2017 - Competency KM-C

Table of Contents

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Competency C: The practice proactively addresses the care needs of the patient population to ensure needs are met.

KM 12 (Core): Proactively and routinely identifies populations of patients and reminds them, or their families/caregivers about needed services (must report at least three categories):

Every PCC practice has access to the Practice Vitals Dashboard, which is a web-based tool tool for tracking and reporting their financial and clinical health. The clinical dashboards are specifically designed to help practices identify patients in need of a pediatric clinical response, from well visits to flu shots to ADHD checks and more. Lists of overdue patients are automatically generated within the Dashboard and include the following information:

• Patient name
• Date of birth
• Primary Care Provider
• Customizable patient status flags
• Date of last office visit
• Date of last well exam
• Date of next appointment and appointment type
• Address
• Phone number
• Email address

These lists include all the information a practice needs when contacting patients to remind them of an overdue service and can be printed from the Dashboard or exported to a spreadsheet in .csv format for use with third party contact systems (Constant Contact, CallEmAll, etc.)

PCC also has a recaller program which is a reporting tool providing the ability to generate counts, lists, mailing labels, and contact information for patients based on dozens of criteria including important preventive or chronic care measures. PCC practices use these lists to communicate with their patients individually and collectively, providing their own population management as suits their practice.

PCC also has a Patient Notification Center (notify) tool for automatically contacting patients and families not recently seen by the practice or in need of services. With notify, PCC practices set up recurring or one-time notifications, and PCC will deliver messages to patients automatically through our partnership with TeleVox, either by phone call, text message, or e-mail.

In this section, we have documented examples of how the Dashboard and recaller applications can be used to generate lists of patients in need of services, and how the notify program can be used to pro-actively remind patients of these needed services.

When choosing preventive care, immunization, and chronic/acute care services to generate lists and reminders for, PCC recommends considering using the same measures you've identified for QI efforts required for QI01. For each of the service categories below, a report of overdue patients and examples of outreach materials (letters, notification log, etc) are required.

• A. Preventive care services.

Description	Example/Screenshot/Documentation	Source	Date Added
Examples of using the Dashboard and recaller for generating lists and reminding patients of preventive care services	Preventive Care Reporting Examples	PCC	8/14/17

• B. Immunizations.

Description	Example/Screenshot/Documentation	Source	Date Added
Examples of using the Dashboard and recaller for generating lists and reminding patients of immunization services	Immunization Reporting examples	PCC	8/14/17

• C. Chronic or acute care services.

Description	Example/Screenshot/Documentation	Source	Date Added
Examples of using the Dashboard and recaller for generating lists and reminding patients of chronic or acute care services	Chronic/Acute Care Reporting examples	PCC	8/14/17

• D. Patients not recently seen by the practice.

Description	Example/Screenshot/Documentation	Source	Date Added
Examples of using recaller for generating lists of patients not recently seen by the practice	Identifying patients not recently seen	PCC	8/14/17

KM 13 (2 Credits): Demonstrates excellence in a benchmarked/ performance-based recognition program assessed using evidence-based care guidelines

At least 75 percent of eligible clinicians have earned NCQA HSRP or DRP Recognition. Alternatively, the practice demonstrates (through reports) that clinical performance is above national or regional averages. Examples of this demonstration may also include MN Community Measures, Brides to Excellence, IHA or other performance-based recognition programs.