A geriatric patient-centered medical home: How to obtain NCQA certification
ABSTRACTThe patient-centered medical home is a rapidly growing concept in reforming American health care. It has spread from its origins in primary care pediatrics to family practice and, more recently, into internal medicine. This review article describes how primary care geriatricians can obtain certification from the National Committee for Quality Assurance (NCQA) for a patient-centered medical home that includes some of the features unique to geriatrics.
KEY POINTS
- The NCQA has six broad standards for patient-centered medical homes: practices must enhance access and continuity, identify and manage patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, and measure and improve performance.
- Each standard has a number of elements, of which six are “must-pass.” These deal with access, data for population management, care management, support for self-care, referral tracking and follow-up, and continuous quality improvement. All must be rigorously documented.
- Practices must identify three important medical conditions for continuous quality improvement.
- Applying for certification is hard work but, if accompanied by real changes to your practice, should improve the care you deliver.
CHOOSE THREE IMPORTANT CONDITIONS FOR QUALITY IMPROVEMENT
One of the most important first steps is to choose three “important” clinical conditions that will be the focus of quality improvement. According to the NCQA, important conditions include unhealthy behaviors, substance abuse, and mental health issues with evidence-based clinical guidelines that affect a large number of people or that consume a disproportionate amount of health care resources.9
The health care providers in your practice should all agree that the chosen conditions are important both to themselves and to their patients and that the proposed interventions will improve the quality of care. At the same time, the conditions and measures of quality need to be relatively easy to define and measure.
The 2011 standards require that at least one of the conditions be related to an unhealthy behavior (eg, obesity, smoking), a mental health issue (eg, depression, anxiety, Alzheimer disease), or substance abuse.
How can quality of care be measured in frail elderly patients?
A special consideration in geriatrics is the frailty of our patients and their limited life expectancy. Chronic care management has not been well studied in the frail elderly, and the benefits of controlling various markers of a chronic illness—for example, diabetes—all have differing time horizons that, depending on patient prognosis, may never be realized.
For some chronic diseases, the practice may need to develop new quality measures that are appropriate for its patient population. These measures must be evidence-based, or, where evidence is lacking, expert consensus must be attained. The American Geriatrics Society has several clinical practice guidelines, including the treatment of diabetes in older persons, the prevention of falls, and the pharmacologic management of persistent pain.10
Another option is to rely on the traditional Healthcare Effectiveness Data and Information Set quality measures for your chosen chronic condition, but to target appropriate patients for the interventions. One way to do this is to incorporate a prognostic indicator such as the Vulnerable Elders Survey11 or gait speed12 into your office flow so that you can categorize patients into groups and then target interventions.
One more option is to choose a geriatric syndrome that is equally relevant to all your geriatric patients regardless of frailty. However, you must be able to measure aspects of the syndrome and have interventions that will improve specific outcomes.
SETTING PRIORITIES
At the outset, it is important to review the NCQA’s standards for a patient-centered medical home and to identify standards for which you have appropriate processes in place, standards in which you are deficient but which can be fixed, and standards that will be more difficult to address.
One way to do this is to complete the Web-based self-assessment survey, which provides a score by element. Each deficiency discovered is an opportunity to brainstorm solutions and to embark upon a rapid cycle of improvement (“plan, do, study, act”).13 Deficiencies should be tackled over time, however, to avoid overwhelming the practice. It is particularly helpful to create small work-groups, to assign tasks with definite deadlines, and to meet regularly to review progress and assign new tasks.
The NCQA released new standards in 2011. A new requirement is that the practice’s electronic health record system must incorporate Meaningful Use Criteria of the Centers for Medicare and Medicaid Services (CMS). These criteria show that the practice is using the electronic health record effectively. As a result, attaining medical home certification will ensure that the practice also meets CMS Meaningful Use Criteria.
Six standards for a patient-centered medical home
The NCQA has six standards for a patient-centered medical home, which align with the core components of primary care14:
- Standard 1: Enhance access and continuity
- Standard 2: Identify and manage patient populations
- Standard 3: Plan and manage care
- Standard 4: Provide self-care support and community resources
- Standard 5: Track and coordinate care
- Standard 6: Measure and improve performance.
Each of these standards is broken down into elements, designated A, B, C, and so on—27 in all. Each element is scored on the basis of the number of “factors” the practice meets in each element. For example, element E in standard 1 has four factors, and the practice will receive 100% of the two possible points if all four factors are met, 50% of all points if the practice meets two factors, and no points if the practice meets none of the factors.
NCQA now designates a “critical factor” for some elements. These are factors thought to be “central to the concept being assessed within particular elements,”9 and they must be met to score any points for the element. In the same element as above, for example, having regular team meetings or a structured communication process is designated as a critical factor. A practice must meet this factor in order to achieve any of the four points assigned to the element.
SIX ‘MUST-PASS’ ELEMENTS
Of the 27 elements, six are considered essential, and the practice must get a score of at least 50% in all six of these to pass. Since they are the most critical elements, it is often useful to focus on them first to ensure that your practice puts into place policies and other building blocks necessary to make these important elements happen.
Policies must be in place for at least 3 months before submission. Most practices will discover many unwritten workflows as they review these processes.
What follows is a summary of the must-pass elements and their requirements. This is meant to be used only as an overview to better understand the scope of the medical home requirements; the actual requirements should be obtained from the NCQA Web site.
Standard 1, element A: Provide timely access during office hours
This element requires that your office have a policy or process in place for patient access. Same-day appointment availability is deemed a critical factor and must be met to receive any score on the whole element.
The practice needs to measure availability for several different appointment types—new, urgent, and routine—and show that same-day access is available. This can be done by completing at least a 5-day audit measuring the length of time from when a patient contacts the practice to request an appointment to the third next available appointment on his or her clinician’s schedule. It is not enough to simply double-book patients in an already full schedule.
The remaining aspects of this element require being able to provide timely clinical advice by telephone or by secure electronic messages, or both, during office hours, and to document it. The practice must have policies in place that define “timely.” It also must audit phone calls to prove adherence to that policy. The audit should cover at least 5 days. The practice then needs to show at least three examples of clinical advice documented in patients’ charts. We recommend not monitoring all the components during the same week, since the monitoring is laborious and would be overwhelming if attempted all at once.
