NCQA’s Patient-Centered Specialty Practice program rewards specialists who coordinate care with primary care physicians, other specialists and patients
Supplier success in a post‐reform healthcare market depends on a lot of factors, including a fundamental and thorough understanding of the foundation of healthcare reform. This is part of an ongoing series designed to help Repertoire readers understand the implications of reform.
There is a communication breakdown between primary care physicians and the specialists to whom they refer patients. Consider:
- A 2011 study found that 25 to 50 percent of referring physicians did not know if their patients went to the specialist to which they were referred.
- In a related article, authors found that although primary care physicians report sending a history or reason for a specialist consult 70 percent of the time, specialists stated they received this information about 35 percent of the time.
- On the other side, specialists claim to send consult notes and patient advice to primary care physicians 81 percent of the time, but primary care physicians report receiving this information 62 percent of the time.
Coordination of care is crucial for increasing care quality and reducing overall costs. To encourage that coordination, the National Committee for Quality Assurance (NCQA) – architect of the Patient-Centered Medical Home – extended the medical home concept to specialists with its Patient-Centered Specialty Practice (PCSP) recognition program. As of April 2014, 22 individual sites and 278 clinicians were enrolled or recognized as Patient Centered Specialty Practices.
The program recognizes specialty practices that successfully coordinate patient care and communicate with their primary care colleagues, other specialists and patients.
Like medical homes, PCSPs must demonstrate patient-centered care through:
- Streamlining their referral processes and care coordination with referring physicians.
- Timely patient and caregiver-focused care management.
- Continuous clinical quality improvement.
It requires clinicians to organize care around patients – across all clinicians seen by a patient – and to include patients and their families in planning care and managing conditions.
Who is eligible?
All types of medical specialties or subspecialties are eligible for the program, including those that see patients infrequently, see patients for a short episode of care, and those that provide care for chronic diseases or extended illnesses.
Also eligible are clinicians who receive referrals from primary care physicians and other non-primary care specialists, and can demonstrate a capability to meet the standards. That includes non-primary-care specialty doctors of medicine, doctors of osteopathy, nurse practitioners, physician assistants, certified nurse midwives, doctoral or master’s-level psychologists, clinical social workers and marriage and family counselors who are state-certified, registered or licensed by the state to practice independently.
Learn it, earn it, keep it
Practices that are interested in gaining recognition should consult the NCQA website (see below) to learn if they are eligible, to gain access to standards and guidelines, and attend a free training program. This is called the “Learn It” phase of the program.
The application process begins in the second stage, called “Earn It.” During this phase, practices train and work to transform their facilities to meet six PCSP-specific standards:
- Track and coordinate referrals. The specialty practice collaborates with other specialists and primary care physicians to coordinate testing and care for shared patients.
- Provide access and communication. The practice offers timely access to appointments; timely responses to telephone and email requests during and after office hours; and explains the role of primary care physicians, specialists and patients in this new collaborative relationship.
- Identify and coordinate patient populations. The specialty practice captures clinical and administrative data on their specific populations, uses evidence-based tools to manage care for those populations, and follows up when care is needed.
- Plan and manage care. The practice develops a patient-centered care plan on its own or in collaboration with primary care physicians or other specialists. This team manages patient medications, provides educational resources, and refers patients to community services, as needed.
- Track and coordinate care. The specialty practice coordinates labs, imaging and other specialty referrals with primary care physicians or other specialists caring for the patient, tracking them from request through receipt of care.
- Measure and improve performance. The practice measures clinical processes, outcomes and patient experience, showing improvement over time, and reports this information internally and externally to improve the process.
Along with these six standards, practices must focus on five “must pass” elements. The maximum score a facility can receive on these elements is 100 percent. Each facility must achieve a score of 50 percent or higher on these to keep their PCSP status.
Once recognized, practices enter the “Keep It” phase, in which they promote their NCQA status, and work to upgrade and maintain their recognition status by continuously improving care and their patients’ experiences.
Supply chain impact
How does the patient-centered specialty practice model affect suppliers calling on specialists?
Specialists who move to the model need assistance streamlining their practices while improving the overall patient experience. A large part of a successful PCSP is the coordination of care between referring physicians and other specialists. Electronic health records can play a major role in helping all parties perform this successfully.
Once recognized, specialists will be looking for new ways to keep their recognition and to move up in levels, so they are maximizing their incentives. Reps who are able to discuss the six standards required for a PCSP and how their products can help specialists in these areas will find a growing niche with these customers.
For more information on the Patient-Centered Specialty Practice Recognition program, go to
http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredSpecialtyPracticePCSP.aspx
MDSI – the parent company of Repertoire – has developed the Healthcare Reform Navigation Series, an online program designed to make the task of preparing your organization for 2014 and beyond easier. This series will help you and your team with online courses that explain many of the key elements integral to understanding reform and the transformation from fee‐for‐service to fee‐for‐value. The program includes a 12-month schedule of topics and live sessions with industry experts.
To learn more about the Healthcare Reform Navigation Series, contact Scott Adams, corporate vice president, at (800) 536-5312 x5256 or sadams@mdsi.org.
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Patient-centered medical homes receive good report card
Patient-centered medical homes reduce costs and utilization of some healthcare services when compared to practices that have not earned that designation, according to a study conducted by RTI International and published in the Health Services Research journal. The study involved practices serving participants in Medicare’s fee-for-service program.
The patient-centered medical home (PCMH) is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into what patients want it to be, according to the National Committee for Quality Assurance, architect of the program. Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.
Key findings of the study include:
- Practices that received PCMH recognition from NCQA during the study saw a 5 percent greater reduction in average Medicare payments than their non-accredited counterparts, with two-thirds of the difference due to a decline in payments to acute care hospitals.
- Emergency room visits declined by 6 percent once a practice received PCMH recognition from NCQA.
- Among “sicker than average” patients studied, NCQA-recognized PCMHs reduced hospitalizations by 4 percent more than non-recognized practices and emergency room utilization by 10 percent more.
To access the study, go to http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12217/abstract
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