© Colorado Clinical Guidelines Collaborative Revised October 2009

CCGC�’s Workbook (Version 3) for NCQA�’s Physician Practice

Connections® Patient-Centered Medical Home�™ (PPC®-PCMH�™)

Colorado Clinical Guidelines Collaborative (CCGC) has developed this workbook to assist you on your Medical Home journey. This workbook is not a replacement for NCQA�’s Physician Practice Connections® Patient-Centered Medical Home�™ (PPC®-PCMH�™) Standards and Guidelines document and does not guarantee recognition. NCQA�’s program information can be found on www.ncqa.org/ppcpcmh.aspx. Colorado Clinical Guidelines Collaborative (CCGC) is a unique non-profit coalition of health plans, physicians, hospitals, employers, government agencies, quality improvement organizations, and other entities working together to reduce fragmentation and implement systems and processes, using evidence-based clinical guidelines, to improve healthcare in Colorado. To learn more about CCGC visit our website www.coloradoguidelines.org. Created by:- Zula Solomon, MBA �– PCMH Quality Improvement Coach Deb Barnett, RN, MS, FNP �– Coordinator, Grants Management & Program Development R. Scott Hammond, M.D. -- Primary Care Consultants, Inc. Acknowledgment to:- National Committee for Quality Assurance (NCQA) for creating the Physician Practice Connections®- Patient-Centered Medical Home�™ (PPC®-PCMH�™) Standards and Guidelines . Special Thanks:- American Academy of Family Physicians (AAFP), Medical Group Management Association (MGMA) and Richard J. Barron, MD for selflessly sharing materials with us.

Table of Contents Organizational Steps __________________________________________________________________4

NCQA�’s PPC® PCMH�™ Definitions ________________________________________________________5

Abbreviations to Know ________________________________________________________________7

PPC® PCMH�™ Standards and Scoring _____________________________________________________8

PPC 1: Access and Communication (9 Points) ______________________________________________11

PPC 2: Patient Tracking and Registry Functions (21 Points)___________________________________17

PPC 3: Care Management (20 Points) ____________________________________________________29

PPC 4: Patient Self Management Support (6 Points)________________________________________38

PPC 5: Electronic Prescribing (8 Points)___________________________________________________42

PPC 6: Test Tracking (13 Points) ________________________________________________________46

PPC 7: Referral Tracking (4 Points) ______________________________________________________50

PPC 8: Performance Reporting and Improvement (15 Points)_________________________________52

PPC 9: Advanced Electronic Communications (4 Points) _____________________________________61

Frequently Asked Questions ___________________________________________________________65

Organizational Steps

1. Build your team

2. Establish regular meeting time

3. Delegate roles and responsibility (who will be the

project manager?)

4. Establish planning time

5. Identify practice champion and block non-clinic time

for the provider(s) to do the work

6. Understand what it means to be a medical home.

7. What are the joint principles?

8. Who is NCQA and what are the standards and

guidelines for PPC®-PCMH�™?

9. What is the Chronic Care Model?

10. Establish Aim and milestones

11. Create a time table

12. Identify a project manager who will hold the team accountable to meeting goals and milestones?

13. Read the workbook

14. Do the work

NCQA’s PPC®-PCMH™ Definitions: Allergies: Adverse reactions to substances. Business associate: A person or organization that on behalf of a covered entity (health plan, health care clearinghouse or health care provider) or organized health care arrangement, which includes a covered entity, performs, or assists in the performance of, but not in the capacity of a workforce member, functions or activities involving the use or disclosure of individually identifiable health information from the covered entity or organized health care arrangement. Clinical visit data: A record of patient activity at the practice. Clinically important condition: A chronic or recurring condition that a practice sees most frequently, such as otitis media, asthma, diabetes or congestive heart failure. The most frequently seen single-episode conditions may also be clinically important conditions such as colds or urinary tract infections. Contact information: Patient location facts that may include telephone number, e-mail address, payor ID and emergency contact information. Demographic information: Information that includes at least ethnicity, gender, marital status, date of birth, type of work, hours of work and preferred language. Diagnoses: Problem list of conditions, injuries or other health issues. Documented process: Written statements describing the practice's procedures. The statements may include protocols or other documents that describe actual processes or blank forms the practice uses in work flow such as referral forms, checklists and flow sheets. Emergency admissions: Any unscheduled medical or behavioral health care event that results in either an emergency room visit or hospital admission. Evidence-based: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion. Evidence-based guidelines: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion. See PRACTICE GUIDELINES. Example: One document, report or prepared material that serves as a model for those used by the practice. Factor: An item within an element that is scored. For example, an element may require the organization to demonstrate that a specific document includes four items. Each item is a factor. Materials: Prepared material that the practice provides to patients, including clinical guidelines and self-management and educational resources such as brochures, Web sites, videos and pamphlets. Multi-Site Group: Multiple practice sites of a larger organization that provide standardized systems across the practice. In this case, NCQA reviews some elements once and applies the results to all practice sites in the Multi-Site Group. Must Pass elements: Designated elements that a practice must pass at a 50% or greater score to achieve Recognition. Population management: The assessment of all patients in a practice to identify groups of patients who require specific services.

Practice: Physician or a group of physicians at a single geographic location who practice together. Practicing together means that, for all the physicians in a practice: 1) The single site is the location of practice for at least the majority of their clinical time; 2) The non-physician staff follow the same procedures and protocols; 3) Medical records, whether paper or electronic, for all patients treated at the practice site are available to and shared by all physicians as appropriate; 4) The same systems--electronic (computers) and paper-based--and procedures support both clinical and administrative functions:

scheduling time, treating patients, ordering services, prescribing, keeping medical records and follow-up. Practice guidelines: Systematically developed descriptive tools or standardized specifications for care to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Practice guidelines are typically developed through a formal process and are based on authoritative sources that include clinical literature and expert consensus. Practice guidelines may also be called PRACTICE PARAMETERS, TREATMENT PROTOCOLS or CLINICAL GUIDELINES. Preventive health data: A patient's status regarding receipt of preventive screenings, immunizations and counseling appropriate for the patient's age and gender. Records or files: Actual patient files or registry entries that document an action taken. The files are a source for estimating the extent of performance against an element. There are two ways to measure this performance: 1) a query of electronic files yielding a count, and 2) the sample selection process provided by NCQA--instructions for choosing a sample and a log for reviewing records are in the Record Review Workbook. Registry: A searchable list of patient data that the practice actively uses to assist in patient care. Reports: Aggregated data showing evidence of action; may include manual and computerized reports. Risk factors: Behaviors, habits, age, family history or other factors that may increase the likelihood of poor health outcomes. Sample: A statistically valid representation of the whole. Treatment plan: A written action plan based on assessment data that identifies the individual or patient's clinical needs, the strategy for providing services to meet those needs, the treatment goals and objectives.

Abbreviations to Know Acronym Acronym AAFP American Academy of Family Physicians NIH National Institute of Health

ABFP American Board of Family Physicians NQF National Quality Forum ABIM American Board of Internal Medicine PBM Pharmacy Benefit Management company ABMS American Board of Medical Society PCM Planned Care Model ABP American Board of Pediatrics PDSA Plan Do Study Act ACP American College of Physicians PHR Personal Health Record AHRQ Agency for Healthcare Research and Quality PPC Physician Practice Connections

AMA American Medical Association PPC®-PCMH�™

Physician Practice Connections® Patient-Centered Medical Home�™

AQA Ambulatory Quality Alliance QI Quality Improvement CAFP Colorado Academy of Family Physicians RIA/E Rapid Improvement Activity/Event CBGH Colorado Business Group on Health RMD Reach My Doctor CCGC Colorado Clinical Guidelines Collaborative TRIA Tobacco Rapid Improvement Activity CCM Chronic Care Model CMS Colorado Medical Society CMS Centers for Medicare and Medicaid Services EHR Electronic Health Record EMR Electronic Medical Record EPIC Enhancing Practice, Improving Care FPM Family Practice Management HIT Health Information Technology ICIC Improving Chronic Illness Care IHI Institute for Healthcare Improvement IOM Institute of Medicine IPIP Improving Performance in Practice ISS Interactive Survey System NCQA National Committee for Quality Assurance NICHQ National Initiative for Children�’s Health Care Quality

PPC®-PCMH™ Standards and Scoring PPC-PCMH Elements by HIT Type

Basic Intermediate Advanced PPC 1 A - B PPC 2 B, C,

F PPC 6 B

PPC 2 A, D, E

PPC 5 A - C PPC 8 F

PPC 3 A - E PPC 8 E PPC 4 A - B PPC 9 A - C PPC 6 A PPC 7 A PPC 8 A - D Practice can achieve a passing score on all Must Pass Elements with Basic Health Information Technology (HIT)

Of the 30 elements in PPC®-PCMH�™, 10 are Must Pass, that is, elements that a practice Must Pass at 50% or greater score to achieve Recognition. Practices that achieve less than 5 Must Pass elements receive a Not Recognized status. If there is a difference in Level achieved for the number of points and the Must Pass elements, the practice will be awarded the lesser level. For example, if a practice has 65 points but passes only 7 Must Pass Elements, the practice will achieve Level 1 Recognition.

Possible Status Number of Points Must Pass Elements at 50% Scoring Level

Recognized �– Level III 75- 100 10 out of 10 Recognized �– Level II 50-75 10 out of 10 Recognized �– Level I 25- 50 5 out of 10 Not Recognized 0 - 25 0 out of 10

Worksheet for Project Managing PPC® PCMH�™ Must

Pass Actions for

Point Person Staff

responsible # of factors

met Ready for

NCQA Final review assigned to

Standard complete

Linked to NCQA Server

Points completed

Points pending

Upload completed

Total points

PPC 1 Element A x Yes No Yes No Yes No Element B x Yes No Yes No Yes No PPC 2 Element A Yes No Yes No Yes No Element B Yes No Yes No Yes No Element C Yes No Yes No Yes No Element D x Yes No Yes No Yes No Element E x Yes No Yes No Yes No

Element F Yes No Yes No Yes No PPC 3 Element A x Yes No Yes No Yes No Element B Yes No Yes No Yes No Element C Yes No Yes No Yes No Element D Yes No Yes No Yes No Element E Yes No Yes No Yes No PPC 4 Element A Yes No Yes No Yes No Element B x Yes No Yes No Yes No PPC 5 Element A Yes No Yes No Yes No Element B Yes No Yes No Yes No Element C Yes No Yes No Yes No PPC 6 Element A x Yes No Yes No Yes No Element B Yes No Yes No Yes No PPC 7 Element A x Yes No Yes No Yes No PPC 8 Element A x Yes No Yes No Yes No Element B Yes No Yes No Yes No Element C x Yes No Yes No Yes No Element D Yes No Yes No Yes No Element E Yes No Yes No Yes No Element F Yes No Yes No Yes No PPC 9 Element A Yes No Yes No Yes No Element B Yes No Yes No Yes No Element C Yes No Yes No Yes No

The layout of this workbook NCQA�’s Intent : From the PPC-PCMH Standards and Guidelines

CCGC�’s interpretation of NCQA�’s Intent

Who will manage this standard? NCQA Workshop Slides: - See examples in the most recent PowerPoint presentation at http://www.ncqa.org/tabid/165/Default.aspx.

PPC

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points

Notes:

Element XX: Description of the Element (Must pass elements are in red)

Whether this is a must pass element or not X Points

NCQA’s description of the Element

NCQA�’s Factors CCGC Suggested

Documents Process Owner

Due Date

Practice is done working on Element

Practice is focusing on this Element

Practice is choosing not to work on this Element

NCQA�’s factors from the Standards and Guidelines document

Work area for the practice. These are tools and resources that CCGC has collected to help you.

Person assigned to work on this.

PPC 1: Access and Communication (9 Points) NCQA�’s Intent : The practice provides patient access during and after regular business hours, and communicates with patients effectively.

CCGC�’s interpretation of NCQA�’s Intent:- Element 1A: What are your written policies for access and communication to your patients? Element 1B: Proof that shows your practice meets its goals defined in1A for patient access and communication. Who will manage this standard? NCQA Workshop Examples: - :- Standard 1 or click here for newer version.

PPC 1

Must

Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard Complet

e

NCQA docume

nt(s) linked

(number of

documents

linked)

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points

A x

Not started In process Done Not working on

this

Yes Yes

B x

Not started In process Done Not working on

this

Yes Yes

Notes:

Element 1A: Access and Communication Processes (Must Pass) 4 Points

NCQA�’s Factors Do we have these factors in

writing? CCGC Suggested Documents Process Owner

Due Date

Scheduling each patient with a personal clinician for continuity of care

Yes No Written policy for scheduling

provider. patients with a requested

Coordinating visits with multiple clinicians and/or diagnostic tests during one trip

Yes No Written procedures for staff for making appointments/ scheduling patient visit so that it is one trip to get the services they need.

Determining through triage how soon a patient needs to be seen

Yes No Written policy for triage on what needs to been seen urgently.

Maintaining the capacity to schedule patients the same day they call

Yes No Measuring capacity tool

Scheduling same day

practice's appointments based on triage of patients' conditions

Yes No Procedures

Scheduling same day appointments based on patient's/family's requests

Yes No Open Access Article

Providing telephone advice on clinical issues during office hours by physician, nurse or other clinician within a specified time

Yes No

Providing urgent phone response within a specific time, with clinician support available 24 hours a day, 7 days a week

Yes No Policy on returning urgent calls

What is your after hour�’s coverage?

Sending to ER doesn�’t meet standard.

Providing secure e-mail consultations with physician or other clinician on clinical issues, answering within a specified time

Yes No Policy on checking e-mail If using, website for appt, rx refill, test results, etc�… what is your policy? Tool: RMD if your EMR doesn�’t have this functionality

Providing an interactive practice Web site

Yes No If using, website for appt, rx refill, test results, etc�… what is your policy? Tool: RMD if your EMR doesn�’t have this functionality

Making language services available for patients with limited English proficiency

Yes No

A written process should be provided if services are used and an explanation can be provided in Support Text/Notes stating determination of languages needed and languages spoken by staff.

What percent of your practice have limited English proficiency? Do you have bilingual staff? Resources: Language lines (AT&T, Sprint..) Note:-PPC 4A asks a similar communication question.

Identifying health insurance resources for patients/families without insurance.

Yes No What are the phone numbers and contact information for other health insurance options such as SCHIP, Medicaid or Medicare? Are there other resources you can provide patients without health insurance?

NCQA Data Source

Data source: Written procedures for staff for appointments, triage and patient communication; log or schedule to demonstrate capacity (Item 3).

CCGC Suggested

Policies and Procedures (chapter 3) MGMA�’s - Operating Policies and Procedures: Manual for Medical Practices by Elizabeth Woodcock.

Tools/ Resources

(MGMA Member $135, Joint MGMA-ACMPE member , MGMA affiliate $162.00 , Non-member $211.00)

1. Measuring Demand and Capacity What Works, Effective Tools & Case Studies To Improve Clinical Office Practice by Sue Houck. HealthPress Publishing, 2004,

Murray MD, Mark. Same Day Appointment: Exploding the Access Paradigm. FPM 2000 (click here) IHI�’s Demand and Capacity Diagnostic Tool (click here) IHI.org - Shortening Waiting Times: Six Principles for Improved Access (click here) Access Workbook (click here)

Language Resources Office of Health Disparities website - http://www.cdphe.state.co.us/ohd/lep.html AT&T�’s Language Line (http://www.languageline.com/page/industry_healthcare ) RMD – Activation of all of the RMD features (click here)

Percentage Min. score to pass Our Score 100% Practice has written processes for 9 -12 items 75% Practice has written processes for 7 - 8 items 50% Practice has written processes for 4 - 6 items X 25% Practice has written processes for 2 �– 3 items 0% Practice has written processes for 0 - 1 item Notes:

Element 1B: Access and Communication Results (Must Pass) 5 Points The practice's data shows that it meets access and communication standards in 1A:

NCQA�’s Factors What needs to happen? CCGC Suggested

Documents Process Owner

Due Date

Visits with assigned personal clinician for each patient

Not started In process Done Linked

Report

Appointments scheduled to meet the standards in Items 2-6 in 1A

Not started In process Done Linked

Report

Response times to meet standards for timely response to telephone requests

Not started In process Done Linked

Report

Response times to meet its standards for timely response to e-mail and interactive Web requests

Not started In process Done Linked can exclude patient that don�’t have email

Language services for patients with limited English proficiency.

Not started In process Done Linked can mark NA if language services aren�’t required

NCQA Data Source

Tracking reports, either paper or screen shots, showing records for a period of appointments with personal clinicians, average wait for appointments, average time for returning telephone calls and emails. Visits with assigned physician Timely response to phone, e-mail and Internet requests Language services if the practice�’s population requires it

CCGC Suggested Tools/ Resources

Patient Satisfaction Survey Patient Feedback Card (click here) & Excel Tracking Sheet (click here) Include questions on physician communication, patient confidence level etc so you can use the results for 8B Logs 3rd next available appointment, no show, telephone response time, # of same day appointments available, fill rate, ..etc (click here) Open Access information - https://www.aap.org/visit/keymeasures.htm Supply Demand worksheet - click here

Reports from �“How�’s your Health” www.howsyourhealth.org Article:- Getting the most of your phone system (click here) Panel Size How Many Patients Can a Provider Handle (click here)

100% Practice data meets 5 items 75% Practice data meets 4 items 50% Practice data meets 3 items X 25% Practice data meets 2 items 0% Practice data meets 0-1 items Notes:

PPC 2: Patient Tracking and Registry Functions (21 Points) NCQA�’s Intent: The practice systematically manages patient information and uses the information for population management to support patient care. CCGC�’s interpretation of NCQA�’s Intent:- The practice has readily accessible, clinically useful information on patients that enables it to treat patients comprehensively and systematically. Element 2A: The practice has the ability to query basic patient demographic information Element 2B: The has the ability to search clinical data for things like allergies, blood pressure, BMI, imaging, etc Element 2C: The practice has the ability to query & report patient clinical information from 2B Element 2D: Flowsheet and/ or templates used to organize and document clinical information such as problem lists, medication lists, and risk factors Element 2E: The practice can identify its most frequently seen diagnoses, most important risk factors for the patient population, and the practice�’s three clinically important conditions. Element 2F: Practice uses electronic information to generate lists of patients and remind patients and clinicians of services needed

Who will manage this standard?

NCQA Workshop Examples: - :- Standard 2 or click here for newer version.

PPC 2

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A B C D X E X F Notes:

Element 2A: Basic System for Managing Patient Data 2 Points The practice uses an electronic data system for patients that includes the following searchable patient information:

NCQA�’s Factors Can we search by

this field? If no, what needs to happen? Process Owner

Due Date

Name Yes No

Date of birth Yes No

Gender Yes No

Marital status Yes No NA

Language preference Yes No

Voluntarily self-identifiedrace/ethnicity Yes No

Address Yes No

Telephone (primary contact number)

E-mail Address (or �“none�” for pts) Yes No

Internal ID Yes No

Your internal tracking number (i.e. Chart #)

External ID Yes No

Emergency contact information Yes No

Current and past diagnoses Yes No

Dates of previous clinical visits Yes No

Billing codes for services Yes No

Legal guardian Yes No NA

Health insurance coverage Yes No

Patient/family preferred method of communication. Yes No

NCQA Data Source

Reports from electronic systems

CCGC Suggested Tools/ Resources/ Tips

You need to have numerators and denominators for this factor You don�’t have to have one report that has all of these factors but it would be helpful when you are uploading the document A report of patients seen in the last 3 months that have these fields completed. Practices with EMRs it might be helpful to contact your vendor to run this report. Think of factors that are �“required�” fields.

Percentage Min. result to score Our Score 100% 12-18 items were entered for 75 -100% of patients 75% 8-11 items were entered for 75 -100% of patients 50% 6-7 items were entered for 75 -100% of patients 25% 4-5 items were entered for 75 -100% of patients 0% 0-3 items were entered for 75 -100% of patients X Notes:

Element 2B: Electronic System for Clinical Data 3 Points The practice�’s clinical data system or systems to manage care of patients include the following clinical patient information in searchable data fields:

NCQA�’s Factors Can we search by

this field? If no, what needs to happen? Process Owner

Due Date

Status of age-appropriate preventive services (immunizations, screenings, counseling)

Yes No

Allergies and adverse reactions

Yes No

Blood pressure

Yes No

Height

Yes No

Weight

Yes No

Body mass index (BMI) calculated (Under 18- BMI is percentile plotted on growth chart)

Yes No

Laboratory test results

Yes No

Presence of imaging results

Yes No

Presence of pathology reports Yes No

Presence of advance directives. Yes No

Head circumference for patients 2 years or younger

Yes No NA

NCQA Data Source

Screen shots or reports showing fields in patient records. Where applicable, these fields may show that the patient has no allergies or lab or imaging tests.

CCGC Suggested Tools/ Resources/ Tips

For items 7-10, data may indicate the presence of a written report not in the system Must be from an EMR or registry that includes all patients.

Percentage Min. result to score Our Score 100% System has 9 �– 11 data fields 75% System has 7 - 8 data fields 50% System has 5 - 6 data fields 25% System has 3 - 4 data fields 0% System has 0 - 2 data fields X Notes:

Element 2C: Use of Electronic Clinical Data 3 PointsThe practice uses the fields listed in 2B consistently in patient records.

NCQA�’s Factors

What is our percentage of these measures for patients seen in the last 3 months?

CCGC Suggested Documents

Process Owner

Due Date

Status of age-appropriate preventive services (immunizations, screenings, counseling)

Report from your EMR or registry that includes all patients or NCQA Excel Workbook

Allergies and adverse reactions Blood pressure Height Weight Body mass index (BMI) calculated Laboratory test results Presence of imaging results Presence of pathology reports Presence of advance directives. Head circumference for patients 2 years or

younger

NCQA Data Source Reports from electronic systems CCGC Suggested Tools/ Resources

This element and PPC 2D, 3D and 4B are based on data collected from a sample of patient medical records. You need to have numerators and denominators for this factor and may use one of two methods: Query your electronic registry, practice management system or other electronic or manual system using the total number of patients seen in the past 3 months. Use PPC-PCMH Workbook located in the Survey Tool. Select patients following NCQA�’s method. Choose patients with the three clinically important conditions. Use the same patients for PPC 2C, 2D, 3D, and 4B Enter data from the medical records in the Excel Worksheet. SEE PPC-PCMH WORKBOOK INSTRUCTIONS FOR DETAILS ON PATIENT SELECTION

Percentage Min. score to pass Our Score 100% 75 -100% of patients seen in last 3 months have at least 7 fields completed 75% 50 - 74% of patients seen in last 3 months have at least 7 fields completed 50% 25 – 49% of patients seen in last 3 months have at least 7 fields completed 25% 10 - 24% of patients seen in last 3 months have at least 7 fields completed 0% Less than 10% of patients seen in last 3 months have at least 7 fields completed X

Notes:

Element 2D: Organizing Clinical Data (Must Pass) 6 PointsThe practice uses the following electronic or paper-based charting tools to organize and document clinical information in the medical record:

NCQA�’s Factors Do you currently have a place in your chart (paper or electronic)

to document these items? Tools Process Owner

Due Date

1. Problem lists Yes No Flowsheets, templates or screen shots Yes No

Report from your EMR or NCQA Excel Workbook Same as 2C

2. Lists of over-the-counter medications, supplements and alternative therapies

Yes No Flowsheets, templates or screen shots Yes No

3. Lists of prescribed medications including both chronic and short-term

Yes No Flowsheets, templates or screen shots Yes No

4. Structured template for age-appropriate risk factors (at least 3)

Yes No Risk #1:__________ ___Flowsheets, templates or screen shots

Yes No Risk #2:_____________ Flowsheets, templates or screen shots

Yes No Risk #3:_____________ Flowsheets, templates or screen shots Yes No

5. Structured templates for narrative progress notes

Yes No Flowsheets, templates or screen shots Yes No

6. Age appropriate standardized screening tool for developmental testing

Yes No Flowsheets, templates or screen shots Yes No

7. Growth charts plotting height, weight, head circumference and BMI, if less than 18 years.

Yes No Flowsheets, templates or screen shots Yes No

NCQA Data Source

Medical record review or system report showing percent of patients seen in past 3 months with information documented in at least 3 charting tools

CCGC Suggested

This element and PPC 2D, 3D and 4B are based on data collected from a sample of patient medical records. You need to have numerators and denominators for this factor and may use one of two methods:

Tools/ Resources

Query your electronic registry, practice management system or other electronic or manual system using the total number of patients seen in the past 3 months. Use PPC-PCMH Workbook located in the Survey Tool. Select patients following NCQA�’s method. Choose patients with the three clinically important conditions. Use the same patients for PPC 2C, 2D, 3D, and 4B Enter data from the medical records in the Excel Worksheet. We have found it to be easier to do a chart audit of 36 charts instead of trying to run a report from the EMR. SEE PPC-PCMH WORKBOOK INSTRUCTIONS FOR DETAILS ON PATIENT SELECTION

Percentage Min. score to pass Our Score 100% 75 -100% of patients seen in last 3 months have at least 3 tools with information documented.

75% 50 - 74% of patients seen in last 3 months have at least 3 tools with information documented.

50% 25 – 49% of patients seen in last 3 months have at least 3 tools with information documented. X

25% 10 - 24% of patients seen in last 3 months have at least 3 tools with information documented.

0% Less than 10% of patients seen in last 3 months have at least 3 tools with information documented.

Notes:

Element 2E: Identifying Important Conditions (Must Pass) 4 Points The practice uses an electronic or paper-based system to identify the following diagnoses and conditions:

NCQA�’s Factors Can you run a report in your billing system or your EMR to get

the following information?

CCGC Suggested Documents

Process Owner

Due Date

1. Practice�’s most frequently seen diagnoses

Dx practice sees most often may include single episode conditions (colds, UTI, or chronic conditions).

o # of patients with condition/ problem/ # of visits for the condition or problems

o High cost (billed) conditions, problems

Reports from billing/ Practice management system, or EMR

2. Most important risk factors in the practice�’s patient population

Community based demographic characteristics Check your local health department for risk factors in your

community Check CDC�’s website for risk factors for your community.

3. Three conditions that are clinically important in the practice�’s patient population.

Chronic or recurring condition practice sees Most patients, visits, greatest cost, amendable to care management

See 1 and 2 below for information on three clinically important conditions

NCQA Data Source

Reports from EHR, PM system, billing system or scheduling system to query patients with Diabetes, Hypertension and Hyperlipidemia.

CCGC Suggested Tools/ Resources

Refers to Factor 3.- Colorado Multistate Multi-stakeholder PCC-PCMH has identified Diabetes, Hyperlipidemia, and Hypertension as the 3 clinically important conditions for the practices. Refers to Factor 3.- In the Support Text/Notes the practice states, the three clinically important conditions. Either in a document or in the Support Text box the practice explains or shows the data used to select the conditions. The clinically important conditions are chronic or recurring conditions that the practice sees such as otitis media, asthma, diabetes or congestive heart failure. Wording for “Support Text/ Notes�” on the PPC®-PCMH�™ Interactive Survey System - As part of a National PCMH Demonstration Project the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia as Clinically Important Conditions which represent the best likelihood of being amenable to care management and providing value on costs to the health care system based on regional experience. These conditions have associated required metrics which will be reported by the physician practices as part of the National PCMH Demonstration Project. Some practices may chose to exchange one of the clinically important conditions with a condition that meets the standards established on page 19 of the PPC®-PCMH�™ Standards and Guidelines.

Percentage Min. score to pass Our Score 100% Practice identifies 3 items 75% Practice identifies 2 items 50% Practice identifies 1 items X 25% No scoring option 0% Practice identifies 0 items

Element 2F: Use of System for Population Management 3 Points The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed, as follows:

NCQA�’s Factors What is our current status?

What needs to happen? CCGC Suggested Documents

Process Owner

Due Date

1. Patients needing pre-visit planning (obtaining tests prior to visit, etc.)

Flowsheets, templates or screen shots

Yes No

EMR/RMD Flowsheet & CarePlan screen

2. Patients needing clinician review or action

Flowsheets, templates or screen shots

Yes No

EMR/RMD Flowsheet & CarePlan screen

3. Patients on a particular medication

Flowsheets, templates or screen shots

Yes No

4. Patients needing reminders for preventive care

Flowsheets, templates or screen shots

Yes No

EMR/RMD Flowsheet & CarePlan screen

5. Patients needing reminders for specific tests

Flowsheets, templates or screen shots

Yes No

RMD Patient handout

6. Patients needing reminders for follow-up visits such as for a chronic condition

Flowsheets, templates or screen shots

Yes No

Screen shot of reminder email to patients/ copy of letters to patients

7. Patients who might benefit from care management support.

Flowsheets, templates or screen shots

Notes:

Yes No

CCGC Suggested Tools/ Resources

Lists generated -- reports from EHR, registries, billing systems RMD Guideline at Point of Service (CarePlan) List of patients (a1c over 9) Population management reports (RMD Diabetes Summary Report) Outreach reports Patient handout DM Flowsheet, Prevention Flowsheet

Percentage Min. score to pass Our Score 100% Practice used information to take action on 5 �– 7 items 75% Practice used information to take action on 3 – 4 items 50% Practice used information to take action on 1 - 2 items X 25% No scoring option 0% Practice does not use information to take action Notes:

PPC 3: Care Management (20 Points)

NCQA�’s Intent: The practice systematically manages care for individual patients according to their conditions and needs, and coordinates patients' care. CCGC�’s interpretation of NCQA�’s Intent:- The practice maintains continuous relationships with patients by implementing evidence-based guidelines and applying them to the identified needs of individual patients over time and with the intensity needed by the patients. Element 3A: The practice has evidence based clinical guidelines embedded into daily workflow and uses it Element 3B: Providers have alerts and reminders to address evidence-based guidelines when seeing patients Element 3C: Practice uses standing orders and protocols for non-physician staff to manage patient care Element 3D: Practice has a care management plan for patients with clinically important conditions Element 3E: Practice coordinates care and follow up for patients who receive care in inpatient and outpatient facilities

Who will manage this standard?

NCQA Workshop Examples: - :- Standard 3 or click here for newer version.

PPC 3

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A X B C D E Notes:

Element 3A: Guidelines for Important Conditions (Must Pass) 3 Points The practice adopts and implements evidence-based diagnosis and treatment guidelines for:

NCQA�’s Factors What are our clinically

important conditions? CCGC Suggested Documents Process Owner Due Date

1. First clinically important condition

i.e. Diabetes

1. Copy of the guideline you are using (i.e. CCGC DM Guideline or ADA guidelines 2. Copy or screen shot of templates/ flowsheets used for Diabetes management

2. Second clinically important condition i.e. Hypertension

1. Copy of the guideline you are using for Hypertension (ie JNC7) 2. Copy or screen shot of templates/ flowsheet used for a Hypertension management

3. Third clinically important condition. i.e. Hyperlipidemia

1. Copy of the guideline yo u are using for Hyperlipidemia (i.e. ATP III) 2. Copy or screen shot of templates/ flowsheets used for Cholesterol management

NCQA Data Source

Workflow organizers, which demonstrate both a ion of guidelines by the practice. Paper-based organizers�–algorithms for developing treatment plans, flow sheets or templates for documenting progress.

doption and implementat

Electronic system organizers (registry, EHR or other system)�–screenshots showing templates for treatment plans and progress. CCGC Suggested Tools/ Resources

Provide source of guidelines Diabetes {CCGC DM Guideline} CVD {CCGC Cardiovascular & Stroke Prevention Guideline} Prevention {CCGC Prevention Guideline}

Depression {CCGC Depression Guideline} Asthma {CCGC Asthma Guideline} Low Back Pain {ICSI Low Back Pain Guideline}

Paper flow sheets, templates for documenting progress Diabetes {CCGC Diabetes Flowsheet--Version 1}, {CCGC Diabetes Flowsheet--Version 2} CVD Prevention {CCGC Prevention Flowsheet--Adult}

Depression {CCGC Depression Flowsheet--Adult} Asthma {CCGC Asthma Flowsheet} Low Back Pain

Screen shots showing templates/ flowsheets for treatment plans and documenting progress.

Percentage Min. score to pass Our Score 100% Practice implements guidelines for 3 conditions 75% No scoring options 50% Practice implements guidelines for 2 conditions X 25% Practice implements guidelines for 1 conditions 0% Practice does not implements guidelines for any conditions Notes:

Element 3B: Preventive Service Clinician Reminders 4 Points The practice uses a paper-based or electronic system with guideline-based reminders for the following services when seeing the patient:

NCQA�’s Factors Do we have these tools available? CCGC Suggested Documents Process Owner

Due Date

1. Age-appropriate screening tests

Yes No Examples of preventative screening

Prevention Flowsheet Disease Specific Flowsheets

2. Age-appropriate immunizations (e.g., influenza, pediatric)

Yes No

Adult Immunizations Pediatric Immunizations

3. Age-appropriate risk assessments (e.g., smoking, diet, depression)

Yes No Tobacco Assessment

Depression Screening Flowsheet

4. Counseling (e.g., smoking cessation).

Yes No

Tobacco Assessment Obesity

NCQA Data Source

Reports, screen shots or paper flow sheets showing how the reminders are available to clinicians during the visit Documentation from an electronic system may include reports or screen shots. Documentation from a paper-based system may include templates, flow sheets, algorithms or reminders. The practice must show that its clinicians have available decision support for interactions with patients including in-person appointments, telephone calls and e-mail communication.

CCGC Suggested Tools/ Resources/ Tips

Paper based practices: Flowsheet/ template that reminds providers to check for risk assessments, immunizations, screening tests. a. Example: Incorporation of flowsheet use detailing prevention activities and when due {CCGC Prevention Flowsheet--Adult} Electronic based practices: screen shot of health maintenance screen.

Consider utilizing CIIS Registry flowsheet; also a mapping of process incorporating CIIS flowsheet use�—which team members are responsible for which part of the workflow.

Percentage Min. score to pass Our Score 100% Practice uses reminders for 4 items 75% Practice uses reminders for 3 items 50% Practice uses reminders for 2 items 25% Practice uses reminders for 1 items X 0% Practice uses reminders for no items

Notes:

Element 3C: Practice Organization 3 Points The care team manages patient care in the following ways:

NCQA�’s Factors What needs to happen? CCGC Suggested

Documentation

Process Owner

Due Date

1. Non-physician staff remind patients of appointments and collect information prior to appointments

Copy of appointment confirmation log

2. Non-physician staff execute standing orders for medication refills, order tests and deliver routine preventive services

Job descriptions ACP Diabetes Standing orders

3. Non-physician staff educate patients/families about managing conditions

Job descriptions of mid-level staff. Care coordinators, MAs, etc

4. Non-physician staff coordinates care with external disease management or case management organizations.

Job descriptions of mid-level staff. Care coordinators, MAs, etc

NCQA Data Source

Job descriptions, protocols, written standing orders

CCGC Suggested Tools/ Resources/ Tips

Team-Based Care: Using Huddles Huddle video (http://www.youtube.com/watch?v=Wttxm7jAnb4) b. Article: Stewart, EE et. al. (2007). Huddles Improve Office Efficiency in Mere Minutes. FPM. c. Huddle worksheet {click here to open PDF} d. Article: Bodenheimer, T. et al. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine (5):457- 461. Job Descriptions Article: Capko. (2007). Get Better Results with Staff Performance Standards. FPM. Standing Orders Example of interactive page to set-up diabetes standing orders {ACP Diabetes Standing Orders} Immunization standing orders {Immunization Action Coalition Standing Orders--web link} Article: Escobedo. (2002). Rethinking Refills. FPM {article PDF} Refill Protocol from the Article (some Medication(s) on this list like Salmeterol and Serzone may need to be removed. Please review the list before using this protocol)

Percentage Min. score to pass Our Score

100% Staff manages 4 items 75% Staff manages 3 items 50% Staff manages 2 items X 25% No scoring options 0% Staff manages 0-1 items Notes:

Element 3D: Care Management for Important Conditions 5 Points For the three clinically important conditions, the physician and non-physician staff use the following components of care management support:

NCQA�’s Factors What is our current status?

What needs to happen? CCGC Suggested Documents

Process Owner

Due Date

1. Conducting pre-visit planning with clinician reminders

Report from your EMR or NCQA Excel Workbook Same as 2C,2D

2. Writing individualized care plans 3. Writing individualized treatment goals 4. Assessing patient progress toward

goals

5. Reviewing medication lists with patients

6. Reviewing self-monitoring results and incorporating them into the medical record at each visit

7. Assessing barriers when patients have not met treatment goals

8. Assessing barriers when patients have not filled, refilled or taken prescribed medications

9. Following up when patients have not kept important appointments

10. Reviewing longitudinal representation of patient�’s historical or targeted clinical measurements

11. Completing after-visit follow-up

NCQA Examples

Medical record showing the components of care management Patient record shows Care plans, treatment goals, progress assessments, review of home monitoring results, barriers addressed Item descriptors: 2. Written care plan�—addresses respective responsibilities of the medical home and specialists the patient is referred to. 7-8. Barriers�—include the patients�’ lack of understanding, motivation, financial need, insurance issues, or transportation problems. 9. Important appointments—those that the practice has requested are made in order to follow standards of care. 10. Longitudinal patient data—Graphs or flowsheets showing clinical measures (LDL, BP, Wt.) over time. 11. After visit follow-up—Examples may include checking to see if the patients filled a prescription or received care by the referred consultant.

CCGC Suggested Tools/ Resources

This element and PPC 2D, 3D and 4B are based on data collected from a sample of patient medical records. You need to have numerators and denominators for this factor and may use one of two methods: Query your electronic registry, practice management system or other electronic or manual system using the total number of patients seen in the past 3 months. Use PPC-PCMH Workbook located in the Survey Tool. Select patients following NCQA�’s method. Choose patients with the three clinically important conditions. Use the same patients for PPC 2C, 2D, 3D, and 4B Enter data from the medical records in the Excel Worksheet. We have found it to be easier to do a chart audit of 36 charts instead of trying to run a report from the EMR. SEE PPC-PCMH WORKBOOK INSTRUCTIONS FOR DETAILS ON PATIENT SELECTION

Percentage Min. score to pass Our Score 100% 75% of more of patients seen in the past 3 months have at least 4 items documented

75% 50 – 74% of more of patients seen in the past 3 months have at least 4 items documented

50% 25 – 49 % of more of patients seen in the past 3 months have at least 4 items documented

25% 11 – 24 % of more of patients seen in the past 3 months have at least 4 items documented X

0% Less than 10% of patients seen in the past 3 months have at least 4 items documented

Notes:

Element 3E: Continuity of Care 5 Points The practice on its own or in conjunction with an external organization engages in the following activities for patients who receive care in inpatient or outpatient facilities or patients who are transitioning to other care:

NCQA�’s Factors What is our current status? CCGC Suggested

Documentation

Process Owner

Due Date

1. Identifies patients who receive care in facilities

2. Systematically sends clinical information to the facilities with patients as soon as possible

3. Reviews information from facilities (discharge summary or ongoing updates) to determine patients who require proactive contact outside of patient-initiated visits or who are at risk for adverse outcomes

4. Contacts patients after discharge from facilities

5. Provides or coordinates follow-up care to patients/families who have been discharged

6. Coordinates care with external disease management or case management organizations, as appropriate

7. Communicates with patients/families receiving ongoing disease management or high risk case management

8. Communicates with case managers for patients receiving ongoing disease management or high risk case management

9. For patients transitioning to other care, develops a written transition plan in collaboration with the patient and family

10. Aids in identifying a new primary care physician or specialists or consultants and offers ongoing consultation.

NCQA Data Source May be from the practice itself or from an external case management organization such as a disease management organization with which the practice works. The data sources may include: Policies/protocols that include the practice�’s timeframe for patient follow up after an admission or emergency room visit Policies/protocols for using care plans and patient visit flow sheets Printout from registry, EHR, hospital emergency room, admitting department or other computerized reports that include a list of identified patients, emergency room visits and inpatient admissions Paper or electronic communication forms/tools to use with external facility regarding patient clinical information. Manual or electronic patient health/needs assessments Blinded case management or medical record notes.

Policies and medical record documentation detailing proactive outreach to patients receiving care at another facility (inpatient or outpatient) to ensure that the patient receives appropriate follow-up care. Follow-up care can include physician counseling and/or referrals to community resources, disease management programs, or self-management support programs.

CCGC Suggested Tools/ Resources

Screen shot of RMD�’s CareNotes or CareTeam (click here)

Example ER follow-up log (click here)

Care Transitions resources an HMO workgroup report on Care Management�—excellent background information and resource to operationalize �“Care Management�” {report PDF} �“The Care Transitions Program�” affiliated with UCHSC: www.caretransitions.org Relevant articles Sylvester, I. et al. (2008). Transforming your practice�—what matters most. Family Practice Management, 15(1). Coleman, E. et al. (2004). Post hospital care transitions: Patterns, complications, and risk identification. Health Services Quality Research, 39(5): 1449-1466. {article PDF}

Percentage Min. score to pass Our Score 100% Activities include 5 – 10 items 75% Activities include 3 - 4 items 50% Activities include 2 items X 25% Activities include No scoring option 0% Activities include 1 - 0 items Notes:

PPC 4: Patient Self- Management Support (6 Points) NCQA�’s Intent : The practice works to improve patients' ability to self-manage health by providing educational resources and ongoing assistance and encouragement. CCGC�’s interpretation of NCQA�’s Intent:- The practice collaborates with patients and families to pursue their goals for optimal achievable health. Element 4A: The practice systematically assesses patient-specific barriers to communication Element 4B: Practice documents self-management support activities in the patient record Who will manage this standard? NCQA Workshop Examples: - :- Standard 4 or click here for newer version.

PPC 4

Must

Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A B X Notes:

Element 4A: Documenting Communication Needs 2 Points

The practice assesses patient/family-specific barriers to communication using a systematic process to:

NCQA�’s Factors What is our current status?

CCGC Suggested DocumentationCCGC Suggested Documentation

Process Owner

Due Date

1. Identify and display in the record the language preference of the patient and family

Screening questions in new patient�’s form or physical forms

2. Assess both hearing and vision barriers to communication.

NCQA Data Source

Documents that show how the practice records language preference (e.g., screen shots, patient assessment forms) and how the practice determines the percentage of its patients that prefer another language (e.g., reports from an electronic system, review of a sample of records).

CCGC Suggested Tools/ Resources

Address health literacy issues in the practice�—see the National Patient Safety Foundation website �“Ask Me 3�”: www.npsf.org/askme3/ for simple resources. Office of Health Disparities website: http://www.cdphe.state.co.us/ohd/lep.html

Percentage Min. score to pass Our score 100% Practice assesses 2 items 75% No scoring option 50% Practice assesses1 item X 25% No scoring option 0% Practice does not assess any items Notes:

Element 4B: Self-Management Support (Must Pass) 4 Points The practice conducts the following activities to support patient/family self-management, for the three important conditions:

NCQA�’s Factors What is our current

status?

CCGC Suggested Documentation

Process Owner Due Date

1. Assesses patient/family preferences, readiness to change and self-management abilities

Report from your EMR or NCQA Excel Spreadsheet

2. Provides educational resources in the language or medium that the patient/family understands

3. Provides self-monitoring tools or personal health record, or works with patients' self-monitoring tools or health record, for patients/families to record results in the home setting where applicable

4. Provides or connects patients/families to self-management support programs

5. Provides or connects patients/families to classes taught by qualified instructors

6. Provides or connects patients/families to other self-management resources where needed

7. Provides written care plan to the patient/family.

NCQA Examples

Medical record review includes: Referrals to programs, classes or other self-management resources from the patient record Use of tool for assessing patient preferences, readiness to change and self-management abilities Use of educational brochures, pamphlets and video Self-monitoring tool or personal health record Referrals to community resources.

CCGC Suggested Tools/ Resources

This element and PPC 2D, 3D and 4B are based on data collected from a sample of patient medical records. You need to have numerators and denominators for this factor and may use one of two methods: Query your electronic registry, practice management system or other electronic or manual system using the total number of patients seen in the past 3 months. Use PPC-PCMH Workbook located in the Survey Tool. Select patients following NCQA�’s method. Choose patients with the three clinically important conditions. Use the same patients for PPC 2C, 2D, 3D, and 4B Enter data from the medical records in the Excel Worksheet.

We have found it to be easier to do a chart audit of 36 charts instead of trying to run a report from the EMR. SEE PPC-PCMH WORKBOOK INSTRUCTIONS FOR DETAILS ON PATIENT SELECTION

Percentage Min. score to pass Our score 100% 75 �– 100% of patients seen in the past 3 months have at least 3 activities documented 75% 50 �– 74% of patients seen in the past 3 months have at least 3 activities documented 50% 25 �– 49% of patients seen in the past 3 months have at least 3 activities documented X 25% 11 �– 24% of patients seen in the past 3 months have at least 3 activities documented 0% 10% or less patients seen in the past 3 months have at least 3 activities documented Notes:

PPC 5: Electronic Prescribing (8 Points) NCQA�’s Intent: The practice employs electronic systems to order prescriptions, to check for safety and to promote efficiency when prescribing.

CCGC�’s interpretation of NCQA�’s Intent:- The practice seeks to reduce medical errors and improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost information when prescribing. Element 5A:- The practice can produce a report of all �“new prescriptions�” written with the prescribing system in the last 3 months Element 5B:- There are alerts and reminders at point of care to notify providers of drug �– drug or drug- patient interactions Element 5c:- Practice has alerts and reminders in place to prescribe cost efficient drugs to patients.

Who will manage this standard?

NCQA Workshop Examples: - :- Standard 5 or click here for newer version.

PPC 5

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A B C Notes:

Element 5A: Electronic Prescription Writing 3 Points The practice uses an electronic system to write prescriptions using either:

NCQA�’s Factors What is our current status?

CCGC Suggested Documentation

Process Owner

Due Date

1. Electronic prescription writer�—stand-alone system (general) with either print capability at the office or ability to send fax or electronic message to pharmacy

75-100% of new prescriptions for patients seen in the last 3 months written using this system

Practice has system capable of doing this but does not use it or cannot produce the desired report

System does not have capability or less than 75% of prescriptions written using this system

2. Electronic prescription writer that is linked to patient-specific demographic and clinical information.

75-100% of new prescriptions for patients seen in the last 3 months written using this system

Practice has system capable of doing this but does not use it or cannot produce the desired report

System does not have capability or less than 75% of prescriptions written using this system

NCQA Data source

Reports from system

CCGC Suggested Tools/ Resources

E- prescribing pdf Consumer guide to e-prescribing.pdf

Percentage Min. score to pass Our score 100% 75 �– 100% of new prescriptions for patients seen in the last 3 months written with

Item 2

75% 75 �– 100% of new prescriptions for patients seen in the last 3 months written with Item 1

50% No scoring option 25% Practice has system capable of either Item 1 or Item 2, but does not use it X 0% System does not have capability or less than 75% of prescriptions written using this

system

Notes:

Element 5B: Prescribing Decision Support—Safety 3 Points Clinicians in the practice write prescriptions using electronic prescription reference information at the point of care, including the following types of alerts and information:

NCQA�’s Factors What is our current status?

What needs to happen? CCGC Suggested Documentation

Process Owner

1. Drug-drug interactions based on general information Yes No 2. Drug-drug interactions specific to drugs the patient takes Yes No 3. Drug-disease interactions based on general information Yes No 4. Drug-disease interactions specific to diseases the patient

has Yes No

5. Drug-allergy alerts based on general information Yes No 6. Drug-allergy alerts specific to the patient Yes No 7. Drug-patient history alerts based on general information Yes No 8. Appropriate dosing based on general information Yes No 9. Appropriate dosing calculated for the patient Yes No 10. Therapeutic monitoring associated with specific drug

utilization based on general information (drug-lab alerts) Yes No

11. Duplication of drugs in a therapeutic class based on general information

Yes No

12. Duplication of drugs in a therapeutic class specific to the patient

Yes No

13. Drugs to be avoided in the elderly based on general information

Yes No

14. Drugs to be avoided in the elderly based on age of the patient

Yes No

15. Patient appropriate medication Yes No

Examples Reports from the electronic system showing an example of use of each item. Percentage Min. score to pass Our score 100% Practice uses 8 or more kinds of alerts and information 75% Practice uses 4 �– 7 kinds of alerts and information 50% Practice uses 2 �– 3 or more kinds of alerts and information 25% System has capability of providing 6 or more kinds of alerts, but practice does not use them X 0% No system capability, system has capability for fewer than 6 kinds of alerts or practice uses

fewer than 2 kinds of alerts and information

Notes:

Element 5C: Prescribing Decision Support—Efficiency 2 Points Clinicians engage in cost-efficient prescribing through one or more of the following tools

NCQA�’s Factors What is our current status?

CCGC Suggested Documentation

Process Owner

1. Electronic prescription writer with general automatic alerts for different choices including generics

We use this tool

System has capability to support both options; practice does not use it

System does not have capability or practice does not use either tool

2. Electronic prescription writer connected to payer-specific formulary that automatically alerts clinician to alternative drugs, including generics.

We use this tool

System has capability to support both options; practice does not use it

System does not have capability or practice does not use either tool

NCQA Data source

Reports from the system, screen shots, practice protocols.

CCGC Suggested Tools/ Resources

Percentage Min. score to pass Our Score 100% Practice uses 2 tools 75% Practice uses 1 tool 50% No scoring option 25% System has capability to support both options; but does not use it X 0% System does not have capability or practice does not use either tool Notes:

PPC 6: Test Tracking (13 Points)

NCQA’s Intent: The practice systematically tracks tests ordered and test results, and systematically follows up with patients. CCGC’s interpretation of NCQA’s Intent:- The practice works to improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results. Element 6A:- The practice has systems set-up to track labs and images as well as notifying patients of all lab results Element 6B:- The practice has the ability to get information labs and images directly from the sources

Who will manage this standard?

NCQA Workshop Examples: - :- Standard 6 or click here for newer version.

PPC 6

Must

Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A x B Notes:

Element 6A: Test Tracking and Follow-up (Must Pass) 7 PointsThe practice systematically tracks tests and follows up in the following manner:

NCQA’s Factors What is our current status?

What needs to happen? CCGC Suggested Documentation

Process Owner

Due Date

1. Tracks all laboratory tests ordered or

done within the practice, until results are available to the clinician, flagging overdue results

2. Tracks all imaging tests ordered or done

within the practice, until results are available to the clinician, flagging overdue results

3. Flags abnormal test results, bringing them to a clinician’s attention

4. Follows up with patients/families for all abnormal test results

5. Follows-up with inpatient facility on hearing screening and metabolic screening to get results

6. Notifies patients/families of all normal test results.

Data source Reports across the entire patient population Examples Reports or logs—may be a paper log or an electronic in-box showing outstanding tests and showing how the practice flags

abnormal results. Tools/ newborn screeningResources

Excel workbook for test, results and referral tracking Paper test tracking log {click here} Paper Newborn test tracking log {click here}

Percentage Min. score to pass Our score 100% Practice does 4 �– 6 types of tracking and follow-up 75% No scoring option 50% Practice does 3 types of tracking and follow-up X 25% Practice�’s electronic system has the capability to all 4 types of tracking and follow-up but

practice does not use it

0% system does not have capability to track, or the practice does fewer than 3 Practice�’s types of tracking and follow-up

Notes:

Element 6B: Electronic System for Managing Tests 6 PointsThe practice uses an electronic system to::

NCQA’s Factors What is our current status?

What needs to happen? CCGC Suggested Documentation

Process Owner

Due Date

1. Order lab tests

2. Order imaging tests 3. Retrieve lab results directly from source 4. Retrieve imaging text reports directly

from source

5. Retrieve images directly from the source

6. Route and manage current and historical test results to appropriate clinical personnel for review, filtering and comparison

7. Flag duplicate tests ordered 8. Generate alerts for appropriateness of

tests ordered.

Data source Reports NCQA Data Source

Data source: Reports or screen shots from the system showing examples of each of the functions.

CCGC Suggested Tools/ Resources

See NCQA’s example slides

Percentage Min. score to pass Our Score 100% Practice uses 5 – 8 functions 75% Practice uses 3 – 4 functions 50% Practice uses 1 – 2 functions 25% No scoring option 0% Practice does not use system Notes:

PPC 7: Referral Tracking (4 Points)

NCQA’s Intent: The practice systematically documents and tracks referrals and referral results.

CCGC’s interpretation of NCQA’s intent:- The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners. Element 7A: Do we currently provide all of the necessary information about our patients to people we consult with? Such as reasons for the consult/ referral, dx, social and family history, pertinent clinical finding, insurance information, etc? Do we get the consult back from the specialist or consultant? Do we know if and when a report has come back to the practice? Who will manage this standard? NCQA Workshop Examples: - :- Standard 7 or click here for newer version.

PPC 7

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A Notes:

Element 7A: Referral Tracking (Must Pass) 4 Points Outside of paper medical records and patient visits, the practice uses a paper-based or electronic system to assist in tracking practitioner referrals designated as critical until the specialist or consultant report returns to the practice. The practice uses a system that includes the following information for its referrals:

NCQA�’s Factors What is our current status? What needs to

happen? CCGC Suggested Documentation

Process Owner

Due Date

1. Origination Referring provider Contact information Referral form

2. Clinical details

Reason Pertinent clinical findings Support person Functional status Family history Social history Plan of care Health care providers

Referral form

3. Tracking status Referral tracking

worksheet

4. Administrative details.

Insurance information information about whether the plan

needs approval for services the consultant or specialist will be providing

Referral form

Data source NCQA Examples

Written logs or other paper-based documents if not electronic, reports from the system if electronic.

CCGC Suggested Tools/ Resources

Referral form Audit Paper log or Electronic log Schuldermann, P. (2004). Improving patient care: Using a tracking book for unresolved issues. Family Practice Management, 11(4), 56, 59. Murray, M (2002). Reducing Waits and Delays in the referral process. Family Practice Management 39-42

Percentage Min. score to pass Our Score 100% Practice uses system that includes all 4 items 75% Practice uses system that includes 2 �– 3 items 50% Practice uses system that includes 1 item X 25% No scoring option 0% System does not include any of the items Notes:

PPC 8: Performance Reporting and Improvement (15 Points) NCQA�’s Intent: The practice regularly measures its performance and takes actions to continuously improve.

CCGC�’s interpretation of NCQA�’s intent:- The practice seeks to improve effectiveness, efficiency, timeliness and other aspects of quality by measuring and reporting performance, comparing itself to national benchmarks, giving physicians regular feedback and taking actions to improve. Element 8A:- The practice can produce population reports for clinical outcomes and process. Element 8B:- The practice regularly assesses patient satisfaction and patient experience Element 8C:- The practice produces and shares provider and practice level population reports Element 8D:- The practice uses population reports to do quality improvement initiatives. They have aims, goals and targets they are trying to reach. Element 8E:- The practice has national measures, such as NQF measures they follow Element 8F:- The practice reports their national measure, such as NQF measures to external entities.

Who will manage this standard?

NCQA Workshop Examples: - :- Standard 8 or click here for newer version.

PPC 8

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendi

ng Upload

completed Total

Points A X B C X D E F Notes:

Element 8A: Measures of Performance (Must Pass) 3 Points The practice measures or receives data on the following types of performance by physician or across the practice:

NCQA�’s Factors What needs to happen? CCGC Suggested Documentation Process

Owner Due Date

1. Clinical process (e.g., percentage of women 50+ with mammograms or childhood vaccination rates)

If you a majority of your physicians

have received NCQA Recognition for DM, Heart/Stroke and/ or Back Pain and it is current you can submit that for these 2 factors

2. comes (e.g., HbA1c levels for diabetics) Clinical out

3.

wait times) Service data (e.g., backlogs or

If you did a patient satisfaction survey

for 1B you can use the data for 8B & 8C as well.

4. Patient safety issues (e.g., medication errors).

Data source Reports NCQA Examples

Manual review of a sample of patient records, patient surveys, practice management system, registry, health plan-provided data, medical group provided data, electronic database.

CCGC Suggested Tools/ Resources

Practice gets credit for Item 1 and 2 if they have current NCQA recognition for Diabetes or Heart Stroke Registry Reach My Doctor Reports CINA Reports CIIS Reports Custom electronic reports�—Query, Crystal, etc. MGMA�’s Physician Practice Patient Safety Assessment Tool ( self-assessment tool)

Medication Safety Ghandi, T et al. (2003). Adverse drug effects in ambulatory care. NEJM . 348:1556-1564. �“What Medications Does Your Patient Take: Enhancing Medication Safety in the Outpatient Setting.�” IHI website. {(click here) Examples of outpatient medication reconciliation lists The Med List on Massachusetts�’s Coalition for Prevention of Medical Errors website (click here) Other patient medication reconciliation lists {example medication list PDF} {second example medication list PDF} {third example medication list PDF}

Measurement Patient Safety Background IHI Outpatient Adverse Effect Trigger Tool and Toolkit {(click here)

Percentage Min. score to pass Our Score 100% Practice measures at least 2 types of performance 75% No scoring option 50% Practice measures 1 type of performance X 25% No scoring option 0% No areas of performance measured Notes:

Element 8B: Patient Experience Data 3 PointsThe practice collects data on patient experience with care in the following areas:

NCQA�’s Factors What is our current

status? CCGC Suggested Documents Process Owner

Due Date

1. Patient access to care If you did a patient satisfaction survey for 1B you can use the data for 8A & 8C as well.

2. Quality of physician

communication

3. Patient/family confidence in self care

4. Patient/family satisfaction with care.

NCQA Data source

Reports; may use a phone, paper or electronic survey

Practice may qualify for 50% of points if able to demonstrate that a patient advocacy group or board that meets periodically has been established. The gathering of patient feedback in this context must be documented in order to be eligible.

CCGC Suggested Tools/ Resources

Reports Press Ganey Reports b. CAHPS Reports Patient Satisfaction Survey Patient Feedback Card (click here) & Excel Tracking Sheet (click here) Patient Advocacy Board Institute of Family-Centered Care. (2007). Selecting, Preparing and Supporting Patient and Family Advisors in Primary Care. www.familycenteredcare.org

Related articles a. Luallin, M. (2004). Implementing patient satisfaction survey findings into a customer service action plan. Medical Practice Management, 90-94. {article PDF}

Percentage Min. score to pass Our Score 100% Practice collects data on 3 �– 4 areas 75% No scoring option 50% Practice collects data on 1 �– 2 areas X 25% No scoring option 0% Practice do not collect data in any areas Notes:

Element 8C: Reporting to Physicians (Must Pass) 3 PointsThe practice reports on performance on the measures in 8A and 8B:

NCQA�’s Factors What is our current status? CCGC Suggested Documents

Process Owner

Due Date

1. Across the practice If you are in IPIP, you can use your monthly clinical measures.

RMD has the ability to provider physician level information

If you did a patient satisfaction survey for 1B you can use the data for 8A & 8B as well.

2. By individual

physician.

Data source Reports NCQA Examples

Blinded reports showing summary practice performance or individual physician performance; blinded letters to physicians showing performance.

Addnl. information

Reports may come from within or outside of the practice�—must reflect entire population and not just a subgroup covered by a single payer Practice to demonstrate how report results are communicated to the whole practice as well as to individual providers

CCGC Suggested Tools/ Resources

RMD Registry reports EMR Registry reports Customized electronic reports�—Crystal, Query, etc. Excel workbooks with audit results

Percentage Min. score to pass Our score 100% Practice reports to physicians results both results both across the practice and by

physicians

75% No scoring option 50% Practice reports to physicians results either across the practice or by physicians X 25% No scoring option 0% No areas of performance reported to physicians

Notes:

Element 8D: Setting Goals and Taking Action 3 Points The practice uses performance data to:

NCQA�’s Factors What is our current

status? What needs to happen? CCGC Suggested Documents

Process Owner

1. Set goals based on measurement results referenced in Elements 8A and 8B.

NCQA worksheet If you are in IPIP, you can use your monthly clinical run charts with National goals

2. Take action where identified to improve performance of individual physicians or of the practice as a whole.

Include a description of your PDSA cycles based on your run charts.

Data source Reports NCQA Examples

Reports or completion of the PPC®-PCMH�™ Quality Measurement and Improvement worksheet.

CCGC Suggested Tools/ Resources

Consider incorporating use of meeting minutes and/or PDSA Worksheets Example templates: {Meeting Agenda template}{Meeting Minutes template}{PDSA worksheet} Example templates for setting goals and aim statement : (click here) Article: Schwarz, M. et al. (1999). A team approach to quality improvement. FPM. 6(4):25-30. {article PDF}

Percentage Min. score to pass Our score 100% Practice does 2 items 75% No scoring option 50% Practice does 1 item X 25% No scoring option 0% Practice does no items Notes:

Element 8E: Reporting Standardized Measures 2 Points The practice produces reports on its performance using nationally approved clinical performance measures.

NCQA�’s Factors What is our current

status? What needs to happen? CCGC Suggested Documentation

Process Owner

How many national measures do you produce as a practice?

Data source Reports

NCQA Examples

Reports showing performance measures calculated by practice.

CCGC Suggested Tools/ Resources

See the PCMH Measures Directory for reportable measures associated with DM, CAD, Prevention, Depression, and Low Back Pain National Voluntary Consensus Standards for Ambulatory Care endorsed by NQF: http://www.qualityforum.org/projects/ongoing/ambulatory/index.asp. Participation in Improving Performance In Practice (IPIP) and PQRI qualifies for this factor.

Your data source would be a copy of your registry report. The number you will be entering in the Survey Tool will be one of the following:-

If you are participating in IPIP Diabetes we are tracking 12 NQF measures. If you are participating in IPIP Asthma we are tracking 4 NQF measures. If you are doing IPIP Diabetes and Asthma then it is 16 NQF measures.

Percentage Min. score to pass Our score 100% Practice produces reports using 10 or more nationally approved performance measures 75% Practice produces reports using 5 - 9 nationally approved performance measures 50% Practice produces reports using 3 - 4 nationally approved performance measures 25% No scoring option 0% Practice produces reports using 0 - 2 nationally approved performance measures Notes:

Element 8F: Electronic Reporting—External Entities 1 Point The practice electronically reports results on nationally approved measures to the public sector, health plans or others.

NCQA�’s Factors What is our current

status? CCGC Suggested Documentation Process Owner Due Date

Do you currently participate in report clinical measures to outside organizations?

Yes No

Data source Reports NCQA Examples Report to payer or other user from practice�’s electronic system. CCGC Suggested Tools/ Resources

1. Improving Performance in Practice (IPIP)

Our practice is currently participating in Improving Performance in Practice (IPIP) a state-based, nationally led quality improvement initiative through the American Board of Medical Specialties (ABMS). IPIP was originally piloted in Colorado and North Carolina in 2006 but has now spread to Michigan, Pennsylvania, Minnesota, Washington and Wisconsin. IPIP�’s core strategy is to align with current quality improvement initiatives such as the Medical Home projects, NCQA�’s Physician Practice Connection Patient Centered Medical Home (PPC®-PCMH�™), the Robert Wood Johnson Foundation Aligning Forces for Quality Initiative, Medicare�’s PQRI initiative and other state-based initiatives. All of the IPIP�’s quality measures are either National Quality Forum (NQF) or National Committee for Quality Assurance (NCQA) measures. IPIP focuses on 5 key areas (registries, decision support tools, protocols, team based care, and patient self-management) to help practices provide better care for patients with chronic conditions. IPIP�’s ultimate goal is to improve outcomes for patients with diabetes, asthma and other chronic conditions through the use of QI methods, such as the PDSA cycle, practices engage in redesign activities that create efficiencies and improve care Your proof for this will be a copy of your run charts. The number you will be entering in the Survey Tool will be one of the following:- If you are participating in IPIP Diabetes we are tracking 12 NQF measures. If you are participating in IPIP Asthma we are tracking 4 NQF measures. If you are doing IPIP Diabetes and Asthma then it is 16 NQF measures.

2. Physician Quality Reporting Initiative

PQRI Qualifies for this as well. How many measures did your practices submit to Centers for Medicare & Medicaid Services (CMS) or PQRI approved registry? Your proof for this will be a copy of what you submitted to CMS or PQRI approved registry.

Percentage Min. score to pass Our score 100% Practice transmits 10 or more nationally approved performance measures to an external entity 75% Practice transmits 5 - 9 nationally approved performance measures to an external entity 50% Practice transmits 3 �– 4 nationally approved performance measures to an external entity 25% Practice transmits 1 �– 2 nationally approved performance measures to an external entity X 0% Practice does not transmit any measures

PPC 9: Advanced Electronic Communications (4 Points)

NCQA�’s Intent: The practice systematically manages patient information and uses the information for population management to support patient care. CCGC�’s interpretation of NCQA�’s intent:- The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care. Element 9A:- Patients can use interactive website to request appointments, prescriptions, etc. Element 9B:- The practice sends outreach emails based on gaps in care identified by the practice such as patients needing to come in for DM visits, or medication recalls, etc. Element 9C:- The practices uses electronic communication with care management team Who will manage this standard? NCQA Workshop Examples: - :- Standard 9 or click here for newer version.

PPC 9

Must Pass

Actions for Point Person

Staff responsible

Ready for

NCQA

The person assigned to do the final

review

Standard

Complete

NCQA document linked

Points Complet

ed

Points Pendin

g

Upload complet

ed Total

Points A B C Notes:

Element 9A: Availability of Interactive Web Site 4 Points The practice provides patients/families with access to an interactive Web site that allows them to:

NCQA�’s Factors

Does your practice have a website that allows patients to:

CCGC Suggested Documentation Process Owner

Due Date

1. Request appointments by

reviewing clinicians schedules

Yes No

Website with HIPPA complaint communication function

Reach My Doctor �– �“Basic Patient Communication�” function

2. Request referrals Yes No

3. Request test results Yes No

4. Request prescription refills Yes No

5. See elements of their medical record

Yes No

6. Import elements of their

medical record into a personal health record.

Yes No

NCQA Examples Screen shots showing presence of web-based functionality

CCGC Suggested Tools/ Resource

If your practice doesn�’t have this functionality, sign up for ReachMyDoctor Basic Patient Communication by contacting sschutte@rmdnetworks.com .

Percentage Min. score to pass Our Score 100% Practice providers 5 �– 6 items 75% Practice providers 3 �– 4 items 50% Practice providers 1 �– 2 items X 25% No scoring option 0% Practice does not any items Notes:

Element 9B: Electronic Patient Identification 2 Points The practice combines use of electronic information and clinical decision-support to contact the following types of patients, once identified, by e-mail:

NCQA�’s Factors Do we use email to contact

patients to do this? CCGC Suggested Documentation

Process Owner

Due Date

1. Patients needing clinical review or action Yes No

Website with HIPPA complaint communication function

Reach My Doctor �– �“Premium Patient Communication�” function.

CareNotes and CareTeams

2. Patients on a particular medication Yes No

3. Patients needing preventive care Yes No

4. Patients needing specific tests Yes No

5. Patients needing follow up visits Yes No

6. Patients who might benefit from

disease or case management support.

Yes No

Examples Screen shots showing identification of patients for the above items and an example of e-mail communication with patients based on electronic identification.

Tools/ Resources

If your practice doesn�’t have this functionality, sign up for ReachMyDoctor Premium Patient Communication by contacting sschutte@rmdnetworks.com. The practice can add a subscription fee to this service.

Percentage Min. score to pass Our Score 100% Practice uses electronic information and communication for 5 �– 6 items 75% Practice uses electronic information and communication for 3 - 4 items 50% Practice uses electronic information and communication for 1 - 2 items X 25% No scoring option 0% Practice does not use electronic information for any items Notes:

Element 9C: Electronic Care Management Support 1 Point For patients with the three clinically important conditions, the practice care management team uses electronic communication for the following:

What is our

current status? CCGC Suggested Documentation Process Owner

Due Date

To communicate with disease or case managers about patient needs

Website with HIPPA complaint communication function Reach My Doctor �– �“Premium Patient Communication�” function. CareNotes and CareTeams

Web-based educational modules for patient self-management.

www.howsyourhealth.com www.mayoclinic.com http://www.newhealthpartnerships.org

NCQA Examples Screen shots showing electronic communication about care management. Screen shots or links to education modules. CCGC Suggested Tools/ Resources

Percentage Min. score to pass Our point 100% Practice uses electronic communication for 2 items 75% Practice uses electronic communication for 1 items X 50% No scoring option 25% No scoring option

0% Practice does not use electronic communication for any items

Notes:

Frequently Asked Questions http://www.ncqa.org/tabid/1016/Default.aspx