HCH Recertification Year One Presented by: MDH Health Care Homes Regional Nurse Planners Capacity Building, Certification and Recertification

Kathleen Conboy, RN, BSN Tina Peters, RN, BSN, PHN Joan Kindt, RN-C, BSN, PHN Danette Holznagel, RN, BAN, CDE, PHN, FCN

Health Care Homes

HCH Certification Updates

____ Certified HCH Clinics

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Applicants are from all over the state.

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Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations.

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All types of primary care providers are certified, family medicine, pediatrics, internal medicine, med/peds and geriatrics.

The Health Care Homes Recertification Process Learning Objectives 1. Describe the Health Care Home legislative rule subpart criteria required at recertification year one. 2. Define the progression of quality improvement requirements 3. Identify strategies to implement the standards at recertification year one.

Recertification Process 

Begins at previous year’s certification

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Reflects the progression of the clinic’s HCH journey

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Validates existing processes

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Reflects improvement through outcomes

Timelines: Recertification

The Recertification Process Window is: 90 Days

On the one year anniversary of your initial certification date, MDH will send you an email to notify you that you have 90 days to complete the recertification process:  LOI  Application  Assessment (if changes)  Site Visit •

Your clinic will now have a rolling 15 month recertification due date.

Recertification Time Line: 60 Days

60 days before the end of your recertification: •

Submit a Letter of Intent to indicate your wish to pursue recertification.

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Update the application with new clinicians or clinic information.

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MDH Planner will contact via phone or e mail

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Plan a date for your site visit.

Recertification Time Line: 45 Days

45 days before the end date of your recertification: •

Submit your recertification assessment 

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Address any recommendations from previous year’s report

Complete the HCH audit tool or your clinic audit Update number of care coordinated patients and number of care plans and send to planner Submit corrective action plans for variance resolution Apply for extension of variances, if needed

Recertification Timeline: 30 Days

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All documents have been submitted for MDH review

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MDH conducts site visit team meeting with clinic unless the clinic outcomes are “Superior”

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MDH reviews information presented and may request additional information and/or interviews

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MDH completes the recertification report

Recertification Timeline: Finish Line

Final Steps: •

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MDH sends the recertification final report to the commissioner/assistant commissioner for review and signature MDH sends a signed recertification letter with the final report to the clinic, Along with a list of recertified clinicians MDH updates certified clinicians on the MDH website

HCH Rolling Recertification Dates

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Recertification by Spread As HCH model is implemented in new clinic sites, referred to as

“spread” the new clinicians are certified and the certified status for the clinic will be declared at annual recertification. When a previously certified clinician leaves a clinic and goes to work at a non-certified clinic, the new clinic and clinician/s apply for their certification. The previous clinic employer identifies an “end” date for that clinician in the HCH on-line portal.

Recertification Steps for the Applicant

STEP 1:

Letter of intent, the clinic will receive an automated notification from MDH one year from initial certification.

STEP 2:

Application and Certification assessment

STEP 3:

Team Meeting with MDH

STEP 4:

MDH Review and Notification

STEP 5:

Optional: Variance requests

STEP 6:

Recertification

Recertification Resources:

Training tools for your reference can be accessed by going to:

http://www.health.state.mn.us/healthreform/homes/certification/index.html

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Recertification Assessment Tool

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Recertification Site Visits Team Meeting Format

Recertification Site Team Meeting 

The team meeting is an opportunity for the clinic or organization to “share the story” of progression of the Health Care Home.

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Applicants should include care team representation, care coordinator(s), leadership, and patient partners.

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Preparing for Site Visit Be in contact with your planner / common topics: 

Culture change and care team development

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Successes and challenges

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New planned initiatives

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Discuss the required updates to subparts for recertification

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Share how variances and recommendations were addressed.

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Quality improvement activities, committee structure changes, data collection. 18

Recertification Requirements Year One

Recertification Requirements Year One continued 

Continue to meet all initial certification (ODD numbered subparts: .0040 Subparts 1,3,5,7,9). Submit documentation by exception.

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Address any variances and/or recommendations made at initial certification (if applicable).

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Updates to specific subparts are required (1A, 5A, 9A, 9D)

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At year one recertification the new EVEN numbered subparts are added to reflect progress (2,4,6,8,10).

Recertification Year One .0040 Subpart 1A, 1 Subp. 1A, 1: Services to Patients with Complex and Chronic Conditions 

Submit documentation of progress in identifying patients who would benefit from care coordination services.

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Describe new population-based screening methods for risk stratification, registries, and predictive modeling tools.

Recertification Year One .0040 Subpart 5A Subpart 5A Care Coordination Program Expansion: •

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Submit the number of patients receiving care coordination services and the number of care plans. Update if there are changes to care coordination or goal setting processes. HCH audit as prescribed by MDH. The audit reflects an evaluation and an action plan.

HCH Clinic Audit Tool

Recertification Year One .0040 Subpart 9A Subpart 9A Quality Team 

Submit documentation that the quality improvement team is in place with meeting dates, names, roles of participants, and patient partnership activity.

.0040 Subpart 9D Learning Collaborative Participation • Submit names, roles and dates of those who attended the HCH Learning Collaborative. • Suggested attendees: • One or more clinicians • One or more care coordinators • One or more representatives from the clinic leadership • Describe how patients were encouraged to participate. • Submit how learning collaborative information is shared with the rest of the HCH team.

Recertification Year One New Subparts to reflect progress Subpart 2 Patient Activation Subpart 4 Registries to Track Gaps in Care Subpart 6 Shared Decision Making, Community Partnerships, Teams working to the full extent of licensure, Transitions in Care Subpart 8

External Care Plans

Subpart 10 Quality Measurement and Triple Aim Quality Plan

.0040 Subpart 2 Patient Participation in Managing Their Care Submit strategies used to encourage patients to take an active role in managing their care. Demonstrate one of the following criteria through procedures/workflows and concrete examples: • Participant’s readiness for change • Literacy level • Barriers to learning

.0040 Subpart 2 Patient Participation Examples:

Clinic Level Process: • Measurement of patient and family centered care: • PCMH-A (questions 9-11) • Family voices • The Institute for patient & family centered care

Individual Patient Process: • Teach-Back Method • Ask Me 3 • Patient Activation Measure (PAM) • Literacy Assessment/Questionnaire

.0040 Subpart 4 Registries & Tracking Gaps in Care

• Documented process with identified staff time for: • • • •

Pre-visit planning Call reminders for preventive care or procedures Follow-up appointments for chronic conditions Guidelines to identify patients with gaps in services

• Evidence that the registry is actively worked by the care team • • • •

Internal audit process Job performance review Blinded copies of completed work tools Work assignments

.0040 Subpart 6A Shared Decision-Making

Examples: • Workflows to solicit patient participation & shared decision-making • Policies—patient and family-centered principles • Job descriptions • Education programs • Tools: Patient Activation Measure(PAM), Ottawa Shared Decision Making tools, questionnaires or other tools • TruthPoint • Measurement of patient /family centered care • Patient stories/chart documentation

.0040 Subpart 6B Community Partnerships Demonstration of on-going partnership with at least one community resource. • Meeting Minutes • Communication or education plan • Formal referral agreements • Work plan Examples of community resources • Waiver or Senior services • Local public health • Home Health • Assisted living • Schools • Behavioral Health

.0040 Subpart 6C Care Team Practices to the top of licensure

Clinicians & team members working at the top of their education, licensure, and training. • Job descriptions/responsibilities • Workflows • QI project related to workflow or team responsibilities

.0040 Subpart 6D Planning for Transitions in Care Anticipatory planning care transitions: • Pediatric to adult care • Transition assisted living, skilled nursing or memory care facility • Transition to temporary rehabilitation • Transition to palliative care or hospice

.0040 Subpart 8 External Care Plans • Identify patients with care plans who also have external care plans. • Process used to create a comprehensive care plan which adds relevant information from the external care plan. • Examples: wound care, falls prevention, behavioral health, asthma action plan. • Submit three integrated care plans for review.

.0040 Subpart 10 A Reporting & Quality Improvement 1 Statewide Quality Reporting

Patient level data: Pursuant to Minnesota Rules, chapter 4764.0040, and Minnesota Statutes, section 256B.0752, the applicant will submit health care homes data in the manner prescribed by the commissioner to fulfill evaluation requirements. To meet this requirement, the applicant will submit patient level data to MDH, in the manner prescribed by the commissioner. The applicant will submit data through the MDH contracted data collection vendor; the data collection vendor will provide de-identified patient-level data from the applicant to MDH for the purposes of evaluation.

.0040 Subpart 10 A Reporting & Quality Improvement 2 Statewide Quality Reporting

Required Measures: •Diabetes •Vascular •Pediatric and Adult Asthma, •Colorectal Cancer screening •Depression Remission at 6 months •Patient Experience measured through the CG-CAPHS with the PCMH additional questions New: Pediatric Preventive Care – Adolescent Mental Health and/or Depression Pediatric Preventive Care – Obesity/BMI and Counseling

.0040 Subpart 10 B Quality Improvement Planning Submit a quality improvement plan that addresses the “Triple Aim” of health improvement: • Clinical Improvement • Patient Experience Improvement • Cost effectiveness of services

Health Reform in Minnesota Minnesota’s Three Reform Goals 

Improve the health of the population

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Improve patient experience

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Improve the affordability of health care

Institute of Medicine’s Triple Aim

Health Care Homes Recertification Quality Plan Document

Health Care Homes Recertification Quality Plan Document Examples

.0040 Subpart 10 Quality Measures Examples of Triple Aim Indicators : Reduced duplication of services Hospital readmissions, ER usage Poly pharmacy Patient satisfaction surveys Immunization rates Advanced directives, physician orders for life sustaining treatment (POLST) • Optimal care scores • • • • • •

HCH Benchmark Reporting Preparing for Recertification Years 2, 3 and Beyond

HCH Benchmarks Benchmarking Continuum for HCH Low Average High PerformancePerformancePerformance Variance Low Average Variance for Performance Continued Superior Corrective Transformation Performance Action Plan Action Plan Recertification Performance Continuum for HCH 43

Benchmarking Approach

Internal and external benchmarking using a hierarchy approach: • • • 

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A performance (comparison) benchmark, and An internal improvement benchmark

Benchmarks are established at the clinic level. Statewide averages are the aggregate of all the optimal patients eligible to be in the measure. Health Care Home averages are the aggregate of all the optimal patients eligible for the certified health care home.

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Access to Benchmarking Reports https://hch-data.org/login

Thank you! For more information visit the Minnesota Department of Health, Health Care Home website at: http://www.health.state.mn.us/healthreform/homes/index.ht ml

651-201-5421

HCH Nurse Planners’ Contact Information 

Bonnie LaPlante, Supervisor

651-201-3744 [email protected]

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Tina Peters– Metro Area

651 201-3934 [email protected]

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Kathleen Conboy – Metro Area  •

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Joan Kindt- Southern Region  

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651-201-3753 [email protected] 507-272-4486 [email protected]

Danette Holznagel – Northern Region  

218-206-3239 [email protected]