SAN ANTONIO – Earning patient-centered medical home recognition from the National Committee for Quality Assurance can seem an insurmountable challenge.
Cari Miller, the New Jersey Academy of Family Physicians' director of advocacy and program operations, should know. She recently helped 32 primary care practices achieve patient-centered medical home (PCMH) recognition from NCQA.
After talking a few practices off the ledge as they struggled to meet NCQA's nine PCMH standards – and after being a PCMH coach in the past – she has some advice for others seeking recognition:
▸ Get it in writing. The biggest struggle for most was fulfilling the first standard, which requires written policies for patient access and communication, plus data to prove they're followed.
NCQA, for example, wants to ensure patients are seen mostly by their specific primary care provider. The group “is not saying [that has to happen] every single time, and we would recommend that your policy doesn't say that,” Ms. Miller said in an interview after her presentation at the conference.
“What we have practitioners do is write a policy that may say 80% of the time patients will be scheduled with their primary care provider, then generate reports that show the patients who called in, [and] the percentage of time they actually saw their specific primary care provider versus another provider within the practice,” she said.
▸ Open access isn't an informal option. Along similar lines, to meet NCQA's open access requirement for last-minute patients, “often, practices will say, 'We see [patients] that day, we just fit them in.'” But that's not going to fly with the accreditor. “NCQA is going to say that if you are just fitting people in, that's not meeting the intent,” Ms. Miller said at the conference, also sponsored by the American Academy of Family Physicians.
Instead, the group is looking for dedicated, unscheduled slots held open each day for last-minute patients, she said.
“We found we could work with practices to, on average, keep two slots open for every morning and two slots open for every afternoon,” Ms. Miller explained. That way, NCQA could see that, “in fact, if somebody called at 9 o'clock in the morning, there is always a 10:15 and 11:15 appointment” available, Ms. Miller said.
Staff should know what the process is so that there is no variation. “[NCQA is] trying to take the variation out of things,” Ms. Miller said.
▸ Don't underestimate the power of a “carrot.” Horizon Blue Cross Blue Shield of New Jersey funded the efforts of Ms. Miller and the NJAFP to speed the adoption of the PCMH model in that state. “We really believed there needed to be a really strong carrot” to motivate participation, Ms. Miller said.
The 32 practices she recently coached included large, small, single, and multisite practices. NCQA recognition made them eligible for a $15 per patient per month care-coordination payment for Horizon Blue Cross Blue Shield enrollees with diabetes, plus a portion of any money saved in treating those patients as a result of the PCMH efforts.
The practices all won NCQA's seal of approval by October 2009, after starting the process in March of that year. Most achieved level 1 status, while others achieved level 2 or level 3.
▸ Change requires follow-up. In general, practice transformation is “a 2- to 5-year process,” Ms. Miller cautioned. PCMH recognition is just the first step – after that, practices must make sure the changes remain and are effective.
That's not always easy.
For example, when Ms. Miller visited one practice working toward recognition, it was doing a great job logging lab results, a critical PCMH component. But then the logger took a vacation, and no one was designated to take her place. When she returned, she stopped logging results because she felt she had too many other responsibilities.
Ms. Miller revisited the practice and discovered the system had fallen apart. “There was no information on the logs,” she said.
Similar things happened in other practices. “One of the fastest things that can go right down the drain is the follow-up, monitoring, and tracking,” she said.
The solution is to cross-train staff, let them know why they are being asked to do what they are being asked to do, and check records to ensure they are being kept.
▸ Physicians can't do it all themselves. Although 32 of Ms. Miller's practices passed PCMH muster, 2 did not. The medical assistant at the first practice thought he'd rack up enough points addressing only some of the standards; he let the others slide. The second practice had a problem Ms. Miller saw several times: Physicians had a hard time delegating decision-making responsibilities when they remained accountable for what happened in their practice.