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Physician Group Incentive Program

Patient-Centered Medical Home and Patient-Centered Medical Home-Neighbor Domains of Function

Interpretive Guidelines 20165-20176

V1191.0

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

Table of Contents

READ ME FIRST: THE ESSENTIAL FAQS ABOUT THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR PROGRAM ............................ 3

1. WHAT IS THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR? ...................................................................................... 3
2. WHY ARE THERE ALL THESE “CAPABILITIES?” ............................................................. 4
3. WHY DO WE NEED “INTERPRETIVE GUIDELINES?” ..................................................... 4
4. WHY HAS THE NUMBER OF CAPABILITIES INCREASED OVER TIME?........................... 4
5. WHO IS RESPONSIBLE FOR REPORTING PCMH/PCMH-N CAPABILITIES TO BCBSM? .. 4
6. CAN WE REPORT A CAPABILITY IN PLACE AS SOON AS THE PRACTICE HAS THE ABILITY TO USE IT? OR WHAT ABOUT WHEN ONE PHYSICIAN OR MEMBER STARTS USING IT?..................................................................................................................... 5
7. THE PCPS IN MY PO ARE VERY FAMILIAR WITH THE PCMH MODEL, BUT OUR SPECIALISTS HARDLY KNOW WHAT WE’RE TALKING ABOUT. SOME OF THEM THINK THEY SHOULD BE THEIR PATIENT’S MEDICAL HOME, NOT THE PCP. WHAT SHOULD WE DO ABOUT THIS? ................................................................................................... 5
8. WHY IS IT SO IMPORTANT THAT THE CAPABILITIES BE REPORTED ACCURATELY? ..... 6
9. DO WE HAVE TO IMPLEMENT THE CAPABILITIES IN ORDER? ..................................... 6
10. DON’TYOUPEOPLEKNOWHOWTOCOUNT?WHATHAPPENEDTODOMAIN7AND WHY DOES DOMAIN 8 START AT 8.7? ......................................................................... 6
11. WHATDOESPCMH/PCMH-NHAVETODOWITHORGANIZEDSYSTEMSOFCARE?...7
12. WHYDOESBCBSMDOALLTHOSESITEVISITSANDHOWSHOULDPOSPREPARE PRACTICES?.................................................................................................................. 7
13. WHATDOYOUMEANBY“CO-MANAGEMENT?”........................................................8
14. YOUUSETHETERM“CLINICALPRACTICEUNITTEAMS”ALOT.WHATDOESTHAT MEAN?......................................................................................................................... 9

 

15. WHYAREN’TTHEREANYCAPABILITIESRELATEDTOHEALTHLITERACY?..................9

OVERVIEW: CAPABILITY COUNTS, SITE VISIT REQUIREMENTS, AND PREDICATE LOGIC.. 10

PCMH/PCMH-N INTERPRETIVE GUIDELINES..................................................................... 16

1.0 PATIENT-PROVIDERPARTNERSHIP............................................................................16

2.0 PATIENT REGISTRY ...................................................................................................... 20

3.0 PERFORMANCE REPORTING ....................................................................................... 27

4.0 INDIVIDUAL CARE MANAGEMENT.............................................................................. 32

5.0 EXTENDED ACCESS ...................................................................................................... 44

6.0 TEST RESULTS TRACKING & FOLLOW-UP.................................................................... 49

8.0 ELECTRONIC PRESCRIBING AND MANAGEMENT OF CONTROLLED SUBSTANCE PRESCRIPTIONS.......................................................................................................... 51

9.0 PREVENTIVE SERVICES ................................................................................................ 52

10.0 LINKAGE TO COMMUNITY SERVICES ........................................................................ 56

11.0 SELF-MANAGEMENT SUPPORT................................................................................. 59

12.0 PATIENT WEB PORTAL .............................................................................................. 63

13.0 COORDINATION OF CARE.......................................................................................... 66

14.0 SPECIALIST PRE-CONSULTATION AND REFERRAL PROCESS...................................... 69

READ ME FIRST: THE ESSENTIAL FAQS ABOUT THE PATIENT- CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME- NEIGHBOR PROGRAM

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Physician Group Incentive Program

Patient-Centered Medical Home
And Patient-Centered Medical Home-Neighbor Domains of Function Interpretive Guidelines

INTRODUCTIONREAD ME FIRST: THE ESSENTIAL FAQS ABOUT THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR PROGRAM

1. What is the Patient-Centered Medical Home and Patient-Centered Medical Home- Neighbor?

The Patient-Centered Medical Home (PCMH) is a care delivery model in which patient treatment is coordinated through primary care physicians to ensure patients receive the necessary care when and where they need it, in a manner they can understand. The PCMH-Neighbor model enables support implementation of capabilities that enable specialists and sub-specialists, including behavioral health providers, to partner collaborate and coordinate with primary care physicians engaged in transitioning to the patient-centered medical home model of care, and other providers, to create highly functioning systems of care.

The goals of the PCMH/PCMH-N model are to:

• Strengthen the role of the PCP in the delivery and coordination of health care
• Support population health management, which uses a variety of individual, organizational and cultural interventions to help improve the illness and injury burden and the health care use of defined populations.
• Ensure effective communication, coordination and integration among all PCP and specialist practices, including appropriate flow of patient care information, and clear definitions of roles and

1. Blue Cross Blue Shield of Michigan’s (BCBSM) Physician Group Incentive Program (PGIP) PCMH)-based infrastructure and care processes into 12 “Domains of Function” (listed in Table of Contents). Each PCMH Domain of Function has a set of required capabilities, collaboratively developed and refined annually by BCBSM and PGIP Physician Organizations (POs).
2. Why are there all these “capabilities?”

When BCBSM began developing its PCMH program in 2008 in collaboration with PGIP Physician Organizations (POs), it became clear that practices could not wave a wand and turn into a fully realized PCMH over night. In early demonstration projects, practices began suffering from transformation fatigue, in some cases leading to disillusionment with the PCMH model.

In partnership with the PGIP community, BCBSM decided to develop 12 initiatives to support incremental implementation of PCMH infrastructure and care processes. Each initiative focuses on a PCMH domain of function and defines the set of capabilities that will enable practices to achieve the PCMH vision for that domain of function.

Initially, a 13th initiative was developed for electronic prescribing (domain 8), but then a separate e- prescribing incentive program was implemented, and e-prescribing was removed from the list of PCMH/PCMH-N domains. In the 2016-2017 version of the Interpretive Guidelines, domain 8 was resurrected in order to add capabilities related to electronic prescribing and management of controlled substance prescriptions.

3. Why do we need “Interpretive Guidelines?”

During the first round of site visits in 2009, we rapidly discovered that there were widely varying interpretations of nearly every term and concept in the PCMH model. We created the Interpretive Guidelines to provide definitions, examples, links to helpful resources, and also to address questions regarding extenuating circumstances.

4. Why has the number of capabilities increased over time?

Although the PCMH/PCMH-N model was designed to be highly aspirational, it also continues to evolve based on new research and insights about the delivery of optimal health care. Each year, BCBSM conducts a comprehensive review of the Interpretive Guidelines, incorporating input gathered from the PGIP community throughout the year as well as enhancements based on new findings.

5. Who is responsible for reporting PCMH/PCMH-N capabilities to BCBSM?

Physician Organizations are responsible for reporting These PCMH/PCMH-N capabilities are reported to BCBSM. Capabilities can be reported online at any time, using the Self-Assessment Database. Ttwice a year, in January___ and July___, BCBSM takes a “snapshot” of the self-reported data.

using the Self-Assessment Database.

It is not acceptable for a PO to request that practices simply self-report their capabilities. POs must be actively engaging and educating their practices about the PCMH/PCMH-N model, and must validate all capabilities before reporting them in place.

6. Can we report a capability in place as soon as the practice has the ability to use it? Or what about when one physician or member starts using it?

No and no. Any capability reported to BCBSM as “in place” must be fully in place and in use by all appropriate members of the practice unit team on a routine and systematic basis, and, where applicable, patients must be actively using the capability.

Some examples the field team has seen of capabilities that should not have been marked in place are:

• Patient portal capabilities reported as in place: Practice has patient portal implemented, but no providers or patients are using it.
• After hours/urgent care capabilities reported as in place for specialty practice: urgent care centers are identified in the PO’s PCMH brochure the practice is giving to patients, but specialty practice says they don’t use urgent care and do not counsel patients about how to receive after hours/urgent care, but instead direct patients to the ED.

7. The PCPs in my PO are very familiar with the PCMH model, but our specialists hardly know what we’re talking about. Some of them think they should be their patient’s medical home, not the PCP. What should we do about this?

It is critical that prior to reporting PCMH-N capabilities in place, POs ensure that both allopathic and non-allopathic specialists are aware of and in agreement with the PO’s documented guidelines outlining basic expectations regarding the role of specialists in the PO and within the PCMH/PCMH-N model, including:

• Commitment to support the PCMH/PCMH-N model and the central role of the PCP in managing patient care and providing preventive and treatment services, including immunizations
• Willingness to actively engage with the PO to optimize cost/use of services
• Collaboration with PCPs and other specialists to coordinate care In addition, POs should:

• Visit specialist practices to determine which capabilities are in place and actively in use. (The only exceptions would be those capabilities that are centrally deployed by the PO, such as generation of patient alerts and reminders.) POs should also ensure that specialist practices are aware of, and in agreement regarding, which PCMH-N capabilities are reported as in place for their practice.
• Hold forums and visit practices to educate the specialists and their teams about the PCMH-N model, and, importantly, emphasize the need for specialists to actively engage with the PO and their PCP colleagues to optimize individual patient care management and population level cost and quality performance.

 

Please remember that the point of the PCMH-N program is not to reward specialists for capabilities that just happen to be in place; the purpose is to enable POs to engage specialists in the PCMH-N model, with the goal of building an integrated, well-coordinated medical neighborhood.

As of 2017, if the field team finds during the course of a site visit that any of these elements are missing (e.g., the practice does not understand or support the PCMH/PCMH-N model, has not been visited/educated by the PO, is not aware of which capabilities have been reported in place, etc.), the field team reserves the right to suspend the site visit and find that none of the reported PCMH-N capabilities is are in place.

8. Reporting capabilities accurately is a lot of work. Why is it so important that the capabilities be reported accurately?

Accurate reporting of PCMH-N capabilities is vital, for many reasons:

• The overall integrity of PGIP depends upon POs accurately reporting on their transformation efforts. The continued success of the program requires that BCBSM and PGIP POs are fully aligned in support of PGIP’s goals, and that POs are committed to ensuring the accuracy of their self-reported data.
• Our PCMH/PCMH-N database is the source for extensive analytics and articles published in national peer-reviewed journals regarding the effectiveness of the PCMH and PCMH-N models.
• Inaccurate data will lead to misleading results, which could negatively affect the programmatic and financial viability of the PCMH/PCMH-N model.
• Inaccurate reporting of PCMH-N capabilities leads to inappropriate allocation of PGIP rewards, reducing the amount available to reward other key PGIP activities Any capability reported to BCBSM as “in place” must be fully in place and in use by all appropriate members of the practice unit team on a routine and systematic basis, and, where applicable, patients must be able to use the capability. “Clinical Practice Unit teams” should be composed of “clinicians,” defined as physicians, nurse practitioners, or physician assistants (unless otherwise specified in the guidelines).

9. Do we have to implement the capabilities in order?

Capabilities are not necessarily listed in sequential order (except for patient-provider partnership capabilities) and may be implemented in any sequence the PO and/or practice unit feels is most suitable to their practice transformation strategy.

10. Don’t you people know how to count? What happened to domain 7 and why does domain 8 start at 8.7?

Sort of. Because we have amassed years of self-reported data based on numbered capabilities, we cannot reassign capability numbers. Note: Domains 7 and 8 are not included in this document. Domain 7 was previously used to collect evidence-based care data, and has been retired. and In dDomain 8, capabilities 8.1 through 8.6 were related to incremental implementation of e-prescribing and is used to collect self-reported electronic prescribing data.have been retired.

2. Note regarding expansion to address role of specialists and subspecialists: PCMH- Neighbor (PCMH-N) Interpretive Guidelines (originated in June 2012):

11. What does PCMH/PCMH-N have to do with Organized Systems of Care?

In a word, everything. BCBSM’s PCMH PCMH/PCMH-N program provides the foundation to build Organized Systems of Care (OSCs). These expanded PCMH-N Interpretive Guidelines support implementation of capabilities that enable specialists and sub-specialists, including behavioral health providers, to partner with primary care physicians engaged in transitioning to the patient-centered medical home model of care, and other providers, to create highly functioning systems of care.

12. Why does BCBSM do all those site visits and how should POs prepare practices? Site visits are a vital component of BCBSM’s PCMH/PCMH-N program, and serve many purposes,

includingto:

• Educate POs and practice staff about the PCMH/PCMH-N Interpretive Guidelines and BCBSM expectations
• Enable the field team to gather questions and input to refine, clarify, and enhance the PCMH/PCMH-N Interpretive Guidelines
• Ensure that the PCMH/PCMH-N database is an accurate source for research as well as the PCMH Designation process POs should inform practices that demonstration will be required for certain capabilities (please see site visit requirements table on p. 79). For example, if the practice is asked to show the field team how patient contacts were tracked in the practice system for abnormal test results, the practice should have patient examples identified ahead of time and be prepared to discuss them with the field team during the site visit. The goals of the PCMH-N model are to: •Support population health management in collaboration with PCPs o Population health management uses a variety of individual,organizationa land cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use of defined populations.

 

• Ensure effective communication, coordination and integration with all PCP practices, including appropriate flow of patient care information

• Provide appropriate and timely consultations and referrals that complement and advance the aims of all PCP practices

• Clearly define roles and responsibilities of primary care physicians and specialists in caring for the patient

13. What do you mean by “co-management?”

3. What are principal partners?

There are several types of co-management between PCPs and specialists, as well as other interactions, as defined in the table below.

Under the PGIP program, specialists must be members of one, and only one, PGIP Physician Organization. A specialist practice will be identified as a Principal Partner of another PO (a PO which the specialist is not a member of) if all of the following criteria are met:

• The patients attributed to the non-member PO account for a substantial proportion of the patients a practice serves,

• The non-member PO represents a greater share of the members who received services from the practice than the member PO,

• The practice provided services to at least 50 patients from the non-member PO,

• The non-member PO represents at least 20% of the total BCBSM members who received services from the practice

POs and OSCs are encouraged to execute Primary Care-Specialist agreements with their member and principal partner specialists (a sample template of a high-level, one page agreement is available at the BCBSM website, but providers may also develop their own agreements). When POs nominate a specialist for value-based reimbursement they must attest that there is a signed Primary Care-Specialist agreement with that specialist. (For information on the specialist nomination process for value-based reimbursement, and requirements regarding Primary Care-Specialist agreements, please check the BCBSM PGIP Collaboration site.)

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Types of PCP/Specialist Clinical Interactions

Pre-consultation exchange - Expedite/prioritize care, clarify need for a referral, answer a clinical question and facilitate the diagnostic evaluation of the patient prior to specialty assessment

Formal consultation - Deal with a discrete question regarding a patient’s diagnosis, diagnostic results, procedure, treatment or prognosis with the intention that the care of the patient will be transferred back to the PCMH/PCP after one or two visits.

Co-management Co-management with shared management for the disease – specialist shares long- term management with the PCP for a patient’s referred condition and provides advice, guidance and periodic follow-up for one specific condition. Co-management with principal care for the disease – (referral) the specialist assumes responsibility for long-term, comprehensive management of a patient’s referred medical/surgical condition; PCP receives consultation reports and provides input on secondary referrals and quality of life/treatment decisions; PCP continues to care for all other aspects of patient care and new or other unrelated health problems and remains first contact for patient. Co-management with principal care of the patient for a consuming illness for a limited period – when, for a limited time due to the nature and impact of the disease, the specialist becomes first contact for care until the crisis or treatment has stabilized or completed. PCP remains active in bi-directional information and provides input on secondary referrals and other defined areas of care.

Transfer of patient to specialist - Transfer of patient to specialist for the entirety of care.