August 2012 Webinar

1. August 2012 Webinar Planned Care at Every Visit Planned Care PDSA Sharing Planned Care Essential to NCQA, MU Super Strategy: Site Visit Learning Session #2

2. Planned Care at Every Visit • Process to identify all diabetes patients • Electronic population alert is best—accurate (once tested) and saves time—but stickers good too • Use for all visits (acute, chronic, walk-in) • Alerts and pre-visit planning to identify unmet needs • Highlights or flags on template/flow sheet incorporating evidence-based guidelines • Get as much done as possible • Max-packing! • Team-based care/standing orders • Plan/Schedule follow-up care • Higher-risk patients sooner, more often

3. PDSA Sharing • General Internal Medicine • Population alert in EMR banner, registry cleaning, chart prep, addressing all needs, clarifying who does what, patient resistance, overdue patient list • Seneca • Diabetes template, completing documentation difficult when trying to max-pack, pre-visit planning team huddles, self-management goal sheet • More Sharing…… • What is everyone else working on?

4. Planned Care Essential to NCQA PCMH Standards • Applies directly to 4 of 6 NCQA standards • PCMH 1: Element E (expectation of evidence-based care) and Element G (team-based care) • PCMH 2: Identify and Manage Patient Populations • Must Pass: Use Data for Population Management • PCMH 3: Plan and Manage Care • Must Pass: Care Management (pre-visit planning, risk assessment, follow-up care) • PCMH 5: Track and Coordinate Care • Must Pass: Referral Tracking and Follow-Up

5. Planned Care Essential to Attesting for Meaningful Use • Applies to 4 of 15 Meaningful Use Core Objectives • Core Measure #7: Patient demographics as structured data. • Core Measure #8: Vital signs as structured data. • Core Measure #9: Smoking status on patients age 13 or older. • Core Measure #11: Use and tracking of one clinical decision support rule. • Applies to 2 Menu Measures (5 of 10 required) • Menu Measure #2: Lab test results as structured data. • Menu Measure #3: Lists of patients by specific conditions. • Applies to all 3 Core Quality Measures (BP, tobacco, BMI) • Applies to 8 Additional Clinical Quality Measures related to diabetes (must report on 3)

6. Super Strategy: Site Visit • Medical Group of Corry site visitto Seneca Medical Center • Issue: Laboratory services • Goals: Quality care, structured data • Options: External, internal solutions • Investigation: • Interaction with vendors • Visit to Seneca Medical Center • Benefits of collaboration • Thanks!!

7. Learning Session #2 South Central PA Thursday, Sept. 6: 5-9pm Fitness/Conference Center at Hershey Med Center (same location as before) North West PA Thursday, Sept. 20: 5-9pm Penn State Behrend (same location as before)

8. Tentative Topics • Data Review • Importance of clinical protocols, follow-up visits • PDSA Sharing • Self-Management Support • NCQA PCMH Recognition • What do you want/need?

9. Have Any Questions? • South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.org • North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.org