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.
Standard 2, element D: Use data for population management
This element requires that your practice be able to generate lists of patients and send out reminders of needed services; both are also CMS Meaningful Use Criteria.
Specifically, the NCQA requires that you be able to generate lists of patients’ preventive care and chronic care services and be able to reach out to patients who have deficiencies. The practice must target at least three preventive care services and at least three chronic care services.
One can (and should) link this element to the three important conditions that have been chosen for the practice. For example, if osteoporosis is one of the important conditions, it also can be one of the three preventive care services; a possible quality improvement intervention could be to send reminders to patients to have bone density screening if they have not done so within a certain time frame.
In addition, the practice should have the ability to generate a list of patients who have not been seen at an appropriate interval, as well as a list of patients who are taking certain medications that require regular monitoring. To complete the audit, the practice must produce the four lists just described. Each must then be examined for the previous 12-month period, and documentation must be provided to show how patients with deficiencies were contacted.
Local insurance health plans may be able to help with this element, as these types of lists are often standard practice. Submitting the health plans’ lists is acceptable as long as you can show that they account for at least 75% of the practice.
Standard 3, element C: Manage care for your three conditions
This element focuses on the three clinically important chronic conditions you have chosen. It demonstrates that your practice is following these patients’ outcomes and targeting patients who require more attention to improve their outcomes. Doing so requires documenting pre-visit planning and individualized care plans and treatment goals.
The patient or the family, or both, should be given a written plan of care and a clinical summary at each visit. Barriers to progress need to be assessed, and patients should be contacted if they do not come to scheduled appointments. Patients who have significant barriers should be assessed for additional care management support. This is particularly important for a geriatric population, which may have significant psychosocial barriers such as financial problems, transportation issues, cognitive decline, and overall lack of support.
For each factor in this element, the office must create policies and protocols and assign tasks to appropriate members of the care team. For example, a nurse can make phone calls to targeted patients before their appointments to review goals of care using a standardized form. The form can be given to the physician at the time of the appointment for review and incorporation into the medical record.
Documentation for this element requires that the practice evaluate the number of patients with each chronic condition (the denominator) and the number of patients in each group for whom the above standards have been completed (the numerator) over the previous 3 months. At least 75% compliance is required for each of the three conditions to achieve a passing score for this factor.
This element is very time-consuming, even with an electronic health record. The practice team members should work together to create the systems and tools, but, if possible, it is worth trying to acquire help from an intern or a student. Working on the medical home can be a wonderful educational experience.
Standard 4, element A: Support self-care
For this element, one must show that the practice has educational and self-monitoring tools that are given to all patients depending upon their needs. Involving the patient or family or caregiver in managing the patient’s health is an integral part of the patient-centered medical home.
This is particularly challenging in geriatrics, as many patients may be cognitively unable to participate, and it will be necessary to develop self-management tools that are meaningful for caregivers. When choosing the three clinically important conditions, one needs to keep this element in mind, as the practice must be able to create good educational and self-management tools that are relevant to the important conditions and applicable to the geriatric patient population.
To meet the specific requirements for this element, the practice must show that at least 50% of patients or families receive educational resources and have documented self-management plans, tools, and counseling, and an assessment of their self-management abilities. In addition, one can show that the electronic health record is used to identify patient-specific educational resources in at least 10% of patients. This last factor is also one of the CMS Meaningful Use Criteria.
To document that the practice is completing all the requirements for this element, one must look back 12 months (or at least 3 months if earlier data are unavailable) and use the list of patients with the three clinically important conditions. In addition, the practice needs to identify its high-risk or complex patients over the same time period. These two lists comprise the denominator. The numerator is the number of patients for which you can show documentation of each of the above items.
Because this audit is also time-consuming, it and standard 3, element C (care management) should be combined and performed simultaneously.
Standard 5, element B: Track referrals and follow-up
This is often the most difficult must-pass element to fulfill because it requires coordination with health care providers outside one’s practice. To complete this element, the office must have a system in place to track referrals originating within the practice and to ensure that all relevant information is both sent to and received back from the consultant. This tracking must include the reason for and the urgency of the referral, as well as relevant clinical information. One can also establish comanagement when needed for patients who are seen regularly by a specific specialist.
Making sure that the consultant’s report gets back to the practice is, for most sites, the most difficult part. It is often not feasible to do this entirely through the electronic health record, as it is unlikely that all your consultants have the same electronic health record as your practice. Therefore, this often requires at least a partially paper-based system, creating a file that must be checked on a regular basis to ensure that the appointment with the consultant has been completed and that he or she has sent a note back. If the information is not all there, there must be documentation of a phone call that tried to obtain the necessary information or to document the patient’s refusal to follow up.
Two factors in this element also meet CMS Meaningful Use Criteria: demonstrating the capability for electronic exchange of key clinical information between clinicians, and providing an electronic summary of the care record for more than 50% of referrals. To complete the documentation for this element, the practice must do an audit that reviews at least a week’s worth of referrals.
