Introduction
The following video explains the changes in PCMH 2016 as reported to BCBSM using the self-Assessment Database.
These PCMH capabilities are reported to BCBSM twice a year using the self-Assessment Database.
For background information, please refer to the Interpretive Guidelines originated in June 2012. As a reminder, this program covers the basics around PCMH, yet your practice is still required to meet all documentation, tracking and other requirements, like patient registries for your specific practice, to be considered for designation.
One of the notable changes is that, In place of “uplift”, the discussion is now Value-based reimbursement, which also happens to refer to Outcomes based payments that are a strong focus for the future.
1.0 Patient Provider Partnership
Under 1.0, an additional section 1.10 has been added.
For both PCP and Specialist, the following has been added:
Provider has an established process for repeating Patient –Provider Partnership discussion
(a) Provider has an established process for repeating Patient –Provider Partnership discussion particularly with non-compliant patients and patients with significant change in health status
(b) Providers track date of Patient Provider discussion and repeat discussion at least every 2-3 years
2.0 Patient Registry
In ther Patient Registry section, the capabilities have gone from nine to twelve.
2.1a has been added, which includes
Add- “Active use” is defined as using the key content of the registry to conduct outreach and pro actively manage the patient population
(i) Generating patients lists that are not being actively used to manage the patient population does not meet the intent of this capability
In section 2.13, Some Registry chronic conditions are not addressed in other 2.0 capabilities.
2.20 has been altered to state that Registry contains advanced patient demographics to enable practices to identify vulnerable patient populations, including race and ethnicity, and also including data elements.
Also within 2.20, an example of date of depression screening and result has been added.
2.21 Demographic information now includes: to enable them to identify vulnerable patient populations
3.0 Performance Reports
In 3.1, the following addition discusses the relevant patient population: selected for initial focus and not addressed in other 3.0 capabilities
In 3.3, not addressed in other 3.0 capabilities, was added in relation to the patient’s chronic conditions.
3.16 is a new section that is titled: Performance reports are generated to track one or more Choosing Wisely recommendations relevant to scope of practice
For both PCP and specialist guidelines: Practices or PO’s are tracking and reporting on one or more Choosing Wisely recommendations relevant to scope of practice
4.0 Individual Care Management
Section 4.18 has been replaced with the following detail and more thorough information around Palliative Care needs have been addressed.
A systematic approach is in place for assessing patient palliative care needs and ensuring patients receive needed palliative care services
PCP and Specialist Guidelines:
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i. COPD, or dementia
ii. Multiple chronic illnesses with frequent hospitalizations
iii. Significant scoring on risk stratification tools (e.g. LACE, PRISM, etc)
i. Advance care planning (including Durable Power of Attorney-HC designation, discussion and documentation of patient values and preferences)
ii.Pain and physical symptom management
iii.Psychological and emotional symptoms
iv.Spiritual distress
v.Caregiver stress
vi.Home or community-based support services
vii. Hospice eligibility
Provider with lead responsibility ensures that all care partners are aware that patient is receiving palliative care services
Palliative care services are made available as needed to patients with unmet needs at all stages of seriously illness, not only at time of terminal diagnosis
Reference for definition of palliative care, and an overview of the domains that should be addressed in the delivery of comprehensive palliative care
Practice has established written protocols for determining when patients should be assessed for palliative care needs, based on accepted standards relevant to their patient population. Tools that can be used to support assessment and management of palliative care needs are available.
Brief, evidence-based educational reviews of key palliative care topics:
Advance care planning, Pain and symptom management, Psychological and emotional symptoms, Spiritual distress, Prognosis and Hospice eligibility, including:
5.0 Extended Access
Pertinent only to Specialists, section 5.7 added: Written policy for advanced access is available
Patients are aware of policy and do not feel that they must self-screen to avoid imposing on practice unit staff
For both PCP and Specialists 5.10b was added to explain – not applicable to practices where English is primary language for 95% of more of the practice’s established patient population
9.0 Preventive Services
9.7i was added for both PCP and Specialists to educate that the Practice systematically uses point of care alerts based on identified risk
10.0 Linkage to the Community
Section 10.3i was added for both PCP and Specialist to discuss that in PO, or a Practice, – PO in conjunction with practice has conducted outreach to organizations and held in-person meetings or face-to-face events at least annually that facilities interaction between practices and agencies where they discuss the needs of their patient population
Both PCP and Specialist; 10.4b adds – Practice unit care team is trained to empower and encourage support to alert them to
patient’s possible psychosocial or other needs
10.5a is changed to alert that the practice unit team is to educate new patients
The following segments were also added:
– education process must include intake form and/or conversation in which patients are
asked whether the are aware of or in need of community services
- practice support staff are empowered to alert practice unit staff to possible psychosicial
and other needs
10.6ii was added, that reads- assessments that identify a patient with need for referral are documented in the medical
record to enable providers to follow-up during subsequent visits
11.0 Self Management Support
In section 11.0, please note that there were updates to website links as references.
12.0 Patient Web Portal
12.7b was added, which describes that: an automated care reminder is a patient specific communication, such as a reminder about
13.1 Coordination of Care
PCP and Specialist sections have been separated in 13.2. No changes to PCP, yet here are the specifications for Specialists:
a. Specialist systematically request that patients provide name of PCP
b. Patients are encouraged to request that their PCP be notified of any encounters they may have
with other health care facilities and providers (for example, SNF’s rehab facilities, non-primary
hospitals)
c. Practice units are responsible for ensuring that other providers have relevant medical information in a timely manner necessary to make care decisions
For both PCP and Specialists, 13.12 has been added the following section – Practice is actively participating in the Michigan Admission, Discharge, Transfer (ADT) Medication Reconciliation Use Case
– The practice connects Medication Reconciliation information received through the HIE
process with clinical processes, such as transition of care management following hospitalization
and a process exists for updating patients medical records
Thank you for utilizing the eLearning Portal for your 2016 updates in PCMH training and for allowing better healthcare through PCMH designation.
Learn about PCMH Guideline Updates for 2016.
An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.
An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".
Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.
The identification of a practice within the PGIP program.
An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.
Total number of "current" patients in the practice.
Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past
Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)