The Long and
Sponsored Links
This presentation is the property of its rightful owner.
1 / 20

The Long and Winding Road to PCMH PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

The Long and Winding Road to PCMH. Presenters. Laurel Domanski Diaz, MNO , Director of Business Operations Dan Gauntner, CNP, Director of Clinical Operations Marianella Napolitano, RN, MBA , Clinical Quality Coordinator. Objectives.

Download Presentation

The Long and Winding Road to PCMH

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

The Long and

Winding Road



  • Laurel Domanski Diaz, MNO, Director of Business Operations

  • Dan Gauntner, CNP, Director of Clinical Operations

  • Marianella Napolitano, RN, MBA, Clinical Quality Coordinator


  • Identify all of the workflows needed to implement PCMH

  • Deep dive into NFP PCMH application

  • Identify the challenge areas within the application

  • Describe how to overcome the challenges presented due to limited ability to produce needed data

NFP Background

  • A Federally Qualified Community Health Center founded in 1980

  • Last year served 13,400 patients on the near west side of Cleveland

  • NCQA recognized as PCMH Level 3 under 2011 standards

  • 17 Providers on staff--7 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives

  • Focus on the medically underserved

  • Serve 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 Composition

  • Three Providers—combination of Family MDs, Family CNPs, one team’s providers consists of 3 Certified Nurse Midwives

  • One to two RNs

  • One to two Patient Advocates

  • Medical Assistant for each Provider

  • Front 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 Plan

  • Identify the PCMH Application Team

  • Identify Key Application Facilitators

  • Delegation of different areas of application to relevant person

  • Need to have a variety of people on team, clinical and non-clinical

  • Organization of application and documents

  • Tackle each section, utilizing organization’s resources as needed

  • Weekly working sessions, day long sessions as submission time approached

Survey & Intake – What we needed to create

  • Inventory 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 & Continuity

  • A—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 & Continuity

  • E—Medical Home Responsibilities

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

  • G—The Practice Team

    • Standing Orders Protocol Development

    • Pre-Orders Workflow Implementation (insert workflow)

Pre-Orders Workflow

Pre-Order Protocol

Element 2- Identify and Manage Populations

  • A—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 proxy

  • D—Use Data for Population Management

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

    • Managed Care Plans registries

    • Patient Schedule for pre-natal care outreach & chronic disease management

    • No Show report within EPIC

    • Televox report for daily reminders

Element 3 – Plan and Managed Care and Element 4 – Provides Self-Care Support and Community Resources

  • 3A—Implement Evidence-Based Guidelines

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

    • Health maintenance and best practice alerts

  • 3B–-Identify High Risk Patients

    • High Risk Definition (Solutions)

    • Rosters – Ability to analyze data using excel

  • 3C, 3D, 4A

    • NFP Patient Examples

    • NCQA Manual Chart Audit option

Element 5 – Track and Coordinate Care

  • 5B—Referral Tracking and Follow-up

  • Access to portals for other Epic providers in the region to obtain reports

    • Item 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 Performance

  • Leadership commitment to Quality

    • FQHCs: used your Quality Management Plan from your HRSA grant

    • UDS reports and trends

    • Solutions reports

    • Utilization measures (preventative care measures)

    • Reinforcement of workflows/training

    • Immunization Registries

    • Make mention of any Quality Collaborative that you are currently participating


  • Login