PCMH 2011 Webinar 6 - Community Care of North Carolina

Patient-Centered Medical Home
NCQA’s PCMH 2011 Standards
Training Webinar # 6
David Halpern, MD, MPH
February 15, 2012
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Let’s Review
• Standard 2 – Identify & Manage Populations
PCMH 2A: Patient Information
PCMH 2B: Clinical Data
PCMH 2C: Comprehensive Health Assessment
PCMH 2D: Use Data for Population Management MUST PASS
• Standard 5 – Track & Coordinate Care
– PCMH 5A: Test Tracking & Follow-Up
– PCMH 5B: Referral Tracking & Follow-Up MUST PASS
– PCMH 5C: Coordinate With Facilities & Care
Let’s Track Our Progress
Standard 1 – Enhance Access/Continuity
Standard 2 – Identify/Manage Populations
Standard 3 – Plan/Manage Care
Standard 4 – Self-Care Support/Resources
Standard 5 – Track/Coordinate Care
Standard 6 – Measure/Improve
Today’s Agenda
• What Is The Record Review Workbook?
• Standard 4 – Self-Care Support &
Community Resources
– PCMH4A: Support Self-Care Process –
– PCMH4B: Provide Referrals to Community
Record Review Workbook
What Is the “Record Review
• Elements 3C, 3D, 4A
– Require medical record abstraction of data
– Need % of patients meeting the element
(based on a numerator and a 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 a sample of patients and abstract data
needed for Elements 3C, 3D, 4A
Using The Workbook
1. Find Workbook in Survey Tool
2. Download and save file to computer
3. Review instructions and data needed from
patient records
4. Select patient records to review
5. Review patient records for data
6. Enter data in Workbook
7. Enter numerical result in Survey Tool
8. Link Workbook to Survey Tool
Selecting Patients for Workbook
~ Use same 48 patients for EACH Workbook Element ~
STEP #3.
• Use appointment or billing system to identify
patients with visit on June 5th
• Choose every patient with any of 3 clinically
important conditions who had a visit on this date
that was related to the important condition
DATE = Today’s
date February 15th
STEP #4. Continue choosing patients
going back on consecutive dates until
you have selected 48 patients
STEP #2. Go back
30 days = January 15th
RRWB = Supplemental Worksheet
Click here
Three tabs
 Instructions
 Patient Conditions
 Record Review
RRWB – Enter Important Conditions
Enter three important conditions here including an
unhealthy behavior/mental health or substance abuse AND
high-risk or complex patients, IF you are including them.
RRWB – Enter Conditions
Enter conditions from drop down
menu, for example:
 Diabetes
 Hypertension
 Depression
 High Risk/Complex
RRWB – Enter Data
Entering NOT USED in row 1
“grays” out the column
Response Options
 Yes
 No
 Not Used
 Not applicable
RRWB – automatically calculates the
% of Patients that met factor
Patients that Met Factor
 Number (33/48)
 Percent (69%)
 Result for ISS
Enter RRWB Responses in Survey Tool
Enter responses
 Yes or No
 Percent
PCMH 4: Self-Care Support &
Community Resources
• PCMH4A: Provide Self-Care Support –
• PCMH4B: Provide Referrals to Community
PCMH 4A: Provide Self-Care Support
• Practice conducts activities to support patients in selfmanagement: (MUST PASS)
1. Provides education resources or refers at least 50% of patients
to educational resources
2. Uses EHR to identify education resources and provide them to
10% of patients**
3. Collaborates with at least 50% of patients to develop and
document self-management plans and goals-CRITICAL
4. Documents self-management abilities for at least 50% of
5. Provides self-management result recording tools to at least 50%
of patients
6. Counsels at least 50% of patients on adopting health lifestyles
** Meaningful Use Requirement
PCMH 4A: Provide Self-Care Support
• 6 Points
• Scoring
5-6 factors (including factor 3) = 100%
4 factors (including factor 3) = 75%
3 factors (including factor 3) = 50%
1-2 factors = 25% (not sufficient for passing element)
0 factors = 0%
• Data Sources:
– Report from electronic system or submission of
Record Review Workbook
PCMH 4A: Remember…
• Patient Self management tools are available
by clicking on the last tab in Provider Portal or
by going to the “Patient Mgmt Tools” tab at
the CCNC website:
• These tools are all non-branded, evidence based, low
literacy appropriate and have been vetted by
physicians at CCNC
PCMH 4A: Remember…
Provider Portal allows you
to search AND download
disease-specific selfmanagement tools,
handouts, and video
demos, which patients can
access from home
PCMH 4A: Example – Factor 1
Examples of selfmanagement tools
for patients/families
PCMH 4A: Example – Factor 1
PCMH 4A: Example – Factor 1
PCMH 4A: Example – Factor 3
PCMH 4A: Example – Factor 3
Your Goal HbA1c:
Green Zone: Great Control
HbA1c is under 7
Average blood sugars typically under 150
Most fasting blood sugars under 150
Yellow Zone: Caution
HbA1c between 7 and 9
Average blood sugar between 150-210
Most fasting blood glucose under 200
Work closely with your health care team if you are
going into the YELLOW zone
Red Zone: Stop and Think
HbA1c greater than 9
Average blood sugars are over 210
Most fasting blood sugars are well over 200
Call your physician if you are going into the RED zone
Green Zone Means:
Your blood sugars are under control
Continue taking your medications as
Continue routine blood glucose
Follow healthy eating habits
Keep all physician appointments
Yellow Zone Means:
Your blood sugar may indicate that
you need an adjustment of your
Improve your eating habits
Increase your activity level
Call your physician, nurse, or diabetes
educator if changes in your activity level
or eating habits don’t decrease your
fasting blood sugar levels.
Red Zone Means:
You need to be evaluated by a physician.
If you have a blood glucose over ____,
follow these instructions _____________
Call your physician
PCMH 4A: Example – Factor 4
Demonstrates patient
progress and selfmonitoring results
Demonstrates barriers
to patient’s ability to
meet goals
PCMH 4A: Example – Factor 4 & 5
The practice provides
patient with selfmanagement tool
(flowsheet) and then
includes completed selfmanagement tool in
patient’s chart,
demonstrating patient’s
self-management ability.
PCMH 4A: Example – Factor 5
Example of a
diabetes log book
PCMH 4A: Example – Factor 5
Example of a
log book
PCMH 4A: Example – Factor 5
Example of a
CHF log book
PCMH 4A: Example – Factor 6
Example of
in the EMR
PCMH 4A: Example – Factor 6
Example of
in the EMR
PCMH 4A: Example Using the Record
Review Workbook
PCMH 4B: Provide Referrals to
Community Resources
• Practice supports patients who need access to
community resources:
1. Maintains current resource list covering five (5)
community service areas (e.g. smoking cessation,
weight loss, parenting, dental, transportation, fall
prevention, meal support)
2. Tracks referrals provided to patients
3. Arranges for or provides treatment for mental
health/substance abuse disorders
4. Offers opportunities for health education and peer
PCMH 4B: Provide Referrals to
Community Resources
• 3 Points
• Scoring
4 factors = 100%
3 factors = 75%
2 factors = 50%
1 factor = 25%
0 factors = 0%
• Data Sources:
– List of community services or agencies
– Referral log or report covering at least one month
– Processes to provide/arrange for mental
health/substance abuse treatment and health
education support
PCMH 4B: Example – Factor 2
Next Steps (Homework)
• Download the Record Review Workbook
and start familiarizing yourself with it.
Next Steps (Homework)
• Organize Your Documents
– Create a place on your computer (server or
hard-drive) for all of your documentation
– You should have a folder for each standard
– A checklist can help you determine what you
already have created/saved and what you
need to prepare from scratch
Next Steps (Homework)
– Decide which 3 “Important Conditions”
(e.g. diabetes, asthma, congestive heart
failure, depression, etc) you want to track
over time. One must be related to
unhealthy behaviors, mental health, or
substance abuse.
– Does your practice already follow evidencebased guidelines when caring for patients with
these conditions?
– Are these guidelines documented anywhere?
Community Care PCMH Team
• David Halpern, MD, MPH
Community Care of North Carolina (CCNC)
• R.W. “Chip” Watkins, MD, MPH, FAAFP
Community Care of North Carolina (CCNC)
• Brent Hazelett, MPA
North Carolina Academy of Family Physicians
• Elizabeth Walker Kasper, MSPH
North Carolina Healthcare Quality Alliance (NCHQA)
Feel free to contact me:
David Halpern, MD, MPH
(215) 498-4648
[email protected]

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