Transcription

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018Candace ChittyRN, MBA, CPHQ, PCMH-CCE16 PCMH Concepts within the standards1. Team-Based Care and Practice Organization(TC).2. Knowing and Managing Your Patients (KM).3. Patient-Centered Access and Continuity (AC).4. Care Management and Support (CM).5. Care Coordination and Care Transitions (CC).6. Performance Measurement and QualityImprovement (QI).21

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018The practice systematically tracks tests,referrals and care transitions to achieve highquality coordination, lower costs, improvepatient safety and ensure effectivecommunication with specialists and otherproviders in the medical neighborhood.3 Threecompetencies5 Core Criteria (CC 01, 04, 14, 15, 16) 16 Elective Criteria (CC 02, 03, 05, 06, 07, 08,09, 10, 11, 12, 13, 17, 18, 19, 20, 21) 42

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018Competency A: CC 01- 03 The practice effectively tracks and manageslaboratory and imaging tests important topatient care and informs patients of theresults.5CC-01 is a Core Criteria (aligns with 2014 PCMH 5A Factors1-5).The practice systematically manages lab and imaging tests byA.Tracking lab tests until results are available, flagging and following up on overdue results.B.Tracking imaging tests until results are available, flagging and following up on overdue results.C.Flagging abnormal lab results, bringing them to the attention of the clinician.D.Flagging abnormal image results, bringing them to the attention of the clinician.E.Notifying patients/families/caregivers of normal lab and image results.F.Notifying patients/families/caregivers of abnormal lab and image results.Evidence: Shared (Documented process only)Documented Process: Describes a systematic process for staff to follow to track,report, and notify patients of lab and image testingANDEvidence of Implementation: Examples showing how the process is met includingpatient notification (reports, logs, examples of electronic tracking system, letters,documented phone encounters, etc)63

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-02 is an elective criteria (aligns with 2014 PCMH 5AFactor 6). 1 creditThe practice follows up with the inpatient facility about newbornhearing and blood-spot screening.Evidence: Shared (Documented process only)Documented Process: Describes the process for staff to follow upwith hospitals to obtain hearing and blood-spot screening results.ANDEvidence of Implementation: Examples of follow up completed.7CC-03 is an elective criteria and is New for 2017. 2 creditsThe practice uses clinical protocols to determine when imaging andlab tests are necessary.Evidence: SharedEvidence of Implementation: Examples of clinical protocols usedthat are based on evidence-based guidelines and/or evidence ofimplementation of clinical decision supports to ensure thatprotocols are used.84

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018Competency B: CC 04 - 13 The practice provides important informationin referrals to specialists and trackingreferrals until the report is received.9CC-04 is a Core Criteria (aligns with 2014 PCMH 5B Factors5,6, and 8).The practice systematically manages referral by:A.Giving the consultant or specialist the clinical question, the required timing and the type ofreferral.B.Giving the consultant or specialist pertinent demographic and clinical data, including test resultsand the current care plan.C.Tracking referrals until the consultant or specialist’s report is available, flagging and followingup on overdue results.Evidence: Shared (Documented process only)Documented Process: Describes a systematic process for staff to follow to track andfollow-up on specialist/consultant referrals. The tracking process includes the datewhen the referral was initiated and the timing indicated for receiving the report withdocumentation of staff efforts.ANDEvidence of Implementation: Examples of systematic referral tracking and follow up(reports, logs, examples of electronic tracking system, etc)105

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-05 is an elective criteria and is New for 2017. 2 creditsThe practice uses clinical protocols to determine when a referral toa specialist is necessary.Evidence:Evidence of Implementation: Examples of clinical protocols usedthat are based on evidence-based guidelines and/or evidence ofimplementation of clinical decision supports to ensure thatprotocols are used.11CC-06 is an elective criteria and is New for 2017. 1 creditThe practice identifies the specialists/specialty types frequentlyused by the practice.Evidence:Evidence of Implementation: Examples high volumespecialist/specialty types the practice refers to. (list, report, etc)126

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-07 is an elective criteria (aligns with 2014 PCMH 5BFactor 1). 2 creditsThe practice considers available performance information onconsultants/specialists when making referrals.Evidence: SharedData Source: Lists the data source used such as Health Grades,CMS, etc.ANDExamples of the information provided from the data sources used.NOTE: Information gathered in CC-11 may be useful in thisassessment of consultants/specialists.13CC-08 is an elective criteria (aligns with 2014 PCMH 5BFactor 2). 1 creditThe practice works with nonbehavioral healthcare specialists towhom the patient frequently refers to set expectations forinformation sharing and patient care.Evidence: SharedDocumented Process: Describes the process for establishing formalor informal relationships with nonbehavioral healthcare specialists.ORAgreement between practice and nonbehavioral healthcarespecialist that establishes expectations for the exchange ofinformation (e.g., frequency, timeliness, content).147

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-09 is an elective criteria (aligns with 2014 PCMH 5BFactor 3). 2 creditsThe practice works with behavioral healthcare specialists to whom thepatient frequently refers to set expectations for information sharing andpatient care.Evidence: SharedAgreement between practice and behavioral healthcare specialist that establishesexpectations for the exchange of information (e.g., frequency, timeliness, content).ORDocumented Process: Describes the process for establishing formal or informalrelationships with behavioral healthcare specialists, andEvidence of Implementation: demonstrates across patients in a report, log, orelectronic tracking system of behavioral health services. A notification demonstratinglegal inability to receive a report that includes confirmation of a BH visit occurredmeets the requirement.15CC-10 is an elective criteria (aligns with 2014 PCMH 5BFactor 4). 2 creditsThe practice integrates behavioral healthcare providers into thecare delivery system of the practice site.Evidence: Shared (Documented process only)Documented Process: Describes the process for behavioral healthintegration.ANDEvidence of Implementation: Examples of patient materials,referrals, workflows showing shared accountability andcollaborative treatment and workflow strategies.168

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-11 is an elective criteria and is New for 2017. 1 creditThe practice monitors the timeliness and quality of the referralresponse.Evidence: Shared (Documented process only)Documented Process: Describes the process for monitoring and thedefines the timely on patient need.ANDReport: Data collected to report referral responses in comparisonto the practice’s timeliness standard(s) and evaluates whether theresponse was timely and provided appropriate information aboutthe patient’s diagnosis and treatment plan. (chart audit, report,etc).17CC-12 is an elective criteria (aligned with 2014 PCMH 5BFactor 9). 1 creditThe practice documents co-management arrangements in thepatient’s medical record.Evidence:Evidence of Implementation: Three examples of co-managementarrangements that includes sharing changes in the treatment planand patient health status, in addition to entering information inthe medical record within an agreed upon time frame.189

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-13 is an elective criteria and is New for 2017. 2 creditsThe practice engages with patients regarding cost implications oftreatment options.Evidence: Shared (Documented process only)Documented Process: Describes how the practice engages patients.For example, adding a financial question to the clinical intakescreening (do you have trouble affording the care or prescriptionsprescribed, etc).ANDEvidence of Implementation: Example(s) of discussions about costimplications and how used to recommend less expensive treatmentoptions, if appropriate.19Competency C: CC 14 - 21 The practice connects with health carefacilities to support patient safetythroughout care transitions. The practice receives and shares necessarypatient treatment information to coordinatecomprehensive patient care.2010

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-14 is a core criteria (aligned with 2014 PCMH 5C Factor1).The practice systematically identifies patients with unplannedhospital admissions and emergency department visits.Evidence: Shared (Documented process only)Documented Process: Describes how the practice identifiespatients. The process musts state how often monitoring takesplace.ANDReport with the proportion of local admissions and ED visits(reported separately) to facilities where practices have anestablished notification exchange mechanism.21CC-15 is a core criteria (aligned with 2014 PCMH 5C Factor2).The practice shares clinical information with admittinghospitals and emergency departments.Evidence: Shared (Documented process only)Documented Process: Describes how the practice sharesinformation.ANDEvidence of Implementation: Three examples.2211

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-16 is a core criteria (aligned with 2014 PCMH 5C Factor4).The practice contacts patients/families/caregivers forfollow-up care, if needed, within an appropriate periodfollowing a hospital admission or emergency departmentvisit.Evidence: Shared (Documented process only)Documented Process: Describes how the practice conductsthe follow-up process post discharge and includesestablished time frames for follow-up to occur.ANDEvidence of Implementation: Log documented systematicfollow-up was completed.23CC-17 is an elective criteria and is New for 2017. 1 creditThe practice has the systematic ability to coordinate withacute care settings after office hours through access tocurrent patient information.Evidence: Shared (Documented process only)Documented Process: Describes how the practicecoordinates with acute care facilities when a patient is seenafter the office is closed.ANDEvidence of Implementation: At least one example ofcoordination with the facility.2412

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-18 is an elective criteria (aligns with 2014 PCMH 5CFactor 5) 1 creditThe practice exchanges information with the hospital duringa patient’s hospitalization.Evidence: Shared (Documented process only)Documented Process: Describes how the practice facilitatesexchange of information (portal, calls, etc).ANDEvidence of Implementation: Three examples of the dataexchange during a patient’s hospitalization.25CC-19 is an elective criteria (aligns with 2014 PCMH 5CFactor 3) 1 creditThe practice implements a process to consistently obtainpatient discharge summaries from the hospital and otherfacilities.Evidence: Shared (Documented process only)Documented Process: Describes how the practice obtains dischargesummaries in a consistent manner.ANDEvidence of Implementation: Three examples of obtaining DCsummaries or demonstrates participation in the local admission,discharge, transfer (ADT) system.2613

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/2018CC-20 is an elective criteria (aligns with 2014 PCMH 2AFactor 4) 1 creditThe practice collaborates with the patient/family/caregiverto develop/implement a written care plan for complexpatients transitioning into/out of the practice (e.g.,pediatric to adult care).Evidence:Evidence of Implementation: Example of written care plan. Forfamily medicine practices that do not transition the practice shouldexample how it educates patients and families about ways in whichtheir care experience may change. Sensitivity to privacy concernsshould be incorporated into messaging.27CC-21 is an elective criteria (aligns with 2014 PCMH 5BFactor 7 and 5C Factor 7) 3 credits maximumThe practice demonstrates electronic exchange ofinformation with external facilities, agencies and registries.May select one or more.A.Regional health information organization or other HIE source that enhances thepractice’s ability to manage complex patients (1 credit)B.Immunization registries or immunization information systems (1 credit)C.Summary of care record to another provider or care facility for care transitions(1 credit)Evidence:Evidence of Implementation: Example of electronic exchange(s).2814

2017 NCQA PCMH Webinar Series, StandardFive: Care Coordination and Care Transitions5/9/201829Concept 6:Performance Measurement and QualityImprovement (QI)Wednesday, May 23 2018 from 1PM – 2PMCentral3015