

Inventory of reports that existed, what needed to be created, etc.

Surveyed current workflows and determined how they needed to change to meet the requirements:

Patient Advocate role and new responsibilities to meet requirements Front Office no-show work Clinical Teams work flow around self management goals and patient education Referral follow up process

Deep Dive Into the PCMH Application

Element 1: Enhanced Access & ContinuityA—Access During Office Hours:

Phone reporting system was used to demonstrate volume of incoming calls that RNs used to triage patient calls

B—After Hours Access:Reports from our Answering Service that

shows when the patients called NFP and at what time NFP providers returned the call.

After Hours Documentation

Element 1: Enhanced Access & ContinuityE—Medical Home Responsibilities

CareEverywhere capabilities allowed us to demonstrate care coordination/communication across different settings.

G—The Practice TeamStanding Orders Protocol DevelopmentPre-Orders Workflow Implementation (insert

workflow)

Pre-Orders Workflow

PA identifies patients

with Chronic

Conditions

PA scrubs the chart

and enters routine

labs/immunizations per

protocol

PA calls all DM, HTN patients

to remind them of visit and to bring blood

sugar readings and

medications

Documentation of

pre-visit / pre-order preparatio

n

Team Huddles

From documentation in

EPIC, team is aware of pre-

orders

MA releases pre-orders during the

patient’s visit

Prior to the Visit

Day of the Visit

Pre-Order Protocol

Element 2- Identify and Manage PopulationsA—Patient Information

Primary Caregiver is defined as the name of the Emergency contact for patients under 18

NFP did not identify a legal guardian/health care proxyD—Use Data for Population Management

Solutions (Chronic Care, Well Child Care, Coumadin report)

Managed Care Plans registriesPatient Schedule for pre-natal care outreach & chronic

disease managementNo Show report within EPICTelevox report for daily reminders

Element 3 – Plan and Managed Care and Element 4 – Provides Self-Care Support and Community Resources3A—Implement Evidence-Based Guidelines

Defined guidelines used and inserted screenshots of patient charts where they were used

Health maintenance and best practice alerts3B–-Identify High Risk Patients

High Risk Definition (Solutions)Rosters – Ability to analyze data using excel

3C, 3D, 4ANFP Patient ExamplesNCQA Manual Chart Audit option

Element 5 – Track and Coordinate Care5B—Referral Tracking and Follow-upAccess to portals for other Epic providers in

the region to obtain reportsItem 7 - Providing an electronic summary of

the care record to another provider for more than 50 percent of referrals NFP provides electronic access to outside providers

through Care Everywhere – which is used by majority of healthcare providers in region.

Element 6 – Measure and Improve PerformanceLeadership commitment to Quality

FQHCs: used your Quality Management Plan from your HRSA grant

UDS reports and trendsSolutions reports Utilization measures (preventative care

measures)Reinforcement of workflows/trainingImmunization RegistriesMake mention of any Quality Collaborative that

you are currently participating

Questions?