Practice Resource Tools as planning for HCH certification Continued… HCH Quality Team Manager Provider Champion / Medical Director Practices”:--Sharing innovations that can increase physician’s work-life satisfaction, attract future physicians to the field, and improve the quality of patient care. Will see the movement from a physician-centric model of work to a shared-care model. Practical solutions to common challenges in primary care are discussed 2013 Medical Home in Pediatrics: The HOW TO Webinar Series Steps to Certification (Step 1) Letter of Intent (LOI) Letter of Intent (LOI) to MDH A formal notification of intent to apply for certification as a health care home. Tip: submit as soon as you know you intend to seek certification. Allows MDH planners to assist with any resources or guidance you need during your certification process Print LOI worksheet Request Access to LOI Clinic identifies who will gather and submit all information in HCH database Examples: Manager HCH Program Manager QI Coordinator LOI printable form available as a worksheet to gather information needed prior to submitting in the database Once ready - Request access to HCH database to submit your LOI by submitting a request to access the system Upon submission of the LOI the clinic will receive an automated email notification with next steps. Email #1 Health Care Home Application is Ready for Confirmation Email # 2– HCH Certification Next Steps Attachments to email will include: Planning for the MDH Site Visit HCH Self-Audit Tool and Action Plan Care Coordination Tier Assignment Tool
MDH Planner Resources MDH Nurse Planner- available to assist clinic with Understanding certification process Understanding 5 Standards MDH HCH Database Site Visit Prep Planning / tools for recertification Clinic identifies point of contact to work with MDH nurse planner Examples: Manager Program Manager QI Coordinator The HCH Planner is your primary contact to support you in the process of certification and recertification. Assist with understanding the Legislative Rule and Certification Requirements Performance Reporting & Quality Standard 9B Communicate primary care population based vision/model to all levels of clinic staff Care Delivery Redesign – What is different? Review of HCH standards / elements required for MDH certification Utilize various methods to communicate HCH Concepts: Newsletters /Brochures / Postings Meetings (clinic wide, dept., individual) Intranet / Internet HCH Quality Team Manager Provider Champion / Medical Director Providers All Staff -include front line and ancillary staff HCH Learning Collaborative Webinar “Introduction to HCH Webinars Series” 4 Webinars to help clinic teams: Understand requirements of HCH Identify / plan for closing gaps between current practice and HCH model Prepare to engage in process of changing to a HCH culture. Webinars: Business Case / Overview of Legislation and Standards Patient & Family Centered Care Change Management and Creating an Acton Plan Quality Improvement and Culture Change Power point presentation to assist with HCH education training. Minnesota Approach to Health Care Home- Overview On The Way – Working on Meeting the 5 Certification Standards
3A information and track patient care. Clinic (HCH) Population Manage Health Services Provide Appropriate Follow-Up Identify gaps in care Examples of Registries: Disease Specific Immunizations Preventive Screening Manager Provider Champion / Medical Director QI Staff Providers Care Teams / Care Coordinators Some examples of registry resources available Free / Low Cost Patient Care Registries to Support Health Care Homes Webinar – Free and Low Cost Registries MN Chapter American Academy of Pediatrics and Straits Health Care Coordination Standard 5A 1,2,3 Development of a collaborative care coordination model – helping patient Set goals and identify resources to achieve Communicate with PCP / Care Coordinator Establish frequency of contacts HCH Quality Team Manager Provider Champion / Medical Director Care Teams / Care Coordinators Patients Resources for comprehensive care planning – examples Children with Special Health Needs Persons with Complex Needs and Older Adults Care Coordination Standard 5B A systematic workflow process to select primary care provider / care coordinator – accessible to all who are providing care HCH defined roles & accountabilities Include Family Centered Care Principals HCH Quality Team Manager Provider Champion / Medical Director Care Teams / Care Coordinators Patients Staff Panel reports & guidelines available for empanelment procedures (designating primary care provider) Patient and Family Centered Care Resources Family Centered Care Self-Assessment Tool for Providers
Care Coordination Standard 5C Communication Infrastructure supporting provider – care coordinator face to face interactions. Enhance working to top of license “Share the Care” building blocks HCH Quality Team Manager Provider Champion / Medical Director Care Team / Care Coordinator Providers Staff Patients Practice Improvement Tools - Developing Roles & Responsibilities – as developing your care coordination model Examples for enhancing communication and working at top of license Planning and Managing Care Worksheet – Who does what? Role Activity Analysis Worksheet Practice Team Profile – The Five P’s (Purpose, Patients, Professionals, Processes, Patterns) Article “Sharing the Care to Improve Access to Primary Care” “Share the Care – 10 Building Blocks of High Performing Primary Care” presentation: Care Coordination Standard 5D Designated care coordinators (hire and/or realign current employees) Designated scheduled hours Role Description / Job Duties Tools Available for Care Coordination Training for the Role HCH Quality Team Manager Provider Champion / Medical Director Care Coordination: Comprehensive Patient Assessment Safety Net Care Coordination Toolkit & Resources Care Coordination Standard 5E 1,2,3,4,5,6 Develop a care coordination model for your clinic population (processes and documentation) that include Closing loop on referrals Test results / communication HCH Quality Team Manager Provider Champion / Medical Director Examples of care coordination resources available: Sample Care Plan and Coordination Policy Medical Home Practice-Based Care Coordination: A Workbook
9E Applying For Certification Steps to Certification Step 2 Clinic Application Application for certification thru MDH; assessment tool submission to MDH TIN’s Population Data Examples: Manager HCH Program Manager QI Coordinator Application available from MDH HCH Database – can print ahead of time to gather all information needed prior to submission in MDH HCH Database. Steps to Certification Step 2 Certification Documents to submit Submission of certification supporting documents in MDH HCH Database Only 10 Documents Required at initial certification Corresponds to Eligibility Criteria, Subparts 1,3,5,7,9 Recertification documents correspond to Subparts 2,4,6,8,10 and 11. Designee from clinic – has MDH Web Portal Access Examples: Manager HCH Program Manager QI Coordinator Overview of online certification documentation Upload 10 required documents in the HCH database: Certification Eligibility (0030 subpart 1) Organizational Structure (0030 1 A, B) Primary Care Mission & Aim (0030 1B) Standard 1 - Communication & Access (0040 1) Systematic Screening & Communication Process (0040 1A) Triage & Scheduling Protocol (0040 1 B3) Standard 2 - Registry & Tracking (0040 3) Systematic use of registry workflow (0040 3A) Standard 3 – Care Coordination (0040 5) Care Coordinator Job Description & Scheduled Hours (0040 5D) Systematic Identification of PCP & Care Coordinator in Medical record (0040 5B) Standard 4 – Care Plan (0040 7) Care Plan Policy / Sample Care Plan (0040 7B) Standard 5 – Performance Measurement & Quality Improvement (0040 9) Quality /Learning team members (0040 9A 9D) Procedure for sharing info/ input to and from quality team (0040 9B 9E) Certification and Continuation of the HCH Journey Steps to Certification Step 3 Onsite visit with MDH Team Presentation Interviews HCH Quality Team Assigned HCH Planner communicates with clinic contact as you prepare interview schedules and preparation for site visit.