Fillable DRAFT 2015 Comprehensive Application(new Clinics) (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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DRAFT 2015 Comprehensive Application(new Clinics) (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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This application will enable program administrators to help clinics identify their PCMH focus,
strengths, and weaknesses. Clinics who better understand how they are functioning in their PCMH
journey can take the necessary steps to improve efficiency and enhance their bottom line. CSI also
needs to know PCMHs' current situation technologically and culturally as we explore possibilities
for supporting practice transformation through the Montana Department of Public Health and
Human Services and potential grant funding from other sources.
You must complete and submit the preliminary application prior to this Comprehensive Application.
Your practice must specifically state what PCMH accreditation you have or are pursuing. You can
contact Amanda Roccabruna Eby for the preliminary application at 406-444-4328 or aeby@mt.gov.
1st Year Clinics Only - Required with Preliminary Application
Montana PCMH Program Comprehensive Applicaiton
1. Contact Person Name
Name of Practice
Name of Practice Site (if
applicable)
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
2. Address
1
2
General Practice Information
Montana PCMH Program Comprehensive Applicaiton
3. Practice site ownership (check all that apply)
Individual provider
Group practice
Hospital or health system
Federal, state, local government
Independent non-profit (not hospital)
FQHC/Community Health Center
Other (please specify)
4. Practice type (check all that apply)
Solo (one provider)
Single site, single specialty
Multi-site, single specialty
Single site, multi-specialty
Multi-site, multi-specialty
Residency, academic
Community health center
Other (please specify)
3
5. Primary care specialties (check all that apply)
Family medicine
General practice
Internal medicine
Obstetrics/Gynecology
Pediatrics
Other (please specify)
6. How many years has the practice been in operation?
0 - 5
6 - 10
11 - 15
16 - 20
more than 20
Date
MM
/
DD
/
YYYY
7. If your clinic is qualified, what date did your clinic receive PCMH recognition from NCQA or other
approved accreditation agency?
Date / Time
MM
/
DD
/
YYYY
8. If your clinic is provisionally qualified, what date do you anticipate receiving PCMH recognition from
NCQA or other approved accreditation agency?
9. How many unique patients were seen by primary care providers in your practice between January and
December of 2014?
4
Included in the care team
Primary Care Physician
Primary Care Physician
Assistant
Primary Care Nurse
Practitioner
Integrated Primary Care
related Behavioral
Health Services
Care
Coordinators/Managers
or Patient Navigator
Certified Diabetes
Educator
Administrative Staff
Medical Assistant
Nurse (RN, LPN, etc.)
Dietitian
Clinical Pharmacist
Certified Asthma
Educator
Certified Lactation
Consultant
10. Does your practice integrate the following staff into your care model? Please indicate whether each of
the following roles is utilized for any amount of time.
5
Primary Care Physician
Primary Care Physician
Assistant
Primary Care Nurse
Practitioner
Integrated Primary Care
Related Behavioral Health
Services
Care
Coordinators/Managers or
Patient Navigator
Certified Diabetes
Educator
Administrative Staff
Medical Assistant
Nurse (RN, LPN, etc.)
Dietitian
Clinical Pharmacist
Certified Asthma Educator
Certified Lactation
Consultant
11. For each role included in your care team, please indicate how many full time equivalent staff (FTE) are
currently being used in your clinic. Please enter numbers only.
6
Enhanced Payment Information
Montana PCMH Program Comprehensive Applicaiton
12. Does your practice currently receive enhanced reimbursement from any commercial or public health
plan for primary care related services such as a PCMH participation fee, chronic disease management,
quality improvement, or other PCMH related components? (This question refers only to payor programs
labeled “Medical Home” or “Patient-Centered Medical Home.”)
Yes
No
13. Which payor(s) are you receiving the payments from?
Blue Cross Blue Shield of Montana
PacificSource Health Plans
Medicaid
Allegiance
Humana
New West Health Plans
Montana Health Co-op
Other (please specify)
7
14. If you answered "yes" to Question 12, please indicate the percentage of your practice's total patient
population that your clinic receives PCMH compensation for?
0 - 10%
11 - 25%
26 - 50%
Above 50%
15. What do you feel is the most important work you do for PCMH that you should be reimbursed for in a
reformed payment model? Choose your top 3 only.
Preventive health care services
Chronic disease management
Care coordination
Population management patient outreach
Community partnerships
Primary care related integrated behavioral health services
Primary care related clinical pharmacy services
Scribes (or equivalent clinical assistant)
Electronic health record capabilities
Data registry capabilities
Patient involvement in quality and planning (e.g. patient advisory council)
Other (please specify)
8
Current PCMH Status: Transformation, Progress, and Measurement
Montana PCMH Program Comprehensive Applicaiton
16. Please select below, your current PCMH practice transformation focus points. Choose your top 3.
Preventive health care services
Chronic disease management
Care coordination
Population management patient outreach
Community partnerships
Primary care related integrated behavioral health services
Primary care related clinical pharmacy services
Scribes (or equivalent clinical assistant)
Electronic health record capabilities
Data registry capabilities
Patient involvement in quality and planning (e.g. patient advisory council)
Other (please specify)
9
17. In regard to PCMH transformation in your practice, what technical assistance or other support would be
most useful at this time?
18. Does your practice have a formal quality improvement strategy or use standardized quality
improvement methodologies?
Yes
No
19. Are you using one of the following standardized methods/strategies? Check all that apply.
Lean management principles
Six Sigma
Plan-Do-Study-Act (PDSA) cycles
Institute for Health Improvement's (IHI) model for improvement
Other (please specify)
20. Does your practice have a staff person who has dedicated quality improvement responsibilities?
Yes
No
Name
Title
Email Address
Phone Number
21. If yes, please provide the contact information for the quality improvement staff person.
10
22. Please enter the approximate number of hours your staff person spends on QI per week.
23. Does your practice utilize the following? Check all that apply.
Patient advisory council
Patient surveys
Other (please specify)
24. Has your practice enhanced access to care for patients?
Yes
No
25. Please select the ways in which your practice has enhanced access to care. Check all that apply.
Electronic communication/e-mail
Expanded office hours
Same day appointments
Clinical advice system available when office is not open
Patient portal
Telephonic or electronic visits
Other (please specify)
26. Has your practice incorporated care coordination and/or disease management into care delivery?
Yes
No
11
27. What elements of care coordination/disease management are parts of your care delivery? Check all
that apply.
Collaborate and assist patients in personal goals for their improved health (self-management and goal setting)
Patients receive paper or electronic copy of their Care Plan specific to their chronic disease
Your clinic electronically generates lists of patients needing care and contracts these patients
Your clinic has some system for the team to do pre-visit planning or huddles
Your clinic does additional coordination of care for complex, high use patients (referrals, labs, tests)
System in place to follow-up pro-actively with patients having recent ER visit and/or hospitalization
Other (please specify)
12
EHR/EMR Use
Montana PCMH Program Comprehensive Applicaiton
28. Does your practice currently have an electronic health record (EHR) system (other than for billing)?
Yes, an EHR system is installed and available to all providers in the practice.
Yes, the EHR is currently installed but only available to some providers in the practice.
No, but we plan to implement an EHR system within the next 12 months.
No, and we do not plan to implement an EHR system within the next 12 months.
29. What is the name of the EHR system (or vendor) your practice currently uses?
Allscripts
Amazing Charts
Cerner Powerchart
CPRS
Chart Logic
Dairyland
Digichart
Docsite
eClinical Works
eHealthcare Systems
E-MD's
eMeds: MedNet
EPIC
13
GE Centricity
HealthCare Systems
HMS
Inservio-Medical Office Sol
Integreat IC-Chart
Lavender & Wyatt
MediNotes
Medicat
Meditech
Meditech/Health Partner
NextGen
Practice Partner
PrognoCis
RPMS HR
Soapware
techtime
Vista
Other (please specify)
30. What version of your EHR system is your clinic currently using?
31. When did your clinic initiate use of the current EHR system?
Less than 6 months ago
6 months to less than 1 year ago
1 to 3 years ago
3 to 5 years ago
More than 5 years ago
14
Available Unavailable Unknown
Chronic Disease
Registry
Clinical Decision Support
System
Patient Portal
Ability to document
patient referral
Ability to document
patient reminder or
follow-up
Ability to pull custom
reports
Ability to provide
electronic data exchange
(HL7)
32. For each EHR system function listed below, please check whether it is available in your practice's EHR
system.
Used Unused Unknown
Chronic Disease
Registry
Clinical Decision Support
System
Patient Portal
Ability to document
patient referral
Ability to document
patient reminder or
follow-up
Ability to pull custom
reports
Ability to provide
electronic data exchange
(HL7)
33. For each EHR system function that is available in your practice's EHR, please check whether it has
been used by your staff.
34. Do you have an EHR technical lead or professional IT support person on staff?
Yes
No
15
Name
Title
Email Address
Phone Number
35. If yes, please enter their contact information below.
16
Depression Screening
Montana PCMH Program Comprehensive Applicaiton
36. Does your practice use a standardized depression screening tool (such as PHQ-2, PHQ-9)?
Yes
No
37. If yes, which standardized depression screening tool(s) do you use for adolescents (12-17 years)?
Check all that apply.
Patient Health Questionnaire for Adolescents (PHQ-A)
Beck Depression Inventory-Primary Care Version (BDI-PC)
Mood Feeling Questionnaire (MFQ)
Center for Epidemiologic Studies Depression Scale (CES-D)
PRIME MD-PHQ-2
Other (please specify)
17
38. If yes to question 29, which standardized depression screening tool(s) do you use for adults (18 years
and older)?
Patient Health Questionnaire (PHQ-9)
Beck Depression Inventory (BDI or BDI-II)
Center for Epidemiologic Studies Depression Scale (CES-D)
Duke Anxiety-Depression Scale (DADS)
Geriatric Depression Scale (GDS)
Cornell Scale Screening
PRIME MD-PHQ-2
Other (please specify)
39. The CSI partners with the Montana Department of Public Health and Human Services (DPHHS) in
regard to collecting and analyzing quality metric data from PCMHs. Are you interested in receiving
information from the DPHHS about potential opportunities to support quality improvement initiatives in your
office (e.g. technical assistance, funding opportunities for quality improvement and health information
technology)?
Yes
No
40. Please enter any questions or comments for CSI regarding the Montana PCMH Program here.
18
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DRAFT 2015 Comprehensive Application(new Clinics) (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 13 August 2020

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