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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 .

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The long and winding road to pcmh

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
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
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
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
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
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
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
Deep Dive Into the PCMH Application

Element 1 enhanced access continuity
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.

Element 1 enhanced access continuity1
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)

Element 2 identify and manage populations
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
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
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
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