The DSS PCMH Program& NCQA 2017 StandardsJune 6, 2019A Department of Social ServicesPCMH Presentation hosted byCommunity Health Network of Connecticut, Inc.

Learning Objectives Detail the Department of Social Services (DSS) PersonCentered Medical Home (PCMH) Program Process Define important aspects of National Committee forQuality Assurance (NCQA) PCMH 2017 Program Review the NCQA 2017 Standards and outline changesfrom the NCQA 2014 Standards Identify importance of continuous quality improvement1

PCMH Concept Team-based healthcare delivery model led by aphysician with trained staff that provides coordinatedcare Comprehensive and continuous primary care with theQuadruple Aim of maximizing health outcomes,enhancing the patient care experience, lowering costs,and improving care team satisfaction Responsive to diverse cultural health beliefs andpractices, preferred languages, health literacy, and othercommunication needs2

DSS PCMH ProgramDSSFree ProgramSupport14% FeeDifferentialPaymentDepartment of SocialServicesCHNCTCommunity HealthNetwork ofConnecticut, Inc.Administrative ServicesOrganization (ASO) forDSSNCQANationalCommittee forQuality AssuranceGlide alistNCQAPatient-CenteredMedical HomeRecognition(CPTS)24% FeeDifferentialPaymentDSSPerson-CenteredMedical HomeRecognition3

DSS PCMH Financial Incentives Participation Enhanced Rates Performance Payments An enhanced reimbursement rate on 78 selected CurrentProcedural Terminology (CPT) codesAnnual payments possible based on practice performance ofDSS selected health measure resultsImprovement Payments Annual payments are based on the practice’s improvement ofhealth measures4

Community Practice TransformationSpecialist (CPTS) Support The CPTS team assists with: NCQA processes and annual reporting Analysis of practice’s Annual Profile Report CareAnalyzer data analytic software HUSKY Health Provider Portal Reports training5

NCQA’s RedesignPrevious Process Every 3 years, practicesneeded to submit allmaterials for a full review,with little guidance fromNCQACurrent Process NCQA interacts withpractice from the start Practice submitsinformation at agreedupon intervals untilrecognized Focused annual reviewand ongoing datasubmission to sustainrecognition (no RenewalSurvey at 3 years)6

NCQA 2014 vs. 2017 RecognitionNomenclature changes from the 2014 to 2017 Standardsand GuidelinesStandard ConceptElement CompetencyFactor Criterion2017 Standards and Guidelines EliminatedRecognition levelsCritical factorsScoring up to 100 pointsMust-pass elements7

2017 Core & Elective Criteria Core: Mandatory for all practices seeking recognition(40 criteria) Elective: A selection of additional criteria a practicechooses from includes: Five of the six concepts 25 credits required8

Quality Performance AssessmentSupport System (Q-PASS) Features New web-based platform Claim your organization in Q-PASS Upload evidence and attest to standards Payment portal View all practice sites via one login Pose questions to NCQA9

NCQA Annual PCMH Requirements Attestation to 2017 Standards and Guidelines 40 core criteria Identify and meet 25 elective creditsPCMH Annual Reporting Requirements Updates to the requirements are made each calendar year Subset of the 40 core criteria Special topic questions (not scored) Submit one month prior to NCQA recognition anniversary date (dateNCQA recognition expires)Submit payment10

CHNCT Quality AssuranceAnnual Review (QAAR) Collaboratively review QAAR Gap Analysis Checklist Timing - six months prior to practice’s NCQA anniversary date On-site visit Identify gaps Create action plans for practice transformationmaintenance11

Team-Based Care & PracticeOrganization (TC) ConceptCompetencies Practice leadership Care team responsibilities Staff communication Orientation of patients,families, and caregiversCriteria 5 Core 1 (new to 2017)4 Elective 3 (new to 2017)12

TC Core Criteria Correlates to NCQA 2014 Elements 2B & 2D Staff structure & roles Huddles Staff involvement in quality improvement (QI) activities Medical home responsibilitiesClinician Lead and PCMH Manager (new to 2017)13

TC Elective CriteriaTC 03(new to 2017)External PCMH Collaboration Participation in the DSS PCMH Program countstoward external PCMH collaborationCPTS will provide a DSS PCMH ProgramParticipation letterTC 04(new to 2017)Patient Advisory Council or PracticeGovernanceTC 05Use certified electronic health record (EHR)TC 08(new to 2017)Behavioral Healthcare Manager to coordinatebehavioral health referrals14

TC: Tips and Lessons Learned Earn 3 easy-to-meet elective credits TC 01Your CPTS has a template available to you TC 03CPTS to provide a letter TC 05Simply provide the name of your EHRAnnouncement of project leaders Opportunity to create enthusiasm When starting your attestation project assign TC as thefirst concept Completion of TC “sets the stage”15

Knowing and Managing Your Patients(KM) ConceptCompetencies Collection of patient dataincluding diversity Proactive outreach toreduce gaps in care Medication management Evidence-based care Connection withcommunity resourcesCriteria 10 Core 1 (new to 2017)18 Elective 12 (new to 2017)16

KM Core Criteria Correlates to NCQA 2014 Elements 3A, 3B, 3E and 4C Up-to-date patient problem & medication lists Diversity of population & language assessments Outreach for gaps in care Medication reconciliation Evidence-based clinical decision support KM 03 - depression screenings - now mandatory for 2017 KM 02 - comprehensive health assessments - more extensive (F &G) KM 21 - listing of key patient needs and concerns (new to 2017)17

KM Elective Criteria Correlates to NCQA 2014 Element 4C KM 16 - new prescription education KM 17 - medication responses and barriersElement 4E KM 22 - provide educational resources KM 24 - shared decision-making aids KM 26 - community resource list KM 27 - assess community resources18

KM Elective Criteria (new to 2017)KM 04Behavioral health screeningsKM 05Oral health services - reimbursable fluoride applicationsKM 06Main patient conditions & concerns- Top 20 Diagnosis Code ReportKM 07Care interventions based on social determinants of healthKM 08Health literacy data used to tailor patient materialsKM 11Staff education health literacy & cultural competence, identifies andtakes actions to reduce disparities (new to 2017: A & C)KM 13Benchmarked/performance-based recognition programKM 18Controlled substance database usageKM 19Prescription claims data used to address adherenceKM 23Oral health education & resourcesKM 25School/intervention agency engagementKM 28Multidisciplinary case conferences19

KM: Tips and Lessons Learned KM 07,13,19, 28 each assigned two elective credits KM 26 KM 06 KM 21 KM 28 - TeleECHO Clinic 2 NCQA elective credits earned for a case presentation for a high-riskpatient 1 continuing medical education (CME) credit earned for participating asan expert, presenter, or participant For more o clinics.html20

Patient-Centered Access andContinuity (AC) ConceptCompetencies 24/7 access to practiceand clinical advice Continuity of care EmpanelmentCriteria 7 Core 1 (new to 2017)7 Elective 3 (new to 2017)21

Concept AC Core Criteria Correlates to NCQA 2014 Standard 1 & Element 2A AC 02 - reserved same-day appointments AC 03 - extended hours AC 04 - timely clinical advice by phone AC 05 - documentation/reconciliation after hours clinical advice AC 10 - empanelment AC 11 - percentage visits with PCPAC 01 - evaluate patient access and preferences (newto 2017)22

Concept AC Elective Criteria AC 06 - technology supported visits (new to 2017) AC 07 - patient portal functionalities AC 08 - two-way portal communication AC 09 - address equity of access (new to 2017) AC 12 - continuity of medical records when office is closed (twoelective credits) AC 13 - actively manages provider panel size (new to 2017) AC 14 - reconciles health plan panels (new to 2017) HUSKY Health Secure Provider Portal23

AC: Tips and Lessons Learned It’s concept “AC” not “PC” Patient-centered Access and ContinuityAC 01 data is not used for QI 10 Use QI 03 data for QI 10 AC 02 - walk-in data not permitted AC 10 & 11 - solo providers receive auto credit AC 13 - cannot be selected by solo providers AC 14 - Medicaid population (75% ) use HUSKY Health PatientPanel Report24

Care Management and Support(CM) ConceptCompetencies Identifying patients forcare management Care plan developmentCriteria 4 Core 5 Elective 2 (new to 2017)Correlates to NCQA 2014 Elements 4A, B, and E25

CM Core CriteriaCM 01Identify vulnerable populationsCM 02Unique vulnerable patient reportCM 04Care plansCM 05Care plan offered to patient26

CM Elective Criteria CM 03 - risk stratification for all patients (new to 2017) CM 06 - patient preferences and goals CM 07 - patient barriers to goals CM 08 - self-management tools & resources CM 09 - care plan accessible to external care settings(new to 2017)27

CM: Tips and Lessons Learned Choose populations that will benefit from care plans Ongoing provider involvement is important Write care plan text so that patients can understand thewording Outcomes can improve when patients take responsibilityfor their self-care28

Care Coordination & Care Transitions(CC) ConceptCompetencies Management of lab andimaging results Tracking and managingimportant patient referrals Care transitionsCriteria 5 Core 16 ElectiveCorrelates to 2014 Standard 5 6 (new to 2017)29

CC Core CriteriaCC 01Lab and imaging test managementCC 04Referral managementCC 14Identifying unplanned hospital & ED visitsCC 15Sharing clinical data with hospital & EDsCC 16Post hospital/ED visit follow-up30

CC Elective CriteriaCC 02Newborn testing follow-upCC 07Use performance data when selecting specialistsCC 08Agreements with specialists for expectations forexchange of informationCC 09Agreements with behavioral health specialists forexpectations for exchange of informationCC 10Integrate behavioral health providersCC 12Co-management arrangement documentationCC 18Bidirectional information exchange with hospitalCC 19Obtain discharge summariesCC 20Care plan collaboration for practice transitionsCC 21External electronic exchange of information31

CC Elective Criteria (new to 2017)CC 03Protocols for imaging and lab test necessityCC 05Protocols for referral necessityCC 06Monitor specialists used by practiceCC 11Evaluates timeliness/quality of referral responsesCC 13Cost implications of treatment optionsCC 17Use of acute care settings after hours32

CC: Tips and Lessons Learned 16 elective criteria (24 credits) Opportunities are always present for improvement ofcare coordination Utilize Connecticut Choosing Wisely Collaborative emphasis - behavioral health coordination33

Quality Improvement The mission of NCQA: The mission of DSS: “We, along with our partners, provide person-centered programs andservices to enhance the well-being of individuals, families andcommunities”The mission of CHNCT: “Improve the quality of health care”“To improve the health of the underserved and vulnerable populationsby providing access to high quality and comprehensive healthcare, as anot-for-profit community health-sponsored health plan”These missions emulate the NCQA PerformanceMeasurement and Quality Improvement, Concept QI34

Reasons to Focus onQuality Improvement Improve patient outcomes Increase patient, staff, and provider satisfaction Revenue opportunities Reimbursement model shift from fee for service Value-based contract agreements PCMH Performance-Based Payment Program35

Performance Measurement andQuality Improvement (QI) ConceptCompetencies Collecting performancedata Analyzing performancedata Setting goals Improving practiceperformance Sharing practiceperformance dataCriteria 9 Core 10 ElectiveNCQA 2014 Standard 6 2 (new to 2017)36

QI Core CriteriaQI 01Clinical measurement baseline reportsQI 02Usage/care coordination baseline reportsQI 03Third next available appointment reportQI 04Patient satisfaction survey & qualitative dataQI 08Act to improve upon three QI 01 measuresQI 09Act to improve upon one QI 02 measureQI 10Act to improve upon one QI 03 measureQI 11Act to improve upon one QI 04 measureQI 15Report QI improvement results to staff37

QI Elective CriteriaQI 05Assess clinical & experience disparitiesQI 06Benchmarked patient experience surveyQI 07Vulnerable patient feedbackQI 12Achieves improved performanceQI 13Act to improve upon QI 05 dataQI 14Achieves improvement for QI 13 (new to 2017)QI 16Performance reporting - publicly or with patientsQI 17Patient Advisory Council involved with QIQI 18Report to Medicaid or MedicareQI 19Engage in value-based contract agreements (new to2017)38

QI: Tips and Lessons Learned NCQA AR QI Worksheet “preferred” by reviewers AR Annual ReportingCorrelations - baseline reports and act & succeed QI 01, QI 08, & QI 12 QI 02, QI 09, & QI 12 QI 03 & QI 10 QI 04, QI 11, & QI 12 QI 05, QI 13, & QI 14 (total: 4 elective credits)QI 18 - report to Medicaid or Medicare Medicaid population (75% ) use Annual Profile Report39

Next Steps Read the NCQA 2017 Standards spractices/patient-centered-medical-home-pcmh/ Read the NCQA Annual Reporting Requirements Use NCQA’s PCMH 2014-PCMH 2017 Crosswalk Download and save the NCQA PCMH AR QI Worksheet Claim your organization in NCQA’s Q-PASS!/sign-in/40

Resources Slides 12 - 39 are derived from the following document: Provider Portal Reports (Concepts AC, CC, KM, & QI) ion.html#Transitional Care Services (Concept CC) ta.html#CultureVision