PPC 3

Element D

General description of Care Coordination

Medical Home Coordination Review (MHCR) Tutorial for SETMA’s MHCR

NCQA:  Physician Practice Connections – Patient-Centered Medical Home SETMA’s Medical Home Coordination Review (MHCR) Tutorial

“The better the primary care, the greater the cost savings, the better the health outcomes, and the greater the reduction in health and health care disparities”

“A personal medical provider, usually a physician, leads a team of caregivers who take collective responsibility for ongoing patient care.”

“The personal physician or provider maintains responsibility for providing for all of the patient's health care needs and arranges care with other qualified professionals as needed. This includes care for all stages of life: acute care, chronic care, preventive services, and end-of-life care.”

Physician Practice Connections - Patient-Centered Medical Home

Amazing technological innovations have advanced the potential benefit of modern healthcare to a heretofore unimagined level.  However, those same innovations unintentionally promoted a reimbursement methodology and an organizational structure of the delivery of healthcare which have to some degree abrogated the promise of those same technological advances. 

As the science of medicine grew, due to capabilities and reimbursement, the focus of care delivery came to be on procedures, services and encounters rather than on the global health of the individual patient.  And, technology was applied without regard to whether or not it was benefiting the patient long-term and/or creating health.  The end-of-life, rather than being a time of reflection, reconciliation and resolution, often became a marathon of hospitalizations, surgeries and extraordinary interventions which neither improved the quality nor add to the quantity of life.  Markets were created for “practice enhancement” and new “revenue streams,” which focused upon the benefit of the provider without any realization that what often happened was that the health of the patient suffered.

In this system, the patient encounter was directed toward meeting the immediate expectations and interests of the patient without attention being given to the overall “need” and “health” of the patient.  “Good medicine.” in this system, was defined by a growing patient base, an increasing reputation of the provider as thorough and knowledgeable clinician and the financial success of the practice.

There is no doubt that the patient’s welfare was important and that there was no intention of developing a system which was dysfunctional, but it happened.  The patient was the focus but only as a snapshot in healthcare delivery, which delivery attended to the immediate, expressed needs of the patient and often not to the implications of evidence-based medicine for the patient’s long-term benefit.  The snapshot narrowed the focus of the healthcare system to “parts of the patient,” rather than providing a detailed portrait of the patent which included hopes, dreams, and humanity, as well as physiology and anatomy.

Finally, the dysfunction in the healthcare system, which was created by innovations and advances, was recognized.  Gradually, efforts were made to modify this system and to eliminate the dysfunction.  Quality measures were published which allowed the care of one provider to be measured against the care given by another.  Preventive care was emphasized, but remained difficult because preventive care was rarely if ever a primary reason for a patient seeing a provider and it was often not paid for by insurance companies including CMS.  Efforts were undertaken to move the patient back to the center of the healthcare equation.  Providers began to be encouraged to emphasize points of care other than acute illness.

The compartmentalizing of care by many providers, most of whom were specialists, created a system of incoordination, where patients felt that the only “safe” way to get excellent care was through seeing many different caregivers, each of whom knew everything about one thing but rarely everything about the one patient.  Because the payment for this system was based on procedures and studies, costs escalated.  Patients associated “good care” with a delicatessen kind of medicine in which they got one of these, one of those and one of another.  The care received in this system increasingly lost the focus on the patient as a whole and the health outcome of this system of care deteriorated. 

As the demand for quality care increased and as the need for methods of measuring that quality in quantifiable and comparable ways grew, agencies and organizations stepped into the void.  One solution to the healthcare-delivery conundrum was the introduction of Medical Home.

Seeing the Patient as a Whole and as the Whole Interest

The concept of a Medical Home is new to most healthcare providers as well as patients.  An old idea, which has recently gained momentum, the ideal of Medical Home was adopted by the American Academy of Family Practice, which in 2002 published a monograph entitled The Future of Family Medicine:: A Collaborative Project of the Family Medicine Community Future of Family Medicine Project Leadership Committee.
That paper concluded with 10 points which addressed the future of healthcare in America in general and family practice specifically. These will be addressed below.

The heart of Medical Home is the patient which is why NCQA’s version is entitled Patient-Centered Medical Home.  No longer will procedures, tests and things we do to patients be the focus of healthcare – although these will continue to be an important part of the delivery of health – now the patient will be front and center.  And, the patient will be the center in all aspects of the healthcare experience:

• The patient will be “in charge,” which empowers the patient to be responsible for their care and for their health.  In this system, the patient can no longer “turn his/her care over to a provider” and passively expect “health” to happen.  The patient has to determine that he/she wants to be healthy and has to determine to take the steps to make that happen.  Both the patient and the provider become accountable in this system.  The provider cannot do what the patient refuses to, but the patient can now require that the provider provide evidenced-based, quality-measured health care.
• The patient will no longer see the provider as a “constable” charged with imposing care upon the patient, but the patient will view the provider as a colleague, a counselor and a collaborator in the process of the patient retaining, regaining or maintaining health.  And, in the end, rather than being a “miracle worker” who can forestall the inevitable, in this system, the caregiver will compassionately and with care, with family, friends and others, the provider will help the patient through the final days of life.  Sometimes this will be done in a healthcare facility but increasingly it will be done in the home.
• The patient’s understanding of and education about his/her health condition and/or illness will be the goal of healthcare delivery, particularly in the primary setting.  The marching orders for patient and provider will be to realize the truth of Dr. Elliott Joslin’s (Founder of the Joslin Diabetes Center at Harvard University) statement, “The patient who has diabetes who knows the most about diabetes will live the longest.”  Length of life will be more associated with the knowledge and decisions of the patient than with the power and prescriptions of the provider.
• The patient will be encouraged, supporting and followed by the provider not only when the patient is in the provider’s office but particularly when the patient is not.  Perhaps nothing will be a more fundamental change in the delivery of health care than this point.

As providers modify their work flow, systems, organizations and structures to meet the new demands of Medical Home, they will discover that the complex workflow processes of Medical Home relate to patient convenience, compliance and/or capacity to receive care.  These changes are identified by NCQA in many of the 9 standards, 30 elements and 183 data points which define NCQA’s requirements for recognition as a Medical Home.  Some of these are:

• Follow-up calls after a visit to see if the patient saw the specialist, had the, or got the medication filled.
• Pre-visit reviews to confirm that  all information required for that visit is available
• Coordination of visits between multiple providers and/or other service points on the same day
• Evaluation of barriers to care – language, literacy, sight, hearing, transportation, finances, etc.
• Advanced planning so that the patient’s desires are known and followed
• Ability for the patient to participate in their care by their documentation of part of their medical record on-line before their visit.
• Ability of the patient to initiate and participate in self education about their major health problems.
• Ability for the patient to document in their medical record the data related their conditions such as blood sugars, blood pressures, weight gain or loss, etc.
• Ability for the patient to communicate with their provider electronically which is efficient and effective.

Heretofore, the convenience of the practice or of the provider was the major consideration in the structure and organization of medical practices. It is a significant and necessary change to focus on the patient’s convenience, compliance and capacity to receive the prescribed care.  And, the work of the provider has not concluded simply by telling the patient what needs to be done.  There must be an evaluation by the provider and/or his/her staff as to whether that care can be obtained.  As a great movie is not a finished product until the film editor has taken the work of the director and producer and spiced it together in an intelligible and deliverable final product, so the Medical Home team just take the work of the provider and make sure that it is package in an intelligible and deliverable final product  Without these structural and functional changes, Medical Home can be just another administrative concept, which is a distinction without a functional difference.

Intentional and Incidental

The most innovative aspect of Medical Home and the thing which perhaps distinguishes it from any other well-organized and highly-functioning medical organization is the concept of Coordination of Care.  This is the intentional structuring, reviewing, facilitating and practicing of a standard of care which meets all current measures endorsed by:

• National Committee for Quality Assurance (NCQA)
• Centers for Medicare and Medicaid Services (CMS)
• Healthcare Effectiveness Data and Information Set (HEDIS)
• Physician Consortium for Performance Improvement (PCPPI)
• National Quality Forum (NQF)
• Physician Quality Reporting Initiative (PQRI)

The concept of “intentionality” is critical in this process. This is contrasted with “incidental.”  In health care, most HEDIS compliance and coordination of care are done incidentally to a patient encounter as opposed to the having of a purposeful, provable and persistent fulfillment of national standards of care.  Rather than hoping the result is good, Coordination of Care plans and reviews care to make certain that it meets the highest standards.  In addition, the content and the process of this Coordination pf Care is report to the patient so he/she can be confident that what should be done has been and,. Or so that the patient can request that what should have been done and hasn’t been is done. 

The Medical Home intentionally fulfills the highest and best healthcare needs of all patients.  In addition, the patient is involved in this coordination by making them aware of the standards and giving them a periodic review, in writing, of how their care is or is not meeting those standards.  Patients are encouraged to know and to initiate the obtaining of preventive care on their own.  Perhaps the ultimate judge of the success of Medical Home is when healthcare providers hear the following from their patients, “I am here today for preventive healthcare.”  Today, almost all healthcare providers would tell you that they have never had a patient present with that “chief complaint,” or reason for scheduling an appointment.

While Medical Home will ultimately qualify a practice for increased reimbursement from CMS and other healthcare payers, SETMA believes that this method of healthcare delivery is sufficiently promising to develop it with or without change in reimbursement and not only to apply it to Medicare, Medicaid or Medicare Advantage patients, but to all of SETMA’s patients. 

It is obvious to us that SETMA’s Medical Home will evolve over time.  While we will be guided by CMS and NCQA requirements and by the experience of others, it is our expectation that ultimately, we will innovate, experiment and create a unique expression of Medical Home which will fulfill all of the requirements imposed by these agencies but which will also go beyond that as our vision, understanding and experiences increase.

Medical Home Example

As SETMA began to think about Medical Home, we had the following example set before us in February, 2009.  In a memo to the SETMA staff, SETMA’s CEO said:.

“My business philosophy is, ‘I want it done right and I want it done right now!’  Thus, if we are going to do Medical Home, I want it to be done right.  As I have thought more about this project, it occurs to me that the dynamic and the potential of Medical Home are found in its name.  A ‘home’ is: 

• A place where you need fear no harm from those who are in the home with you. 
• A place where your needs are met.
• A place you can go when you don’t know what else to do. 
• A place where you can be yourself and you can tell others how you really feel without fear of rejection, judgment, or embarrassment.
• A place where others really want to see you succeed.
• A place where if you are away too long, someone is calling to find out if you are OK.
• A place where you are treating like family.
• A place where the safety of one in a crisis or danger is not satisfied until all are safe and secure.

“Coupled with excellence of care, Medical Home has the potential for leveraging great benefit for patients and providers from the healthcare delivery equation.  Seeing the Medical Home as a reflection of the value and attitudes of “a home,” make me think again that what I said this morning is right.  I repeat it:

“In 2008, the partners of SETMA finalized a 501-C3 not-for-profit foundation – The SETMA Foundation – which has as its purpose medical education and underwriting the care for our patients who cannot afford it.  In February, 2009, I saw a patient who has a very complex and fascinating healthcare situation.  I saw him during his hospitalization and then for the first time in my office.  What I discovered was that he is only taking four of his nine medications because he cannot afford them.  I believe in this case, SETMA practiced Medical Home as he left this encounter with:

1. Appointments to SETMA’s American Diabetes Association (ADA) approved diabetes self-management education (DSME) program.  The fees for the education have been waived.  However, while talking to the patient and his wife, I discovered that he could not afford the gas to come to the meetings.  He also left with a gas card with which to pay for the fuel to get the education which is critical to his care.
2. My staff negotiated a reduced cost for his medications with his pharmacy and made it possible for the pharmacy to bill The SETMA Foundation.
3. Because at 60 years-of-age and with his problems he cannot work at his job as a long-distance truck driver, his care also involved counseling him that even in the face of all of the abuse of the disability provision of Social Security, he can no longer work and I will coordinate his application for disability.

“Gas cards, disability, paying for medications – a part of a physician’s responsibilities?  Absolutely not!  Gas cards, disability, paying for medications,  part of Medical Home?  Absolutely! 

“This patient, who was depressed and glum in the hospital such that no one wanted to go into his room, left the office with a smile and feeling that there is hope.  He left as if he had just had a visit to home.  It may be that the biggest result of Medical Home is hope.  This IS Patient-Centered Medical Home!!”

There is a remarkable story told by a missionary to Indonesia.  It is called the Pineapple Story and tells the experience of a missionary who fashioned his life for his convenience and for his comfort, only to discover that he was not able to fulfill his calling.  It is so with Medical Home.  While many of its elements will seem strange and unusual, even objectionable and inconvenient, through the process of developing a patient-centered medical home health care providers will rediscover their mission and their calling.  In the end, both the patient and the provider will win – and that is good.

Concept of Medical Home

In 2002, the American Academy of Family Practice published a monograph entitled, The Future of Family Medicine:: A Collaborative Project of the Family Medicine Community Future of Family Medicine Project Leadership Committee.  That paper concluded with 10 points which addressed the future of healthcare in America in general and family practice specifically::

1. New Model of Family Medicine -- Family medicine will redesign the work and workplaces of family physicians. This re-design will foster a New Model of care based on the concept of a relationship-centered personal medical home, which serves as the focal point through which all individuals—regardless of age, gender, race, ethnicity, or socioeconomic status participate in health care. In this new medical home, patients receive a basket of acute, chronic, and preventive medical care services that are accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. This New Model will include technologies that enhance diagnosis and treatment for a large portion of problems that patients bring to their family physicians.
2. Electronic Health Records -- Electronic health records that meet standards which support the New Model of family medicine will be implemented. The electronic health record will enhance and integrate communication, diagnosis and treatment, measurement of processes and results, analysis of the effects of co-morbidity, recording and coding elements of whole-person care, and promoting ongoing healing relationships between family physicians and their patients.
3. Family Medicine Education -- Family medicine will oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, expert in providing family medicine’s basket of services within the New Model of family medicine, skilled at adapting to varying patient and community needs, and prepared to embrace new evidence-based technologies.
4. Lifelong Learning -- The discipline of family medicine will develop a comprehensive, lifelong learning program. This program will provide the tools for each family physician to create a continuous personal, professional, and clinical practice assessment and improvement plan that supports a succession of career-stage certifications..
5. Enhancing the Science of Family Medicine -- Participation in the generation of new knowledge will be integral to the activities of all family physicians and will be incorporated into family medicine training.
6. Quality of Care -- Close working partnerships will be developed between academic family medicine, community-based family physicians, and other partners to address the quality goals specified in the IOM Chasm Report.
7. Role of Family Medicine in Academic Health Centers  -- Departments of family medicine will individually and collectively analyze their position within the academic health center setting and will take steps to enhance their contribution to the advancement and rejuvenation of the academic health center to meet the needs of the American people.
8. Promoting A Sufficient Family Medicine Workforce -- A comprehensive family medicine career development program and other strategies will be implemented to recruit and train a culturally diverse family physician workforce that meets the needs of the evolving US population for integrated health care for whole people, families, and communities
9. Communications -- A unified communications strategy will be developed to promote an awareness and understanding of the New Model of family medicine and the concept of the personal medical home.
10. Leadership and Advocacy -- A leadership center for family medicine and primary care will be established, which will develop strategies to promote family physicians and other primary care physicians as health policy and research leaders in their communities, in government, and in other influential groups.

Subsequent to this report, in March 2007, the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP) , the American College of Physicians (ACP) and the American Osteopathic Association (AOA), published a statement entitled Joint Principles of the Patient-Centered Medical Home.  In part, these principles stated that a medical home would involve:

1. Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
2. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
3. Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
4. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
5. Quality and safety are hallmarks of the medical home:  

• Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
• Evidence-based medicine and clinical decision-support tools guide decision making
• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
• Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the practice level.
• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
• Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

• It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
• It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
• It should support adoption and use of health information technology for quality improvement;
• It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
• It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
• It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
• It should recognize case mix differences in the patient population being treated within the practice.
• It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
• It should allow for additional payments for achieving measurable and continuous quality improvements.

In December of 2008, an a rticle entitled, The Medical Home:  Growing Evidence to Support a New Approach to Primary Care by Thomas C. Rosenthal, MD, stated in part:

• A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patient's health across a continuum of referrals and services.
• Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction.
• The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home.
• Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit.
• Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/provider boards may be required to safeguard the public interest.

With these concepts as a foundation, Southeast Texas Medical Associates (SETMA) has begun changing its workflow, provider evaluation, provider expectations, procedures and functions to enable SETMA to become a “real” Medical Home.

SETMA and Medical Home Coordination of Care Review Tutorial

On this foundation, SETMA responded to 28 requirements enunciated by the Centers for Medicare and Medicaid Services (CMS) for qualifying as a Medical Home.  In the spring of 2009, CMS should publish the guidelines for practices to qualify for a CMS-Demonstration project on the value of Medical Home.  NCQA is presently recognizing practices as Physician Practice Connections -- Patient Centered Medical Home.   SETMA is preparing to apply for this recognition and is implementing the functions required to fulfill all NCQA requirements.  One of the requirements is for the practice to report on 8 measures endorsed by the National Quality Forum; SETMA will report on 43 of those measures.

In addition to these preparations for transforming SETMA into a Medical Home, SETMA will implement NextGen’s Community Health Solutions which includes an  Interface Engine, a Repository, and a Physician Portal.   This will allow SETMA to send and receive information from other EMRs and from specialty practices which do not have an EMR.  SETMA will also implement NextGen’s WebMD, which will allow our patients to communicate with us electronically over a secure connection and will allow patients to see and/or complete parts of their personal health record on line.

Medical Home Coordination Review

Because care coordination is the heart of the ideal of Medical Home, the hub of SETMA’s Medical Home will be the Medical Home Coordination Review template.

(When the patient’s care encounter is completed, the patient will be given a document which will summarize all of the Care Coordination issues which will be reviewed in this tutorial.  The patient will be charged with the responsibility of directing their own care by requesting the points of care which the quality measures indicate they have not received and which are noted in this Care Coordination review document.)

The following tutorial teaches SETMA’s Medical Home teams how to use this template and defines how and why SETMA’s Medical Home operates as it does.

Accessing the Medical Home Coordination Review from AAA Home

There will be two possible alerts on the AAA Home, which address functions of the Medical home Coordination Review; they appear in red and are entitled::

Patient Has One or More Alerts – appears at the top of the AAA template.  This alert refers to barriers to care such as hearing, seeing, reading, etc., which will impact the ability of the patient to receive care.  These alerts also address patient-driven directives to care choices by the patient, such as Advanced directives.

Needs Attention -- appears under the Medical Home Coordination Review. at the top right of the AAA template.  This alerts lets the provider know that an element of one or more of the six evidenced-based classes of quality measures which appear on the Medical Home Coordination of Care Review needs attention.

The first alert states:  Patient Has One or More Alerts.   This addresses special patient needs which are documented on  the Patient Alert popup which normal launches from the GP Master Template.  To the right of this notation, there is a button entitled “click here to view alerts.”   When this button is activated, the Patient Alert  pop-up is launched.

This function satisfies the NCQA Medical-Home measure, PCC-4 Element A, which is entitled: “Documenting Communication Needs.”  Element A is described as “The practice assesses patient/family-specific barriers to communication using a systematic process.”  A note clarifies this requirement with the following comment, “this element requires a systematic process that does not depend on practice staff remembering to assess the issues; the electronic system must prompt the provider to review this information. “

The following are the communication issues which must be displayed:

• Identify and display in the record the language preference of the patient and family
• Assess both hearing and vision barriers to communication

 These and other issues related to the patient’s access to care are documented on SETMA’s Patient Alert pop-up which can also be accessed from the GP Master template by clicking on the button entitled Alert which is found in the second column of the GP Master template.  See the following screen shot:

The second alert is found on the AAA Home template underneath the Medical Home Coordination button and is entitled “Needs Attention.” 

This alerts the provider that there is a deficiency in one or more of the following:

1. The Elderly Medication Summary  (NCQA)
2. The HEDIS Measures  (NCQA)
3. The NQF Measures (National Quality Forum)
4. The PQRI Measures (Centers for Medicare and Medicaid Services)
5. The PCPPI Diabetes*
6. The PCPPI Hypertension*

*Physician Consortium for Physician Performance Improvement Data Set

Each of these functions displays the evidence-based, quality measures published by the identified organization.  The compliance of the patient’s care with these measures is automatically displayed for quick and easy review by the provider.  These functions will be described below.

Note:  While there are six categories of evidenced-based measures which are tracked by SEMTA, numbers 5 and 6 appear only when a patient has diabetes and/or hypertension. If one or both of these buttons do not appear on the Medical Home Coordination Review template,, it is because the patient does not have that condition. The Medical Home Coordination Review template is organized into three sections from top to bottom and into four columns left to right. 

The first section from top to bottom has five lines in four columns and principally addresses demographic information about the patient.  Each of the data points interact with all other elements of the EMR and are automatically filled when that information appears elsewhere in the EMR.

The first column addresses the patient’s personal information, which is automatically pulled from the EMR’s enterprise-practice-management system:

• Name
• Date of Birth
• Sex and Age
• Home phone
• Work phone

The second column is entitled Ancillary Agencies from which and/or through which the patient is receiving services.  The second and third column information will be principally gathered by a form given to each patient for completion and then will be entered by our staff. Once the data is entered on our current patients – this task should take six to twelve months, we will easily maintain the collection of that information on new patients.

• Home Health
• Hospice
• Assisted Living
• Nursing Home
• Physical Therapy

The Third column addresses:

• Medical Power of attorney and telephone number
• Primary Care Giver and telephone number
• Emergency Contact and telephone number

The fourth column contains three navigation buttons:

• The first is entitled RETURN takes you back to AAA Home
• The second launches he Transtheoretical Model Assessment template
• The Third is entitled Print note and it prints the Medical home Coordination Review document which is to be given to the patient.

Clicking the Transtheoretical Model button launches the following pop-up. 

This tool allows you to assess and document, the patient’s current state of readiness to change their behavior. There are five, disease-specific options.  Each option provides precise language for discussing with a patient their “readiness to change their behavior” of reach of the following conditions:

• CHF
• Diabetes
• Hypertension
• Lipids
• Weight Management

You access these disease-specific options by selecting them from the disease field.

When you click in this field you will get a pop-up with the following options.

In that the goal of Medical Home is patient self-improvement and self-management, it is important to be aware whether the patient is ready to make a change in his/her health and to have a recommendation as to how to address the patient’s current state of readiness. 

If a patient has not reached his/her goal in one of these conditions, or if the patient is not improving toward reaching that goal, the Transtheoretical-Model Assessment should be completed in order to assess where the patient is and what steps are required to encourage them to improve their health. 

The results of this assessment will appear on the printed note which will be given to the patient and which will summarize the review of the Medical Home Coordination of Care.  If more than one condition is assessed with this tool both will appear on the chart note. 

Here is what the template would look like for a patient who has uncontrolled diabetes and who is not well motivated to change.

Under the heading “Select Characteristic”, there are five choices which will display the patient’s Stage of Change for the response they give.  Depending upon which response a patient gives, one of the following stages will be displayed:

1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

When a Stage of Change is selected, the following will be displayed:

• Stage of change
• Appropriate Intervention
• Sample dialogue

Under the heading “Select Patient Verbal cue” there are five choices which are linked to the patients Stage of Change.  Once the Stage of Change is selected, the patient’s Verbal Cue should be noted.

Depending upon the Patient’s “Verbal Cue” the following will appear:

• Stage of Change
• Appropriate Intervention
• Sample Dialogue

To the right of these boxes, there is a button entitled Transtheoretical Chart.

When activated the entire chart for the condition chosen will appear.  For instance if you had chosen “weight management,” the following would appear. 

If you wish to use this tool to assess more than one condition in a visit, simply select as many of the options you wish and ALL of them will appear on your Medical Home Coordination Review document.   

When you are through with this tool, click, Return and it will take you back to the Medical Home Coordination Review template.

The button under the Transtheoretical Model Assessment is Print Note.  Once the entire  Medical Home Coordination Review has been completed, this button is launched in order to prepare a document which is given to the patient with the following instruction:

“This is a working tool. It is imperative that you review it for completeness, accuracy and usefulness to you.  You should schedule a visit if any of your preventive health issues have not been completed and/or if there are issues raise with your review which require and explanation.  You may choose to call your Nurse or Care Coordinator rather than scheduling a visit.  The choice is yours.”

The second section of the Medical Home Coordination Review only has four columns. 

The first column tracks two events:

• Whether or not the coordination of care review was completed today  -- if you 0reviewed this function on the current visit, you should click box next to this function.
• Whether or not the patient’s care coordination needs were discussed at the team conference and if so what date and then the last time the team review was done is listed.

In the second column of the second section, the following is captured.  This will automatically be noted by the system and requires no action on your part.

• The last date the coordination of care review was completed
• The last date that the patient’s coordination of care was discussed at team conference

The third column documents four events which are related to the Medical Home and is entitled Compliance.  This compliance relates to specific functions of the Medical Home.  These are care-coordination issues and relate to the standards SETMA has established for communications with the Medical-Home patient beyond the contact time in the office.  The one exception is the Last H&P which is a clinic-contact issue.

• Last H&P – this will be captured automatically when you use the ICD-9 code V700 for Exam Well Adult, or V7231 for Exam GYN Gynecological Routine.  It is important to use one of these codes as this is one HEDIS measure which requires that it be reported by the health plan through encounter data and not through a chart review or a report by the provider that they have done the examination.
• Telephone contact -- two times per year, the practice will contact the patient about their healthcare needs and/or about preventive care needs.
• Correspondence – two times a year, the practice will contact the patient with education materials and/or with needed preventive care needs.
• Birthday Card – each year, the practice will contact the patient via correspondence on his/her birth date both to acknowledge their birthday and to encourage them with needed preventive care measures.

The fourth column has the patient’s e-mail address

This is neither a secure nor an encrypted contact and cannot be used for communications with a patient of a confidential nature.  For that capability, see the section on NextGen’s web portal entitled NextMD.

The third section of the Medical Home Coordination Review has three columns.

The first column is a list of the patient’s chronic conditions.  This is essentially a Patient Problem List.  While it is not displayed on the Medical Home Coordination Review, the patient’s active medication list and medication allergies will appear on the Medical Home Coordination Review document which will be given to the patient each time it is reviewed.

This provides the reviewer and/or physician a reminder of a patient’s special and specific needs which should be considered in the Coordination of Care review.

The second column in the third section includes six elements

• Care Coordination Team
• Physician
• CFNP
• Care Coordinator
• Nurse
• Unit Clerk

The next element is a button entitled Secondary/Specialist Physicians

This button will launch the following template.

Because Medical-Home implies a Medical Home Neighborhood, it is important to know who other care gives are who participate in the care of this patient.  As SETMA deploys NextGen’s Community Health Solutions (interface engine, repository, physician portal), there will be a more seamless connectivity with the larger neighborhood.  It will be the intent of SETMA’s Medical Home to include each of the patient’s specialist-care givers in the Community Health Solutions.

The next section is entitled Evidenced-based Measures Compliance and has six buttons** 

1. The Elderly Medication Summary
2. The HEDIS Measures
3. The NQF Measures
4. The PQRI Measures
5. The PCPPI Diabetes*
6. The PCPPI Hypertension*

*(Physician Consortium for Physician Performance Improvement Data Sets) for:
**Remember, as previously noted, buttons 5 and 6 will ONLY appear in the records of patients with those diagnoses.  If the patient has neither diabetes nor hypertension only four buttons will appear.

These functions will be discussed below.

The next element is Disease management Tools Accessed.  To achieve NCQA recognition as a Medical Home, SETMA must choose three clinically significant conditions which will be the focus of attention in our Medical Home.  While it will be our intent to manage all patients and all conditions with the same Coordination of Care review, we have chosen four for our NCQA-recognition application:

• Diabetes
• Hypertension
• Lipids
• CHF

From AAA Home, when a specific disease-management tool is:

• accessed and completed on any of these four conditions, and
• when the follow-up document is printed and given to the patient,

the radial button next to that condition will be highlighted on the Medical Home
Coordination Review template. 

Note:  Because these radial buttons cannot be changed from the template and because they are in demographic fields which means they come forward at each visit, the highlighting is faded.

The last element in this column is the Referral History.  The most recent referrals are displayed in this window.

There is a button entitled Click for Detail beside the title Referral History which launches the following:

This will launch a list of all of the referrals which this patient has ever been given and will show their status.  To make certain that no referral is not completed and/or no patient does not follow through, IT will run a query and will let SETMA operations know of patients whose referrals have either not been completed by our department or where we do not have a report from the referral source.

The third column in this third section of the Medical Home Coordination Review template has the following elements:

• Evacuation Options
• Advanced Care Planning
• Barriers to Care

Each of the specific issues documented here are linked to other data points in the EMR where the same information is captured.  This avoids redundancy in data entry and leverages the power of the EMR. 

Evacuation Options allows the Medical Home to know who needs special help in the case of a mandatory evacuation being called by the local authorities.  This function identifies who will be responsible for the patient’s evacuation:

• Self
• Family
• Community

This function also provides a place to document the name and phone number of the family member or community agency which should be contacted to provide evacuation for this patient.

Advanced Care Planning is a HEDIS and a Medical Home requirement for older adults and it is a requirement of Medical Home. This function allows for the documentation of the patient’s:

• Code status
• Whether Advanced Directive was discussed at the present encounter*
• Whether the patient has an Advanced Directive 
• Advanced Care Directive – details

Whether Advanced Directive was discussed – one of the HEDIS measures for “care for older adults” requires that the advanced directive be on file, or that it be discussed at the current encounter.  When you click the check box next to this function on the Medical Home Coordination Review template, it will automatically result in your receiving credit for this function.

If you check the box next to “Advanced Directive was discussed” or that “Whether the patient has an Advanced Directive”, the following HEDIS Measure (see below) will be credited for this patient’s Care for Older Adults record.

The Barriers to Care section of the Medical Home Coordination Review template allows for the aggregation of data which is collected elsewhere.  Three categories of barriers are reviewed:

• Social
• Financial
• Assistive Devices

The Social Barriers of special interest to the Medical-Home-Coordination team are:

• Hearing
• Vision
• Literacy
• Social Isolation
• Language Preferred Language

Each of these data points is already collected in the EMR under Patient Alerts.  See above, this tutorial pp. 11ff. 

Financial Barriers identifies issues in the patient’s care which prevents them from obtaining care due to financial limitations including their inability to pay for:

• Co-pays
• Medications
• Nutrition
• Transportation
• Uninsured

While SETMA’s resources are limited, The SETMA Foundation has been established to assist in the obtaining of care by our patients who need financial help in obtaining care.

The final Barriers-to-Care is Assistive Devices. This is a list of devices which may be used by our patients, including:

• Cane
• Crutches
• Hearing Aid
• Prosthetic Limbs
• Spine/Brace
• Walker
• Wheelchair

The Medical Home Coordination Review will identify the use of these devices as they will affect the patients assess to care and often will limit the kinds of care which can be prescribed for the patient in regard to therapy and exercise.

Evidenced-Based Measures for Quality of Care

The Following is the full detail of using the six categories which appear under the heading Evidenced-based Measures Compliance, in the second column of the Medical Home Coordination Review where there are 6 buttons:

1. The Elderly Medication Summary
2. The HEDIS Measures
3. The NQF Measures
4. The PQRI Measures
5. The PCPPI Diabetes Data Set*
6. The PCPPI Hypertension Data Set*

*These two buttons only appear when the patient is being treated for these conditions.

The First button is the Elderly Medication Summary

This aggregates the material which is gathered automatically on the HEDIS Measures templates where there are six categories of medications which are potentially hazardous in older adults:

• High Risk Medications
• Medications which are contraindicated in the following conditions in older adults

1. Arthritis
2. COPD
3. Dementia
4. Depression
5. Insomnia

When a medication if found which falls into these categories the name of that medication will appear in the appropriate list.  The Alert under the Medical Home Coordination button on AAA entitled “needs attention,” alerts that provider that this needs attention. 

In the two columns beside the medication listed, the provider can document the action taken.  When the provider clicks in the space entitled “action,” the options on the pop-up are;

• Medication changed
• Medication stopped
• Reviewed, must be continued

When this is done, in the space entitled, “Discussed with patient?,” the provider can designate whether this action was discussed with the patient with a “yes” or “no.”

The second button is HEDIS Measures Compliance

What is HEDIS?  -- Healthcare Effectiveness Data and Information Set published by he National Committee on Quality Assurance (NCQA) HEDIS measures are used by more than 90% of United States health plans to measure the effectiveness of care provided through their plans.  HEDIS measures effectiveness of preventive care, acute care and chronic care based on the results of evident-based studies. 

When this button is launched it displays the HEDIS Measures Compliance template which is entitled, “2009 HEDIS Technical Specifications for Physician Measurement.”

This template lists all of the HEDIS measures for which providers are responsible.  All of the activity and fulfillment of the HEDIS measures on this template are captured automatically. 

In the course of the patient encounter, the provider will access this and other evidenced-based quality measures.  Those which appear in red will be reviewed and the action required to fulfill that measure will be taken, i.e., if the colorectal screening shows up in red, the provider will order a stool for occult blood, a colonoscopy, a double contrast barium enema or a flexible sigmoidoscopy.  When the results of the study, or procedure is returned, the measure will be marked as met. To the right of the HEDIS measures are the following buttons:

• Return – this takes you back to the AAA Home screen
• Tutorial – this makes it possible for you to review the content of all of the HEDIS measures whether or not they apply to the current patient or not.  To revert back to the display of only those HEDIS measures which apply to the current patient, simply exit the template and then return.
• There are three Help buttons which display:

1. NCQA – this gives information about the National Committee on Quality Assurance.
2. CAHPS – this gives information about the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program.
3. HEDIS – this gives information about the Healthcare Effectiveness Data and Information Set.

At the top of the template is a section entitled, “LEGEND,” which explains that:

• the measures which apply to the current paitent and are not fulfilled appear in RED
• the measures which apply to the current patient and are fulfilled appear in BLACK
• the measures which do not apply to the current patient are grayed out

Below this explanation is listed the three categories of HEDIS measures

1.      Effectiveness of Preventive Care where there are 10 measures

2.      Effectiveness Acute Care where there are 5 measures

3.      Effectiveness of Chronic Care where there are 13 measures

Screen shots of each of these 28 measures will now be displayed with:

• The name of the measure listed first
• Followed by a screen shot of the pop-up which defines the content of the measure launched.  The content will typically define:

1. The age ranges to which the measure applies
2. The metric which the measure addresses, i.e., the blood pressure, LDL, etc.

*Remember, for any particular patient ONLY those HEDIS measures which apply to a particular patient will be in red or black according to the LEGEND above.

1.      Effectiveness of Preventive Care

Adult BMI Assessment

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Childhood Immunization Status

Lead Screening in Children

Colorectal Cancer Screening

Breast Cancer Screening

Cervical Cancer Screening

Chlamydia Screening in Women

Glaucoma Screening in Older Adults

Use of High-Risk Medications in the Elderly

Care for Older Adults

2.      Effectiveness of Acute Care

Appropriate Treatment for Children with Upper Respiratory Infection

Appropriate Testing for Children with Pharyngitis

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

3.      Effectiveness of Chronic Care

Persistence of Beta-Blocker Treatment After a Heart Attack

Controlling High Blood Pressure

Cholesterol Management for Patients with Cardiovascular Disease

Comprehensive Adult Diabetes Care

Use of Appropriate Medications for People with Asthma

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

Pharmacotherapy Management of COPD Exacerbation

Follow-Up After Hospitalization for Mental Illness

Antidepressant Medication Management

Follow-up Care for Children Prescribed Attention Deficit/Hyperactivity Disorder Medication

Osteoporosis Management in Women

Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

Annual Monitoring for Patients on Persistent Medications

Potentially Harmful Drug-Disease Interactions in the Elderly

The use of this template and its function is explained above. This is the only HEDIS measure which is presented twice – here and as a separate evidenced-based measure on the Medical Home Coordination Review template.  See Above

Medication Reconciliation Post-Discharge

National Quality Forum (NQF)

The next button is entitled NQF Compliance.

National Quality Forum (NQF)  –  In 1998, A report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, proposed the formation of the Forum as a part of a national agenda for improvement in healthcare delivery.  Formed in 1999, NQF’s mission statement declared, “The mission of the National Quality Forum is to improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs.” 

NQF’s vision is that “the NQF will be the convener of key public and private sector leaders to establish national priorities and goals to achieve the Institute of Medicine Aims—health care that is safe, effective, patient-centered, timely, efficient and equitable.  NQF-endorsed standards will be the primary standards used to measure and report on the quality and efficiency of healthcare in the United States. The NQF will be recognized as a major driving force for and facilitator of continuous quality improvement of American healthcare quality.”

To achieve NCQA recognition as a Medical Home, SETMA must report on 10 measures endorsed by NQF.  We have chosen to report on 43 for 2009.

This will launch the below template.

There are 7 categories of NQF-endorsed, evidenced-based measures which SETMA has chosen to report on for our NCQA recognition.  The measures will be reviewed by category and by each individual measures.

General Health Measures

Body Mass Index Measurement

Smoking Cessation

Proper Assessment for Chronic COPD

Adult Immunization Status

Blood Pressure Measures

Blood Pressure Measurement

Blood Pressure Classification Control

Medication Measures

Current Medication List

Documentation of Allergies/Reactions

Therapeutic Monitoring of Long Term Medications

Drugs to Avoid in the Elderly

Appropriate Medications for Asthma

Inappropriate Antibiotic Treatment for Adults with Acute Bronchitis

LDL Drug Therapy for Patients with CAD

Care for Older Adults

Counseling on Physical Activity

Colorectal Cancer Screening

Fall Risk Management

Diabetes Measures

Dilated Eye Exam

Foot Exam

Hemoglobin A1c Testing Control

Blood Pressure

Lipid Screening

Physician Quality Reporting Initiative (PQRI)

The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting Initiative (PQRI).  The 2009 PQRI Measures Specifications Manual for Claims and Registry Release Notes is a 442-page document which explains this program.

PQRI has identified 134 measures and requires that a practice report  to report on  at least 3 individual measures, or 1 Measures Group in order to be recognized by CMS.  SETMA will report on three Measures Groups (Diabetes, Preventive Care, and Rheumatology, and the measures on Ophthalmology) which contain a total of 28 measures instead of the required 3.

The next button is entitled PQRI Compliance

Richmond as soon as Jon gets this in place do the PQRI just like we have done HEDIS and NQF

Physician Consortium for Physician Performance Improvement Data Sets (PCPPI)

The Physician Consortium for Performance Improvement

The Physician Consortium for Physician Performance Improvement (Consortium) is a group of clinical and methodological experts convened by the AMA. The Consortium includes representatives from more than 60 national medical specialty and state medical societies, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services.

The Consortium's vision is to fulfill the responsibility of physicians to patient care, public health, and safety by:

• becoming the leading source organization for evidence-based clinical performance measures and outcomes reporting tools for physicians; and
• ensuring that all components of the medical profession have a leadership role in all national forums seeking to evaluate the quality of patient care.

The Consortium's mission is to improve patient health and safety by:

• Identifying and developing evidence-based clinical performance measures that enhance quality of patient care and that foster accountability;
• Promoting the implementation of effective and relevant clinical performance improvement activities; and
• Advancing the science of clinical performance measurement and improvement.

The Consortium works to develop evidence-based clinical performance measures and clinical outcomes reporting tools to support physicians in quality improvement efforts.

The Consortium has published a number of disease management data sets which established quality of care measures with which physicians and other healthcare providers can measure their own performance.
Physician Consortium for Performance Improvement – this measurement set for various conditions such as hypertension, diabetes, congestive heart failure and others have been developed by the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Institute of Medicine (IOM) and the medical and surgical specialty societies.  These data sets are intended as “open-book tests of provider performance, where the questions have been given to the provider.”  The hope is that as providers measure their own performance that quality of care will improve.  SETMA has embedded some of the Consortium’s data sets into our EMR and we will report on the results of these as well as HEDIS.

The next button on the Medical Home Coordination Review template is entitled PCPPI Diabetes

Note:  Remember, this button on shows up if the patient has the diagnosis of diabetes in their Chronic Problem list.

When launched this button automatically links the provider with the Consortium Data Set which is viewed from the Plan Template on the Diabetes Disease Management Tool which is launched from AAA Home

The following are the steps of how to access the Consortium Data Set via AAA Home.  Of course, it can be launched as above from the Medical Home Coordination Review template.

The Diabetes Disease Management tool is launched from AAA Home.

Once the Diabetes Disease Management is launched the Consortium Data Set for Diabetes (entitled PCPPI Diabetes on the Medical Home Coordination Review template) is found by clicking on Plan in the list of navigational buttons on the Diabetes Master template

When the Diabetes Plan button is launched the following template appears.

On the Diabetes Plan template there is a button in the right hand upper part of the screen entitled Consortium Data Set

When the Consortium Data Set button is launched the following pop-up appears, which is the same pop-up which appears when the Medical Home Coordination Review PCPPI Diabetes button is launched:

The 9 data points which are automatically captured and documented by SETMA's Diabetes Suite of Templates, and, which are collected and displayed on the Consortium Data Set pop-up on the Diabetes Plan, are the quality measures for diabetes developed by the Consortium.

These 9 data points are the basis along with several other data points of SETMA's Daily Diabetes Care Audit. These data points are:

• Collected automatically
• Provide a quick and easy review for the SETMA healthcare provider to evaluate his/her own Diabetes care.
• Provide a quick and easy way of completing the Diabetes measures required if they were not completed.
• Attention to these data points places in you line for additional reimbursement when CMS
• The Consortium material should be completed by the nursing staff and reviewed by the provider.

• The Elements of the Consortium Data Set for Diabetes are listed on the pop-up. 

(A complete tutorial for this function can be found in Appendix A below or on the Diabetes Disease Management tutorial)  

The functioning of the Hemoglobin A1C element illustrates the above:

Hemoglobin A1C -

• The standard is that the patient has had a Hemoglobin A1C in the past three months or has one at this visit.
• The date of the last Hgb A1C is displayed on this template.
• If this data point is out of date, a button will appear to the right of the date box.
• When you depress this button you will automatically order and charge post a Hgb A1C, making it easier to do it right than not to do it at all.

When this Diabetes management tool is accessed from the Medical Home Coordination Review template, any elements which are incomplete will appear in red and the button to the right of that element will appear.  Any incomplete element can be quickly completed by clicking on the button in the right hand column.

The next button is entitled PCPPI Hypertension

When launched this button takes the provider to the Hypertension Disease Management tool and to the template entitled Physician Role.  This template automatically collects the information from the patient encounter and notes whether each element of the evidenced-based management, identified by the PCPPI has been met.  Here are eight elements as they are listed on the pop-up below.

The standard of excellence in the management of hypertension is measured on the following 8 data points.

1. Blood pressure measured at least once this visit
2. Blood pressure measurement repeated if elevated
3. Blood pressure classification determined
4. Weight reduction discussed/recommended
5. Sodium intake discussed/changes recommended
6. Alcohol intake discussed/changes recommended
7. Exercise discussed/recommended
8. Appropriate follow-up scheduled

The elements of evidenced-based measures for hypertension are met in SETMA’s EMR by:

1. Completed by performing a blood pressure check during the current encounter
2. Completed by repeating the blood pressure during the encounter if the initial pressure is above 140/90.
3. Completed by using the Hypertension Disease Management templates which automatically calculates the classification, follow-up recommendation, risk group and treatment recommendation when the Calculate Assessment button is depressed on the Hypertension Master template
4. Completed by accessing the Life-style changes template which is found on the Hypertension Master template and by completing the LESS Initiative
5. Completed by accessing the Life-style changes template which is found on the Hypertension Master template and by giving the patient the Hypertension Follow-up document which includes instructions on low sodium diets.
6. Completed by accessing the Life-style changes template which is found on the Hypertension Master template
7. Completed by using the LESS Initiative with its Exercise Prescription.
8. Completed by accessing the Life-style changes template which is found on the Hypertension Master template and by completing the LESS Imitative.