Download Standards and Guidelines

Enhanced Personal Health Care and
2014 NCQA Patient Centered Medical Home (PCMH)
Standards and Guidelines
Empire designed Enhanced Personal Health Care to align with NCQA PCMH standards and guidelines. The
work you do for NCQA PCMH recognition can also improve your Performance Scorecard and shared savings
payments as a participant in Enhanced Personal Health Care. This document outlines how these programs
align, and how your active participation in Enhanced Personal Health Care can help your team accomplish
quality and performance improvement goals while improving patient care.
Empire’s Performance Scorecard
While NCQA recognition is not a requirement to participate in Enhanced Personal Health Care, achieving Level 2 or Level 3
recognition while participating in the program will generate a bonus on the Performance Scorecard. Practices with NCQA Level 2
or 3 recognition will receive a 10% bonus on the scorecard. The other scorecard composites will be re-weighted to comprise the
remaining 90%.
PCMH Standard 1 – Patient Centered Access
NCQA requires that practices provide same day appointments and have 24/7 access to care. The Empire Enhanced Personal
Health Care program advocates access as a key strategy to improve costs, reduce avoidable emergency room visits, and improve
the quality of care. Your Empire EPHC team offers a set of resources known as an Intervention Bundle, all designed to improve
access to care.
PCMH Standard 2 - Team Based Care
Enhanced Personal Health Care works best under a team based care model. PCMH Standard 2 Element D: The Practice Team
is a “Must Pass” element. This means that team-based care is required in order to achieve any level of NCQA PCMH recognition.
Empire has many resources and training materials to support practices in building care teams and streamlining workflows.
||
Empire Care Consultants can assist practices in identifying the care team, and developing a structured communication
process for team meetings and clinical review of individual patients - which is a “critical factor” in the NCQA guidelines.
||
Empire can also assist in developing job descriptions for positions like the “Care Coordinator” (PCMH Standard 2 Factors
1 and 2).
||
NCQA also requires that care team members receive ongoing training on topics such as population management and selfmanagement support, and Empire offers a variety of live and recorded learning events that can help practices meet these
requirements.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,
an association of independent Blue Cross and Blue Shield plans.
1
PCMH Standard 3 - Population Management
A population-based approach to health care delivery is an efficient method of improving patient care outcomes and reducing
care gaps. For this reason, Population Management is a required “Must-Pass” component for NCQA PCMH recognition and an
expectation for providers participating in Enhanced Personal Health Care. The table below outlines the corresponding metrics.
||
In the NCQA 2014 Standards and Guidelines, Standard 3 requires that practices generate registries and proactively
remind patients about at least two preventative services, two chronic or acute care services, immunizations, patients not
recently seen by the practice, and medication alerts.
||
In addition, Standard 3 requires implementation of evidence-based clinical decision support tools for clinical and
utilization services. Your Care Consultant can be a valuable resource in these efforts.
NCQA
Enhanced Personal Health Care Performance Measures
Preventive Care
Breast Cancer Screening, Cervical Cancer Screening, Well Child Visits, Childhood Immunizations
Acute and
Chronic Care
Diabetes Care (Hb A1C, Urine Protein, Diabetic Eye Exams), Appropriate Testing for Children with
Pharyngitis, Depression Medication, Medication Adherence
Medication Alerts
Annual Serum Potassium and Serum Creatine/BUN for patients taking ACE/ARB, Digoxin, and Diuretics
PCMH Standard 4 Care Management and Support Chronic Disease Management
NCQA PCMH Standard 4 requires that practices have a documented process for identifying high risk patients in need of
additional care management and that at least 75% of those patients have a documented care plan and self-management plan.
||
Providers can identify their high-risk population through a risk stratification process that identifies patients with poorly
controlled chronic conditions, behavioral health diagnoses, high utilization, patients identified by health plans, and social
factors. Empire reports provide a prospective risk score for Empire members that can assist in identifying high risk members.
||
Behavioral health diagnosis is a significant risk factor for physical health complications. Empire staff can help direct you to
tools, resources, and care management programs to assist in behavioral health-related care management.
||
Empire has identified the use of care plans and self-management support tools as key strategies to improve health outcomes
and reducing costs for high risk patients. Enhanced Personal Health Care promotes the use of care plans for patients on the
Chronic and Readmission Hot Spotter reports, and with high ER utilization and ambulatory sensitive admissions.
Your Care Consultant can help develop a process for identifying your high risk patients, and the Provider Clinical Liaison can
provide resources and assistance in care planning and self-management support.
PCMH Standard 5 - Care Coordination and Care Transitions
NCQA standards require that practices are able to track referrals and hospital admissions. Your Empire Enhanced Personal
Health Care team can help you develop care coordination policies. NCQA standards also encourage Behavioral Health
Integration, which is the subject of another intervention bundle available to you as an Enhanced Personal Health Care
participant.
PCMH Standard 6 - Quality Improvement
NCQA standards require that practices set quantitative goals, implement interventions to improve performance, and then
demonstrate improved performance on clinical, and patient experience measures. The ultimate goal of the Enhanced Personal
Health Care Program is to achieve the Triple Aim - improve health care outcomes, patient experience, and cost of care. The table
below shows how Empire’s Performance Scorecard measures align with NCQA PCMH recognition. Tracking these measures as
part of your Quality Improvement Plan will generate success in both the NCQA recognition process and the Enhanced Personal
Health Care Program. Your Care Consultant can help you design a plan that will meet NCQA PCMH standards and facilitate success.
2
NCQA
Enhanced Personal Health Care Performance Measures
Acute and Chronic
Clinical Measures
Diabetes Measures (HbA1C, Urine Protein Screening, Diabetic Eye Exam), Persistent Monitoring
for Medications (Digoxin, ACE/ARB, Directics), Medication Adherence, Appropriate Prescribing for
Asthma and Depression, Appropriate Testing for Pharyngitis
Preventative Measures
Well-Child Checks, Cervical Cancer Screening, Breast Cancer Screening
Utilization Measures
Avoidable ER Visits, Generic Prescribing Rates, Ambulatory Sensitive Admits
Utilization Management
NCQA PCMH 2014 standards promote increased attention to utilization and cost of care as components of delivering patient
centered care. Although NCQA does not have a standard specific to utilization, cost of care is addressed throughout the
standards. Utilization is also the most heavily weighted composite of Enhanced Personal Health Care, comprising 40% of the
Performance Scorecard, which is essential to fund the shared savings pool.
||
The NCQA PCMH 2014 guidelines require practices to collect data on utilization, and then proactively use that data for
patient outreach and quality improvement activities.
||
Practices are encouraged to use decision support alerts (pop-up alerts) to assist providers reduce unnecessary and
duplicative imaging and laboratory procedure orders.
||
Practices also are encouraged to adopt procedures designed to simultaneously improve health care quality and reduce costs.
−− Improvements in access, such as same-day appointments and 24/7 phone access, will meet NCQA PCMH requirements
and can potentially reduce avoidable ER visits.
−− Improving transition of care workflows can help providers meet NCQA PCMH requirements, and can reduce
unnecessary ER visits and ambulatory sensitive hospital readmissions.
Resources
As an Enhanced Personal Health Care practice, you have access to people, training, and tools that can assist you with NCQA
PCMH recognition. Most importantly, your Enhanced Personal Health Care team can provide you direct support with regard
to care planning and clinical review, staff training, and designing your NCQA Quality Improvement Plan in order to meet NCQA
PCMH standards. Additionally, Empire NCQA PCMH 2014 content experts can assist you.
Resource
Description
NCQA Application Discount
20% discount on NCQA application fees
ACP Practice Advisor
Contains over 50 policy and procedure templates
Practice Essentials
Curriculum
Can help meet NCQA training requirements for population management and self-management
support
®
Learning Collaboratives and Live and recorded webinars that can assist in practice transformation and meeting NCQA
Learning Library
training requirements
Other Tools
Tools to assist in developing interventions, registries, patient education, and care plans
3