Patient-Centered Specialty Practice (PCSP) Recognition · PDF file3 Patient-Centered Specialty Practice Recognition Program NCQA Resources Available Free training each month

Patient-Centered Specialty Practice

(PCSP) Recognition Program

Standards Workshop Part 2 2013

All materials © 2013, National Committee for Quality Assurance

2 Patient-Centered Specialty Practice Recognition Program

Agenda Part 1 • Content of PCSP Standards and Guidelines

– Standards 1 – 3

– Documentation Examples*

Agenda Part 2 • Content of PCSP Standards and Guidelines

– Standards 4 – 6

– Documentation Examples*

*Examples in the presentation only illustrate the element intent. They

are NOT definitive nor the only methods of documenting how the

requirements may be met.


NCQA Resources Available

Free training each month http://www.ncqa.org/rptraining.aspx

• Getting On Board • Includes How to Submit as a Multi-site

• Standards (2 part program)

• Software Training • Using the ISS System for PCMH 2011 and PCSP

• The Online Application

http://www.ncqa.org/tabid/631/Default.aspx




PCSP 4: Plan and Manage Care

Intent

• Collaborate with

patient/family/caregiver

and PCP to develop and

implement care plan

• Review and reconcile

medications

• E-prescribe

Meaningful Use

• Use EHR to identify patient

education resources

• Review and reconcile

medications

• Use an e-prescribing

system to write and

transmit prescriptions

• Compare meds. With

formularies, check for

generics, drug-drug and

drug-allergy interactions


PCSP 4: Plan and Manage Care

• Elements

PCSP 4A: Care Planning

and Self-Care Support

PCSP 4B: Medication

Management - MUST PASS

PCSP 4C: Use of Electronic Prescribing


PCSP 4A: Care Planning and Self-Support

The practice provides the following care management

and self-care support for practice-specific conditions:

1. Conduct pre-visit preparations

2. Assess patient risk status to identify patients needing

additional support and services

3. Collaborate with the patient/family/caregiver to

develop a specialist’s plan of care that includes

patient’s goals, potential barriers/self-care ability

-CRITICAL FACTOR

4. Share specialist’s plan of care including

recommendations for self-care support with the PCP

and referring clinician -CRITICAL FACTOR

(con’t)



The practice provides the following care management

and self-care support for practice-specific conditions:

5. Give the patient/family/caregiver a written specialist’s

plan of care including self-care recommendations.

6. Provide educational resources or refer

patients/families/caregivers to assist in self-

management

7. Assess/address barriers when patient has not met

treatment goals

8. Use an EHR to identify patient-specific education

resources and provide to more than 10 percent of

patients++/+

+ Stage 1/2 Core Meaningful Use Requirement

++ Stage 1 Menu Meaningful Use Requirement



• 11 Points

• Scoring

– 100% - 6-8 factors, including Factors 3 and 4



– 25% - 1 factor

– 0% - 0 factor

• Documentation

– Factors 1-7: Written process and examples

– Factor 8: Report with numerator, denominator and

percentage


PCSP 4A: Example Pre-visit Form

Patients complete form pre-visit:

Focus of today’s visit

Medications

Allergies

Pain assessment

Flu vaccine

Depression assessment

Recent ER visit


PCSP 4A: Example Patient Education

Prenatal Care: Steps Toward a Healthy Pregnancy

Prenatal Session #1

PROGRAM: Comprehensive Perinatal Services Program TIME: 1-1 ½ Hours

OBJECTIVES

By the end of the session, the participant will be able to:

1. Identify basic anatomy of human reproductive system

2. Identify common discomforts of pregnancy including aspects of fetal growth and

development

3. Identify danger signs during pregnancy and action to take

during complications

4. Identify lab tests including the importance of ultrasound

5. Understand the importance of Oral health during pregnancy

Practice must also attach a complete set of education materials that could be

provided to the patient.


PCSP 4B: Medication Management

The practice has a process and demonstrates that it

systematically manages medications prescribed by the practice in the following ways:

1. Reviews and reconciles medications for more than

50 percent of patients received from another care setting or a relevant visit++/+

2. Provides information about new prescriptions from

specialty practice to patients/families/caregivers.

3. Coordinates medication management and

reconciliation with the PCP, referring clinician and

patient/family/caregiver

(con’t)



The practice has a process and demonstrates that it

systematically manages medications prescribed by the practice in the following ways:

4. Assesses patient/family/caregiver understanding

of medications from specialty practice

5. Assesses patient response to medications from

specialty practice and barriers to adherence

6. Documents over-the-counter medications, herbal

therapies and supplements





• Must Pass

• 5 Points

• Scoring

– 100% - 5-6 factors

– 75% - 4 factors

– 50% - 3 factors

– 25% - 2 factors

– 0% - 0-1 factors

• Documentation:

– Factors 1-6: Documented process and three

examples for each factor


PCSP 4B: Example Medication Reconciliation

Reconcile meds. at each visit for patient

safety and effectiveness of medications 1. Pts. bring list or meds. to each visit; reminded

when appt. scheduled; signs in pt. rooms

2. Med. asst. reviews meds. at each visit

3. MD reviews current meds.; discusses pt.

concerns

4. Motivational interviewing/shared decision-

making to help with risks/benefits of meds.

5. MD/staff teach pt. about med. administration

6. Follow-up call to pt. when major change to

meds.

7. Check with pt. if refill requests are conflicting


PCSP 4B: Patient Role in Med. Management

Posted in office to

encourage patients to

help managing their

medications



The practice uses an electronic prescription system with the following:

1. Writes at least 75 percent of eligible prescriptions electronically.

2. More than 40/50 percent of eligible prescriptions written by the

practice are compared to drug formularies and electronically

sent to pharmacies++/+

3. Enters electronic medication orders into the medical record for

more than 30/60 percent of patients with at least one medication

in their medication list+

4. Performs patient-specific checks for drug-drug and drug-allergy interactions+

5. Alerts prescriber to generic alternatives





• 2 Points

• Scoring

– 100% - 3-5 factors

– 75% - 2 factors

– 50% - 1 factor

– 25% - No scoring option

– 0% - 0 factors

• Documentation

– Factors 1, 2 and 3: Report with a numerator, denominator

and percentage

– Factors 4 and 5: Report or screen shot demonstrating

capability


PCSP 4C: Example Electronic Prescription

Writing

Prescription Writing Activity

Electronic 57% 2563 Rx

Printed, given to patient 31% 1419 Rx

Print, fax to pharmacy 1% 89 Rx

_______________________________________

TOTAL

Rx 4474 Rx

% E-RX 89%


PCSP 4C: Example

Drug-Drug Interactions

Drug-Drug

Interactions


PCSP 4C: Example Prescription Allergy


PCSP 4C: Example Generic Alternatives


PCSP 5: Track and Coordinate Care

Intent

• Track/follow-up on lab

and imaging results

• Exchange test results

with primary care

• Track/follow-up on

referrals

• Coordinate with

hospitals/ ERs; transition

patients back to

primary care

Meaningful Use

• Incorporate clinical lab test

results into the medical

record

• Electronically exchange

clinical information with

other clinicians and

facilities

• Provide electronic

summary of care record for

referrals and care

transitions

CMS EHR Incentive Programs: http://www.cms.gov/Regulations-

and-Guidance/Legislation/EHRIncentivePrograms/index.html


PCSP 5: Track and Coordinate Care

Elements

PCSP 5A: Test Tracking and Follow-Up

PCSP 5B: Referral Tracking and Follow-Up

PCSP 5C: Coordinate Care Transitions



The practice has a documented process for and

demonstrates that it:

1. Requests and tracks receipt of test results from PCP and

referring clinician

2. Provides PCP and referring clinician with results of

relevant tests ordered by the specialist - CRITICAL

FACTOR

3. Tracks lab tests until results are available, flagging and

following up on overdue results

4. Tracks imaging tests until results are available, flagging

and following up on overdue results

5. Flags abnormal lab results, bringing them to the

attention of the clinician

(con’t)


PCSP 5A: Test Tracking and Follow-Up (cont.)



6. Flags abnormal imaging results, bringing them

to the attention of the clinician

7. Patients/families/caregivers are notified about

normal and abnormal lab and imaging test

results

8. More than 30 percent of laboratory orders are

electronically recorded in the patient record+

(con’t)


PCSP 5A: Test Tracking and Follow-Up (cont.)



9. More than 30 percent of radiology orders are

electronically recorded in the patient record+

10.Electronically incorporates more than 40/55

percent of all clinical lab test results into structured

fields in medical record++

11.More than 10 percent of scans and tests that result

in an image are accessible electronically+++



+++ Stage 2 Menu Meaningful Use Requirement

NOTE: Factor s 8, 9 and 11 will not be scored until 1/1/2015



• 5 Points

• Scoring

– 100% - 6-11 factors, including factor 2


– 50% - 3 factors, including factor 2


– 0% - 0 factors or does not meet factor 2

• Documentation

– Factors 1-7: Documented process and report with 5 days of data or three examples of meeting the process for each factor

(demonstrate the implemented process)

– Factors 8, 9, 10, 11: Report with a numerator, denominator and

percentages


PCSP 5A: Example, Lab Process

Missing Flagging

Overdue labs and FU


PCSP 5A: Example Policy for

Abnormal Test Results

Policy: Definitions for

Abnormal Test Result

Categories and Reporting

Requirements for Each

• Abnormal

• Abnormal (Priority)

• Abnormal (Critical)


PCSP 5A: Example Test Tracking Log

DATA COLLECTED

Patient name

DOB

Provider

Order date

Test ordered

Urgency

Date results received

Results normal/abnormal

Date results to provider

Date results to patient


PCSP 5A: Example Electronic Test Tracking

All lab and imaging tests are

tracked until results are

available

Overdue results are flagged

Abnormal results are

flagged

Practice tracks:

Date ordered

Overdue

Abnormal

Priority

Patient name

Provider

Order description

Last appointment

Next appointment


PCSP 5A: Example Tracking Imaging


PCSP 5A: Example Letter for Patient

Notification of Abnormal Imaging Results

Patient/family was notified by

provider of abnormal test results

and given follow-up instructions



The practice coordinates referrals to other

(secondary) specialists by:

1. Consulting with PCP and referring clinician and

patient/family/ caregiver regarding secondary

referrals

2. Giving the consultant or specialist the clinical

reason for the referral and pertinent clinical

information - CRITICAL FACTOR

3. Tracking the status of the referral, including

required timing for receiving a specialist’s report

4. Following up to obtain specialist’s report

(con’t)





5. Establishing and documenting agreements with

specialists in the medical record if co-

management is needed

6. Asking patients/families/caregivers about self-

referrals and requesting reports from clinicians

7. Assuring the PCP and original referring clinician are notified of the secondary referral results.

8. Providing an electronic summary of care record to

another provider for more than 50 percent of referrals++/+





9. Electronically transmitting a summary of care record to another care provider for more than 10

percent of care referrals+

10. Conducting one or more successful electronic exchanges with a recipient who has technology

developed by a different EHR developer or

successfully tests with the CMS designated test EHR.+ + Stage 1/2 Core Meaningful Use Requirement


NOTE: Factors 9 and 10 will not be scored until 1/1/2015



• 6 Points

• Scoring

– 100% - 8-10 factors, including Factor 2




– 0% - 0 factors

• Documentation

– Factors 1-7: Documented process

– Factors 1-7: Reports or logs showing data collection in a tracking

system

– Factors 8 and 9: Report with numerator , denominator and

percentages

– Factor 10: Screen shot showing capability


PCSP 5B: Example Referral Tracking

Referral Tracking Data - 5 days

• Date ordered

• Referring provider

• Diagnosis

• Referred to

• Supporting clinical information

• Urgency

• Type of referral

• Appointment date

• Date results received

• Date of follow-up for missing report


PCSP 5B: Example Co-Management Policy


PCSP 5B: Example Follow-Up to

Get Referral Report



For conditions managed by the specialist, the

practice systematically:

1. Demonstrates its process for identifying

patients with a hospital admission and patients

with an emergency department visit

2. Demonstrates its process for sharing clinical

information with admitting hospitals or

emergency departments

3. Demonstrates its process for consistently

obtaining patient discharge summaries from

the hospital and other facilities



For conditions managed by the specialist, the practice

systematically:

4. Demonstrates its process for transitioning patients back

to the primary care practice

5. Provides an electronic summary-of-care record to

another care facility for more than 50 percent of

transitions of care++/+

6. Electronically transmits a summary of care record to

another care setting for more than 10 percent of care

transitions+



NOTE: Factor 6 will not be scored until 1/1/2015



• 5 Points

• Scoring

– 100% - 4-6 factors

– 75% - 3 factors

– 50% - 2 factors

– 25% - 1 factor

– 0% - 0 factors

• Documentation

– Factors 1-4: Documented process and three examples

– Factors 5 and 6: Report with a numerator, denominator

and percentages


PCSP 5C: Example Identifying

Patients in Facilities

Practice receives admission

reports electronically from

hospital


PCSP 5C: Example ER

Visit Follow-Up Log


PCSP 5C: Pediatric to Adult Transition

Diabetes Care Self-Assessment

Self-assessment of worries,

concerns, burdens related to

diabetes and preparation for

transitioning

I would like to talk about:

• Challenged by diabetes

burdens

• Social/emotional/cognitive

issues

• Transition preparation/

readiness to move on


PCSP 5C: Clinical Summary for New Health

Care Team


PCSP 6: Measure and Improve Performance

Intent

• Measure clinical

performance,

coordination of care,

utilization affecting

costs, access to care,

patient experience and

report performance

• Use and monitor

effectiveness of quality

improvement process

Meaningful Use

Report:

• Ambulatory quality

measures to CMS

• Immunization data to

registries

• Syndromic surveillance data to public health

agencies

• Cancer cases to registry


PCSP 6: Measure and

Improve Performance

Elements

• PCSP 6A: Measure Performance

• PCSP 6B: Measure Patient/Family Experience

• PCSP 6C: Implement & Demonstrate

Continuous Quality Improvement - MUST

PASS

• PCSP 6D: Report Performance

• PCSP 6E: Use Certified EHR Technology


PCSP 6A: Measure Performance

The practice measures or receives data on:

1. At least three clinical measures related to the

practice specialty

2. Coordination of care results

3. At least two utilization measures affecting

health care costs

4. Performance data stratified for vulnerable

populations (to assess disparities in care).

5. Timely access to appointments

based on established criteria


PCSP 6A: Measure Performance

• 5 Points

• Scoring

– 100% - 4-5 factors

– 75% - 3 factors

– 50% - 1-2 factors


– 0% - 0 factors

• Documentation

– Factors 1-5: Reports showing performance


Vulnerable Populations Defined

“Those who are made vulnerable by their

financial circumstances or place of

residence, health, age, personal

characteristics, functional or

developmental status, ability to

communicate effectively, and presence

of chronic illness or disability.”

Source: AHRQ


Vulnerable vs. High Risk


PCSP 6A: Example Chronic

Care Clinical Measures


NCQA Clinical Program Recognition Where Can it Be Used to Meet Elements?

• NCQA Clinical Recognition Programs

– Diabetes Recognition Program (DRP)

– Heart/Stroke Recognition Program (HSRP)

• Credit for Clinical Program Recognition may be used for meeting some requirements if 75% of clinicians are Recognized:

– PCSP 6A Factor 1

– PCSP 6C Factors 1 and 7 (if renewed), for Element A portion

– PCSP 6 D Factor 1, 2 and 3 for Element A portion


NCQA Clinical Program Recognition

Where Can it Be Documented to Meet Elements?


PCMH 6 ELEMENT A: Factor 3

Care Managers receive referrals from PCP'S, Hospitalists, Social Workers or family members

requesting evaluation for patients to be treated at an alternative level of care (home, SNF) or in the

office. The team has had a 22% success rate in saving hospital admissions since Nov 2007.

CARE MANAGEMENT ACTIVITIES

2011 JANUARY - MAY

TOTAL CM REFERRALS / SAVED ADMISSIONS

2011 2011 2011 2011 2011

TOTAL TO

DATE

JAN FEB MARCH APRIL MAY 2011

TOTAL CM REFERRALS 220 202 299 221 219 1161 TOTAL CM REFERRALS

SAVED ADMISSIONS 57 53 55 49 57 271 SAVED ADMISSIONS

FAILED ATTEMPTS 5 7 2 3 3 20 FAILED ATTEMPTS

PCSP 6A: Example

Measures Affecting Health Care Costs

PCSP


PCSP 6A: Example Data for

Vulnerable Populations


PCSP 6B: Measure Patient/Family Experience

The practice obtains feedback from patients/families on

their experiences with the practice and their care.

1. The practice conducts a survey (using any instrument) to evaluate

patient/family experiences on at least three of the following

categories:

– Access

– Communication

– Coordination

– Self-management support

2. The practice uses CAHPS** Clinician & Group (CG) Survey Tool

3. The practice obtains feedback on experiences of vulnerable patient groups

4. The practice obtains feedback from patients/families through

qualitative means

**Consumer Assessment of Healthcare Providers and Systems (CAHPS)

https://www.cahps.ahrq.gov/clinician_group/


PCSP 6B: Measure Patient/Family Experience

• 6 Points

• Scoring

– 100% - 3-4 factors


– 50% - 2 factors

– 25% - 1 factor

– 0% - 0 factors

• Documentation

– Factors 1-4: Reports showing performance


PCSP 6B: Example of Reported CAHPS

Questions for Patient Experience


PCSP6B: Example Patient Experience Data


PCSP6B: Example Patient Experience Survey Results

Survey questions include:

Access

Communication

NEEDS A THIRD CATEGORY


PCSP 6C: Implement & Demonstrate

Continuous Quality Improvement

The practice demonstrates ongoing monitoring of

the effectiveness of its improvement process by:

1. Setting goals/acting to improve on at least

three clinical quality or utilization measures

2. Setting goals/acting to improve quality on at

least one patient experience measure

3. Setting goals/acting to improve timeliness of

patient access

4. Setting goals/acting to improve coordination

with primary care




The practice demonstrates ongoing monitoring of the

effectiveness of its improvement process by:

5. Tracking results over time

6. Assessing the effect of its actions

7. Achieving improved performance on one

measure

8. Achieving improved performance on a second measure

9. Setting goals and addressing at least one

identified disparity in care/service for vulnerable populations




• MUST PASS

• 4 Points

• Scoring

– 100% - 6-9 factors

– 75% - 4-5 factors

– 50% - 3-4 factors

– 25% - 2 factors

– 0% - 0-1 factor

• Documentation

– Factors 1-8: Reports or completed PCSP Quality Measurement

and Improvement Worksheet

– Factor 9: Written process and three examples demonstrating the process


PCSP 6C: Quality Measurement and

Improvement Instructions


PCSP 6C: Quality Measurement and

Improvement Worksheet

Performance Measures (A)

Disparities in Care (A)

Patient/Family Experience (B)

Measure (C)

Opportunity Identified (C)

Initial Performance/

Measurement Period (A/B)

Performance Goal (C)

Action Taken and Date (C)

Re-measurement Performance (C)

Demonstrate Improvement (C)


PCSP 6C Example of Goals for

Vulnerable Populations 1. EQUITABLE

• …whoever you are.

• No inequality

• Aim Statement:

• Eliminate differences in clinical care & health status between racial, ethnic and

socioeconomic groups

Measure

• “0” disparity by race for all effectiveness measures

2. ACCESSIBLE

• We promote access to comprehensive health services to all in our service area,

regardless of ability to pay.

• No barriers to health care services for all who seek it

• Aim Statement:

• Serve 50% of our target populations

Measure

• Health center penetration rate for underserved/special populations in specified

service areas


PCSP 6C: Example Tracking

Data Over Time


PCSP 6D: Report Performance

The practice shares performance

data from Element A and Element B:

1. Within the practice, results by

individual clinician

2. Within the practice, results across

the practice

3. Outside the practice to patients or

publicly, results across the practice

or by clinician


PCSP 6D: Report Performance

• 2 Points

• Scoring

– 100% - 3 factors

– 75% - 2 factors

– 50% - 1 factor

– 25% - no scoring option

– 0% - 0 factors

• Documentation

– Factors 1-2: Reports to practice or clinicians and practice

staff; explains how results are provided

– Factor 3: Example of report to patients or the public


PCSP 6D: Example Reporting by Clinician

1 2 3 4 5 6

Blinded 6 Clinicians


PCSP 6D: Example Practice Level

Diabetes Data


PCSP 6D: Example of External Reporting


PCSP 6E: Use Certified EHR Technology

1. The practice uses an EHR system (or modules) that

has been certified and issued a Certified HIT

Products List (CHPL) Number(s) under the ONC (Office of the National Coordinator for Health

Information Technology) HIT certification program+

2. The practice attests to conducting a security risk analysis of its electronic health record (EHR) system

(or modules) and implementing security updates as

necessary and correcting identified security deficiencies+

3. The practice demonstrates capability to submit

electronic syndromic surveillance data to public health agencies electronically++/+++



4. The practice demonstrates capability to identify and report

cancer cases to a public health central cancer registry

electronically+++

5. The practice demonstrates capability to identify and report

specific cases to a specialized registry electronically (other

than a cancer registry)+++

6. The practice reports clinical quality measures to Medicare or

Medicaid agency as required for Meaningful Use.

7. The practice demonstrates the capability to submit electronic

data to immunization registries or immunization information

systems.++/+



+++Stage 2 Menu Meaningful Use Requirement



• 0 Points

• Documentation

– Factors 1-7: Responding

“yes” or “no” in each

element of the survey tool

is an attestation that the

practice meets the

respective requirements


Meaningful Use Attestation Accepted Attestation

Attestation Tracking Information

Attestation Confirmation Number


NCQA Contact Information

Contact NCQA Customer Support: 1-888-275-7585 PCSP standards documents, application account,

and survey tools Questions about your user ID, password, access

Visit NCQA Web Site: http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx

View Frequently Asked Questions

View Recognition Programs Training Schedule View other Recognition Programs – PCMH, DRP, HSRP

Submit to questions about interpretation of PCSP standards to: [email protected]

http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx




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