1. Overview
PCMH Learning Community
Dec 6, 2011
Mazhar Shaik, Chief Clinical Officer
Lynda Meade, Program Manager

2. Agenda
• Why We are Doing it? How We are Doing it? What Does
the PCMH Initiative Entail?
• Goals and Aspirations of This Collaborative
• Features, Benefits and Value Proposition
• Approach, Structure and Requirements
• Tools and Resources
• Q&A (MPCA/PCDC)

3. Why MPCA is Initiating the PCMH Learning Community?
Prioritization Grid of Health Center Areas of Need (Operations)
MPCA is responding to our stakeholders’ needs.

4. Preferred Methods of Learning
Again, MPCA is responding to stakeholders’ needs
and preferences.

5. How Are We Doing It?
We are executing the PCMH initiative in partnership with a national
expert agency.
MPCA identified the national expert agency on PCMH through an
evaluation process:
- Interview - Presentations
- Proposal Evaluation - Reference Check
National Pool Finalists Winner
NCQA TransforMed PCDC
JACHO PCDC
AAAHC
TransforMed
PCDC

6. What Does the PCMH Program Entail? Goals and Aspirations:
This 12-month program, entitled the “PCMH Learning Community”
will equip Health Centers with knowledge, tools, resources and
one-on-one consultations to successfully:
• Compile an NCQA PPC‐PCMH survey submission with the goal of
obtaining PCMH recognition at a level appropriate for the
organization
• Collect and organize data for required Stage 1 MU objectives
with the goal of attesting
• Identify future areas for improvement that fully embody the
principles behind PCMH and MU concepts

7. PCMH Learning Community Road Map
• The Regulations
• The Objectives
Understand
• The Measures
• The Collaborative
• PCMH Readiness
Assess • MU Readiness
• The Gaps
• The Organization
• Medicaid/Medicare
• Level 1,2,3
Decide
• 2011, 2012
• The Collaborative
• Join the Collaborative
• Redesign
Map
• Collect and Organize
• Attest and recognize

8. Features of This Collaborative
• Builds a learning community – brings together
organizations committed to making improvements in care
delivery
• Uses evidence-based best practices as framework for
designing improvement at individual sites/practices
• Is an action-learning approach – you learn and do and
learn…
• Change is specific, measureable and directly related to an
improvement outcome
• Uses teams (in partnership with leaders) to learn, test and
lead implementation of change improvement
• Builds in sustainability at all points
• Coaching and technical assistance support (e.g., coaching
calls, webinars, on-site and virtual site visits)
• Increases the degree of improvement achieved

9. Strengths of Learning Community
1. Cost-effective/scalability (leverage experts)
2. Activity (real world) focused
3. Leads to actionable work plan
4. Peer networking
5. High participant accountability
6. Action period reinforces learning
7. Supports self-paced learning
8. Allows for wider organizational participation

10. Benefits
 Timeline flexibility/resource availability
 One effort, two results (PCMH/MU)
 Content value
 Not a cookie cutter approach - we meet you where you are
 CHC expertise
 Build capability - preparing for future stages of PCMH and
MU

11. Benefits …
 MPCA has high knowledge of CHCs, has established working
relationships with CHCs
 MPCA is a trusted partner of Michigan CHCs
 PCDC trusted consultant to the Primary Care Community
 PCDC reputation with collaborative assistance for over 400
locations
 MPCA/PCDC have the capacity and capability to do this work
 Dollar savings $20,000 - $25, 000 per CHC

12. PCDC: A Learning Community
Partner
December 6, 2011
Peter Cucchiara, BSMIS ,MBA, Managing Director
Deborah Johnson Ingram, Sr. Program Manager

13. PCDC Background

15. A Sample of Significant PCDC Activities
Funded by New York Community Trust
Manual Released 11/09 “Comprehensive “How To”
10,000 Downloads
At more than 20 conferences, forums, webinars
Presentations Several 1-2 day training sessions
Focus on rationale, standards and process
PCMH/MU Partnered with CHCANYS (NY PCA)
Collab. 12 CHC in Wave 1; Planning Wave 2
Focus on achieving two results in one effort
Redesign Faciliation
Technical
Assistance Project Management Coaching
Consulting toward HH recognition and MU certification

16. PCDC Partners with PCA’s
PCMH/MU CHCANYS/PCDC Collaborative PCMH Assessment/Facilitation Services
• Access CHC • Bassett Healthcare Network
• Basics/Promesa Systems Inc • Lutheran Family Health Center
• Bronx Lebanon Hospital • Maimonides Medical Center – ICL
• Brooklyn Plaza Medical Center • Montefiore Community Pediatrics Program
• Charles B. Wang CHC • Montefiore Medical Group
• East Harlem Council for Human Servics Inc. • St. Barnabas Ambulatory Care Clinics
• Joseph P. Addabbo FHC • Stepping Stone Pediatrics
• Morris Heights Health Center • Bedford Stuyvesant FHC (Emblem)
• Pediatrics 2000 • Primary Medical Care – PC (Emblem)
• Settlement Health • SL Quality Care DTC (Emblem)
• Soundview Healthcare Network • Fort Drum Region Health Planning Org.
PCMH/MU Training/Educational Sessions for PCAs
• Alabama Primary Health Care Association
• Alaska Primary Care Association, Inc.
• Bi-State Primary Care Association (Vermont & New Hampshire)
• California Primary Care Association (120 Centers)
• Community Health Care Association of the Dakotas
• Michigan PCA
• Wisconsin Primary Health Care Association (April 2011)
• CTPCA
• OKPCA
• SCPCA

17. % of NYS Practices PCDC Assisted with PCMH Recognition as of
12/2011
10%
PCDC 75
NYS 739
94%

18. % of U.S. Practices PCDC Assisted with PCMH Recognition as of
10/2011
3.0%
PCDC
USA
97.0%

19. Value Proposition Considerations

20. Value Proposition Considerations
Average Cost of Two Day Conference $3,000
Average Cost EMR 2 day education $1,500
Average Cost for HIT 2 day education $1,500
NCQA PCMH Training 1 ½ day $1,000
Plus Travel Expenses $3,000
Total Range $4500 - $6000
PCMH MU Collaborative
4 Learning Sessions (4 days)
12 Webinars
Weekly T/A Coaching for PCC
Weekly T/A Coaching for PCA
Other:
Webinars
Webinettes
Sharepoint
Tools
Resources
Total Price for 12 month package $5,000

21. Value Proposition Considerations
What Comes With your HRSA 35K
Going it alone yields: Joining the MPCA collaborative
yields:
• A link to tools and resources
from NCQA • 12 months of direct/
indirect consultant services
• The challenge to stretch from industry experts
your 35K to gain NCQA
submission/recognition • Guided process to getting a
– Hire a private consultant (> submission completed in
$30,000.00) not including in kind projected time frame
cost
• Projections of ROI (inclusive
– Send staff to NCQA training
(1.5 day training w/ travel and hotel of in-kind costs*)
>$1700.00) not including in kind cost

22. Medicaid FFS
10,000 Medicaid FFS visits/year
Level 1: 10,000 * $ 5.50 = $ 55,000/year
Level 2: 10,000 * $11.25 = $112,500/year
Level 3: 10,000 * $16.75 = $167,500/year
Medicaid Managed Care (PMPM)
3,000 Medicaid Managed Care patients
Level 1: 3,000 * $2 * 12 months = $ 72,000/year
Level 2: 3,000 * $4 * 12 months = $144,000/year
Level 3: 3,000 * $6 * 12 months = $216,000/year

23. • Practice with 10 providers that sees 10,000 Medicaid managed care patients per
year and achieves level 3 PCMH and MU Stage 1 by 2011 could generate by 2015 a
total of:
– MU
• $63,750/EP/five years X 10 MDs = $ 630,750
– PCMH
• L3: 10k pts X $6/Pt/yr = $720,000/year X 5yrs = $3,600,000
Projected 5 Year Total = $4,230,750

24. PCDC Approach

25. Guiding Principles
Balance – test/principles
Measure twice cut once
Map – see the path Three work strands as one
before we walk it
2 Decision Catalogue
1
Teams & Collaboration

26. Our Traditional Approach
Focuses on system design as source of results
Integrated
Redesign of specific system elements for
Approach
desired results and outcomes
Client needs through use of a targeted, results- and
Understanding outcomes-focused assessment (combination of
data, interviews, observations and organizational strategic
goals)
Synthesize data and observations
Identify key opportunities for change
Develop an implementation plan focused on redesign
Implementation for high impact results and sustainable changes
Training supports implementation to enable
Coaching effective, sustainable changes in operations and
results.

27. Work Area Considerations
Knowledge & Skills
The Team Trusted Colleague
Protected Time
Assessing Scope & Capacity
Decisions
Getting Organizational Backing
The Messages
Communications
The Audience
Detailed Assessments – evaluating readiness/capability
Assessments Defining gaps
Optimization
Outlining Plan, Resources, Timeline
Workplan Managing the Plan and by the Plan
Making the Adjustments

28. PCMH/MU Overlap Summary
100% of MU is incorporated into PCMH but
1 Only 44% of PCMH is met by MU and
You only get 1 must pass element out of 6
MU objectives fall in All 6 standards
2 12 of the 27 elements
34 of the 149 factors
In several cases, multiple PCMH factors relate to 1 MU
3 objective
E.g., MU C8 incorporates 5 PCMH factors
When choosing 6 MU clinical measures
…align them with the 3 diagnostic
conditions you selected for PCMH and
your UDS clinical measures

29. Structure

31. Activity Periods
Learning Events
Theme
Objectives Objectives
Core Concepts/Topics Activities (Based on Topics)
Activities Progress Monitoring
Tools Work Tools
Resources Work Aids/Resources
Delivery Methods

32. Phase 1: Pre- Work (October December 2011-January 2011)
The first phase of the project called “pre-work” will place strong emphasis on completing assessments of each of the 18 practices. Using several of PCDC’s tools from its 2009 publication Obtaining
Patient-Centered Medical Home: A How-To Manual, and other tools. Practices will conduct comprehensive practice profiles and self-assessments to provide understanding of their operational and
technological capacity as it relates to the four clinical interventions. PCDC will analyze the data from these assessments and earlier data, as well as conduct an on-site visit to each practice, to
produce gap analyses and generalized project work plans. This phase will include a number of webinars and virtual meetings to orient practices to the goals of the collaborative and to use
assessment and profile tools effectively. This pre-work phase takes a blended approach of using site visits and virtual coaching to establish and reinforce the coach/practice relationship.
Objectives Topics/Activities Tools/Resources Recommended Delivery Methods
Introduction and overview of the Leadership Orientation (PCDC/ Practice Team Leaders) 1. PCDC Practice Profile: Webinars – pre training
Learning Collaborative model and Completing “practice profile” a. PCDC PCMH 2011 Self- Site Visits
curriculum. Selecting a team Assessment: focus on Recorded Webinars and Webinettes
Kickoff (PCDC/ Practice Teams) standards directly related to Conference calls
Identify and evaluate each practice’s Introduction to CCBC four clinical interventions the four interventions (e.g. Virtual weekly meetings with PCDC
operational and technological Preliminary exploration of goals and measures Standard 2 Element D “using coaches via Webex, conference call,
strengths and gaps related to the Organizational Impact Review data for Population video conference, etc.
four clinical interventions Pre-Training Management) Case Studies
Introduction to PCDC’s PCMH 2011 Self- b. Depth of PCMH review Simulations
Identify change/process management Assessment Tool c. Post-recognition dashboard
steps that need to be taken in order On-Site Visits (PCDC Coach) 2. Team Selection Grid Estimated T/A time allocation: 5 hours per
to ensure successful adoption of Review results and deliver feedback of practice 3. Team Selection Toolkit practice, per week
performance improvement practices profile and self-assessment 4. EMR Assessment Tool to identify
Identify practice goals and units of measure for Clinical Decision Support, Health
CCBC clinical quality measures Information Exchange, e-prescribing
Design general project workplan (to be expanded and reporting capabilities
and customized in Learning Session 1)
Additional activities (for each site):
Collect baseline data and assess practice
capabilities
Assess ability to collect data, run reports, use
registries and current care management
capabilities
Identify current staff/clinical team member
composition
Collect and review any prior assessment data
Evaluate level of technical assistance required

33. Tools and Resources

34. Sample Resource Inventory
1 – Pre Work Tools
Team Chart and Team Development Template
PCMH Assessment, Gap Analysis Template
Workplan Development Template
Communications Campaign Outline
2 – Webinars & Webinettes
Beginning your Team Journey
Webinettes for Every Standard
Meaningful Use/PCMH FAQ
3 - Reference
Manuals – PCMH, CDSS
MU/PCMH Vendor Guide
Vendor Inquiry

37. Deborah Johnson Ingram Peter Cucchiara BSMIS, MBA
Senior Program Manager Managing Director
Performance Improvement
22 Cortlandt St. 22 Cortlandt St.
New York, NY 10007 New York, NY 10007
212-437-3935 212-437-3921
Djingram@pcdc.org pcucchiara@pcdc.org

38. Questions?
More information and to access
information, resources and tools:
www.mpca.net/PCMH
Mazhar Shaik, Chief Clinical Officer
mshaik@mpca.net
517.827.0487
Lynda Meade, Program Manager
lmeade@mpca.net
517.827.0470