Becoming a Patient Centered Medical Home - AIDS Foundation of


Becoming a Patient Centered Medical Home

Presenter: Kristin Andrews Empanelment/Scheduling Manager [email protected]

Deciding on Certification

• Why Get Certified? • Which Certification and With Whom?

• Perform A Self Assessment –PCDC PCMH Assessment •

PCMH Scoring 6 standards = 100 points 6 Must Pass elements NOTE: Must Pass elements require a ≥ 50% performance level to pass Level of Qualifying


Must Pass Elements at 50% Performance Level

Level 3

85 - 100

6 of 6

Level 2

60 - 84

6 of 6

Level 1

35 - 59

6 of 6

Not Recognized

0 - 34


Practices with a numeric score of 0 to 34 points and/or achieve less than 6 “Must Pass” Elements are not Recognized.

Developing a Team

• • • • • • • •

PCMH Coordinator/Project Manager Medical Directors Senior Director of Clinic Operations Senior Director of Strategy Director of Development Director of Nursing EMR Manager Empanelment/Scheduling Manager

Choosing Areas of Focus

• Review PCMH Guidelines • Analyze Impact on Organization • Develop Timeline for Implementation

NCQA PCMH 2011 Content and Scoring PCMH 1: Enhance Access and Continuity


A. B. C. D. E. F. G.

4 4 2 2 2 2 4

Access During Office Hours** Access After Hours Electronic Access Continuity (with provider) Medical Home Responsibilities Culturally/Linguistically Appropriate Services Practice Organization

20 PCMH 2: Identify and Manage Patient Populations


A. B. C. D.

3 4 4 5

Patient Information Clinical Data Comprehensive Health Assessment Use Data for Population Management**


A. B.

6 3

Support Self-Care Process** Provide Referrals to Community Resources

9 PCMH 5: Track and Coordinate Care


A. B. C.

6 6 6

Track Tests Track Referrals** Coordinate with Facilities/Care Transitions


16 PCMH 3: Plan and Manage Care


A. B. C. D. E.

4 3 4 3 3

Implement Evidence-Based Guidelines Identify High-Risk Patients Manage Care** Manage Medications Use Electronic Prescribing

PCMH 4: Provide Self-Care and Community Resources

PCMH 6: Measure and Improve Performance


A. B. C.

4 4

D. E. F.

Measure Performance Measure Patient/Family Feedback Implement Continuous Quality Improvement** Demonstrate Continuous Quality Improvement Report Performance Report Data Externally


3 3 2 20

Optional Patient Experiences Survey



Must Pass Elements

Implementation Timeline

LCHC Focus Areas

• Patient Experience – Brochure, Video, Surveys, Empanelment

• Electronic Communication – E-Prescribing, Patient Portal, Secure Messaging

• Quality Improvement – Reports, Self Management, Patient Outreach, Result Tracking

• Workflow Documentation

Sustaining Change

• Plans for Future • Continuing to Improve

• Keeping the Patient at the Center


Becoming a Patient Centered Medical Home - AIDS Foundation of

Becoming a Patient Centered Medical Home Presenter: Kristin Andrews Empanelment/Scheduling Manager [email protected] Deciding on Certific...

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