TRICARE West Region Health Leadership Conference Mina L. Harkins, MBA, MTASCP NCQA AVP, Physician Recognition Programs

1. TRICARE West Region Health Leadership ConferenceMina L. Harkins, MBA, MT(ASCP)NCQA AVP, Physician Recognition Programs Recognizing Patient-Centered Medical Homes with NCQA’s PPC-PCMH Program

3. NCQA Mission To improve the quality of health care Vision To transform health care through Quality measurement Transparency Accountability

4. Measurement We can’t improve what we don’t measure Transparency For measurement to be accepted we have to show how we intend to measure Accountability Once we can measure we can hold everyone accountable for improvement

5. MEASUREMENT, TRANSPARENCY, AND ACCOUNTABILITY Quality measurement means: Objective measures based on evidence Results that are comparable across organizations Impartial third-party evaluation and audit Public Reporting NCQA’s quality programs include: Performance-based Health Plan accreditation HEDIS clinical measures CAHPS consumer survey Measurement of quality in provider groups Physician Recognition

7. NCQA Recognition Programs

8. What are Recognition Programs? Voluntary evaluation programs that assess structure, outcomes and processes of care at the physician level. Requirements based on clinical evidence and agreed upon best practices. Developed collaboratively with national health organizations and professionals. Recognition is granted for either two to three years, depending on the program.

9. Current programs: DPRP, HSRP, BPRP, PPC, PPC-PCMH What measures included: Structure, process and outcomes of excellent care management Where they come from: partnership with leading national health organizations and professionals Who supports recognized physicians: health plans, medical boards, state and national government agencies and coalitions of employers Who is recognized: more than 15,000 physicians nationally NCQA Recognition ProgramsPhysician-Level Measurement

10. NUMBER OF PPC & PPC-PCMH CLINICIAN RECOGNITIONS BY STATE

11. Steps in Development of Physician Recognition Programs Identification of need and market opportunities Development of potential content and review by expert panel Feasibility testing Development of draft program standards and scoring and review by expert panel Review and approval of measures by Committee on Performance Measurement (if measures included) Review and approval by Committee on Physician Programs Review and approval by NCQA Board of Directors

12. Early Development of PPC Document evidence base linking specific systems to clinical performance Medline Review Cochrane Collaborative Manuscripts in press Convene expert panel to review evidence and suggest standards/measures Conduct analysis of practice defects using six sigma process (with GE in BTE project) Create standards Test survey tool incorporating standards developed related to chronic care model and patient-centered care literature

13. Principles Focus on evidence-based requirements related to improved quality and reduced costs Consider capabilities of small and large practices, but don’t sacrifice quality Balance desirable requirements with feasibility and burden of review Require electronic information when necessary; electronic systems are not sufficient

14. Goals forPhysician Practice Connections (PPC) Evaluate systematic approach to delivering preventive and chronic care (Wagner Chronic Care Model) Build on IOM’s recommendation to shift from “blaming” individual clinicians to improving systems Create measures that are actionable for physician practices Validate measures by relating them to clinical performance and patient experience results

15. Theoretical Frameworks Informing Physician Practice Connections

16. Wagner Model for Effective Prevention and Chronic Illness Care

17. Identified Needs Response to IOM reports To Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systems Change from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeed Raise awareness of physicians of importance of systems in enhancing quality Link health services research on systems and clinical outcomes to practice

18. Adapting PPC for thePatient-Centered Medical Home New PPC-PCMH version released in January 2008 Aligned standards with Joint Principles Incorporated critical attributes of PCMH Defined foundational elements (“must pass” requirements) PPC-PCMH endorsed by ACP, AAFP, AAP, AOA, other specialties and PCPCC

19. The Patient-Centered Medical Home DefinedACP, AAFP, AAP, AOA Joint Principles – April 2007 Personal physician – patient has ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. Physician directed medical practice – personal physician leads a team at the practice level who take responsibility for the ongoing care of patients. Whole person orientation – personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. Care is coordinated and/or integrated across all elements of health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and to assure that patients get care when and where they need and want it in a culturally and linguistically appropriate manner.

21. Physician Practice Connections®?Patient-Centered Medical Home (PPC-PCMH™) Encourage practices to adopt proven systems for improving care Provides mechanism for incentivizing investment in quality infrastructure and processes Complements measurement of clinical effectiveness, patient experiences, and efficiency

22. Patient-Centered Medical Home Standards

23. NCQA PPC-PCMH Standards

24. PPC-PCMH Content and Scoring

25. PCMH Must Pass Elements PPC1A: Written standards for patient access and patient communication PPC1B: Use of data to show meeting this standard PPC2D: Use of paper or electronic-based charting tools to organize clinical information PPC2E: Use of data to identify important diagnoses and conditions in practice PPC3A: Adoption and implementation of evidence-based guidelines for three conditions PPC4B: Active support of patient self-management PPC6A: Tracking system for tests and identify abnormal results PPC7A: Tracking referrals with paper-based or electronic system PPC8A: Measurement of clinical and/or service performance PPC8C: Performance reporting by physician or across the practice

26. PPC-PCMH Scoring

27. Access & Communication The practice establishes in writing standards for the following processes to support patient access and measures to show whether it meets the standards scheduling each patient with a personal clinician for continuity of care coordinating visits with multiple clinicians and/or diagnostic tests during one trip determining through triage how soon a patient needs to be seen maintaining the capacity to schedule patients the same day they call scheduling same day appointments based on practice's triage of patients' conditions scheduling same day appointments based on patient's/family’s requests providing telephone advice on clinical issues during office hours by physician, nurse or other clinician within a specified time providing urgent phone response within a specific time, with clinician support available 24 hours a day, 7 days a week

28. Patient Tracking & Registry The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed patients needing clinician review or action patients on a particular medication patients needing reminders for preventive care patients needing reminders for specific tests patients needing reminders for follow-up visits such as for a chronic condition patients who might benefit from care management support.

29. Care Management For the three clinically important conditions, the physician and nonphysician staff use the following components of care management support: -conducting pre-visit planning with clinician reminders-writing individualized care plans-writing individualized treatment goals-assessing patient progress toward goals-reviewing medication lists with patients/families -reviewing self-monitoring results and incorporating them into the medical record at each visit-assessing barriers when patients have not met treatment goals-assessing barriers when patients have not filled, refilled or taken prescribed medications-following up when patients have not kept important appointments-reviewing longitudinal representation of patient’s historical or targeted clinical measurements

30. Patient Self-Management Support For the three clinically important conditions, the physician and nonphysician staff use the following components of care management support: - conducting pre-visit planning with clinician reminders- writing individualized care plans- writing individualized treatment goals- assessing patient progress toward goals- reviewing medication lists with patients/families - reviewing self-monitoring results and incorporating them into the medical record at each visit- assessing barriers when patients have not met treatment goals- assessing barriers when patients have not filled, refilled or taken prescribed medications- following up when patients have not kept important appointments- reviewing longitudinal representation of patient’s historical or targeted clinical measurements

31. Test and Referral Tracking Tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice. Tracking laboratory tests until results are available to the clinician, flagging overdue results flagging abnormal test results follows up with patients/families for all abnormal test results notifies patients/families of all normal test results

32. Quality Measurement & Improvement The practice measures or receives data on the following types of performance by physician or across the practice clinical process (e.g., percentage of women 50+ with mammograms or childhood vaccination rates) clinical outcomes (e.g., HbA1c levels for diabetics) service data (e.g., backlogs or wait times) patient safety issues (e.g., medication errors) The practice collects data on patient experience with care in the following areas 1. patient access to care 2. quality of physician communication 3. patient/family confidence in self care 4. patient/family satisfaction with care.

33. What is the PPC-PCMH application and survey process? 

34. How PPC-PCMH Recognition Works Physician/practice Self-assess, collect data using Web-based software Submit documentation to NCQA when ready May be asked to submit more data if needed NCQA Evaluates and scores all applications Checks licensure of physician Audits a sample of applications Posts Recognized physicians and practices on web Distributes list of Recognized physicians and practices monthly to health plans and others Practices sent media kit, press releases, letter & certificate

35. Who is Recognized? NCQA Recognizes a practice and the clinicians who meet the criteria described by the endorsed principles of the Patient-Centered Medical Home Clinicians listed on NCQA Web site A practice is a physician or physicians and clinicians practicing together at a single geographic location An organization with multiple sites submits a survey for each site.

36. What is a Multi-Site Survey? The multi-site survey is a process for organizations with multiple sites to complete the PPC-PCMH assessments for multiple locations more efficiently Practice completes a questionnaire about shared electronic processes in the organization NCQA reviews and approves those elements that can be answered once in a multi-site survey and links those results with each associated practice site survey submitted

37. Recognition Process Practices may use the Survey Tool to self-assess before submitting to NCQA Recognition is based on: Responses in Web-based Survey Tool Supporting documentation attached to Survey Tool Element specifies type of documentation Reports Reports from EHR, registry, practice management & billing systems Documentation of processes Policies and procedures, protocols Records or files NCQA’s Medical Record Review Workbook Screen shots from EHR

38. NCQA Web-Based Survey Tool Interactive System Survey (ISS) Tool allows practices to: Enter responses in Survey Tool Attach documents to Survey Tool that support responses Survey Tool scores the responses Practices can use the Tool to self-assess

40. Training Scheduled audio-conference workshops on standards and meeting the documentation requirements WebEx demonstrating the Interactive Survey System software (ISS) Recorded versions of both training programs Live training presentations may be arranged Resources Customer Support 888-275-7585 Dedicated email address ppc-pcmh@ncqa.org for on-going Q&A answered within 2 business days FAQs posted on web site covering each standard Guided multi-site application process for large practices sharing systems across multiple sites

41. What Have We Learned?

42. How to further assess patient-centeredness, including patient survey results? How to engage patients? How to make name resonate positively? When should performance results be part of scoring? How to adapt to promote quality and cost gains across settings? Primary care—subspecialty Physician—hospital, other facilities How to streamline requirements, documentation? For all practices For practices renewing Significant PPC-PCMH Issues for Future

43. Study of Validity: Accuracy of Self-Report Test accuracy of self-reports of practice systems using on site audit as “gold” standard Varies by domain, by staff position, and by medical group The predictive value of a positive report of a practice system is generally high. Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management). Several factors may explain lack of agreement Variable implementation of systems across sites and conditions Variations in staff members’ exposure to systems Lack of familiarity with systems

44. Studies of Correlation with Clinical Performance and Patient Experience Overall score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma) Overall score does NOT appear to correlate with patient experiences of care Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures However, practices with fully functional EMR’s achieve highest scores

45. Evidence: Higher patient ratings of care improve adherence and outcomes Patients who report being treated with dignity and were involved in decisions were likelier to adhere to doctor recommendations (Beach 2005) Sustained provider relationship and trust are associated with receipt of preventive services (Parchman 2003) Lower patient satisfaction is associated with more poorly controlled diabetes, migraine-related disabilities, and hassles with the healthcare system (Redekop 2002, Walling 2005, Parchman 2005) There are simple and effective methods for training physicians to improve interaction with patients (Rodriguez 2008)

46. Goals Incorporate patient experiences into evaluation Encourage practices to use patient experiences data Allow opportunity for holding practices accountable for achieving patient-centeredness from patient’s point of view

47. NCQA Contact Information Contact NCQA Customer Support to: Acquire standards documents, application materials, and survey tools Questions about your user ID, password, access 1-888-275-7585 Visit NCQA Web Site to: View Frequently Asked Questions View Recognition Programs Training Schedule Submit to questions to ppc-pcmh@ncqa.org Please use this e-mail box to: Ask about interpretation of standards or elements Submit application materials (physician workbook and application) Request registration for ISS Survey Tool demonstration (Web-ex)

48. Questions?