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Monica J. Lindeen Commissioner of Securities & Insurance (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Monica J. Lindeen
Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Ave. • Helena, MT 59601
Phone: 406.444.2040 or 800.332.6148
Fax: 406.444.3497 • Web: www.csi.mt.gov
Montana PCMH Program Comprehensive Application
The Montana Patient-Centered Medical Home Law requires qualified and provisionally qualified
medical homes to submit a report to Montana Office of the Commissioner of Securities and
Insurance (CSI) in March 2015. CSI needs to collect data from practices now, to set a baseline for
data in advance of the March 2015 report.
CSI wants to help practices meet their PCMH goals. This application will enable us to help practices
identify their PCMH focus, strengths, and weaknesses. Practices 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.
If your practice is not already provisionally qualified or qualified in the Montana PCMH Program
and would like to be, 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.
Name of Practice: Name of Parent Site (if applicable):
First Name: Last Name:
Title: E-mail:
Phone Number: Practice site street name:
Zip Code: City: State:
General Practice Information
1. Is the practice a Medicaid Passport to Health Provider?
Yes
No
2. Is the practice participating in a CMS Demonstration Project for Medicare?
Yes
No
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
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
5. Primary care specialties (check all that apply)
Family medicine
General practice
Internal medicine
Obstetrics/Gynecology
Pediatrics
Other
6. How many years has the practice been in operation?
0 - 5
6 - 10
11 - 15
16 - 20
more than 20
7. How many unique patients were seen by primary care providers in your practice between
January and December of 2013? (estimate if necessary)
Practice Site Team Members
8. Does your practice integrate the following staff into your care model? Please indicate how many
hours per week your practice utilizes the following roles. (For example, 80 hours per week would
equal 2 full time Care Coordinators.)
a. Primary Care Physician b. Primary Care Physician Assistant
c. Primary Care Nurse Practitioner
d. Integrated Primary Care Related
Behavioral Health Services
e. Care Coordinators/Managers or
Patient Navigator f. Certified Diabetes Educator
g. Administrative Staff h. Medical Assistant
i. Nurse (RN, LPN, etc,.) j. Dietitian
k. Clinical Pharmacist l. Community Health Worker
n. Certified Asthma Educator o. Certified Lactation Consultant
p. Other q. Other
Payment Information
9. 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?
Yes
No
9b. Which insurer(s) are you receiving the payments from?
Blue Cross Blue Shield of Montana
PacificSource Health Plans
Montana Health Co-op
Humana
Assurant/Time
New West Health Plans
Allegiance
Medicaid
Other
9c. Are any of these payer programs labeled "Medical Home" or "Patient-Centered Medical
Home?"
Yes
No
10. What do you feel is the most important work you do for PCMH that you should be
reimbursed for in a reformed payment model?
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
11. Rate below, your organizational leadership's level of commitment to PCMH development. (1
being the lowest level of commitment and 5 being the highest)
1 2 3 4 5
Dedicated resources
Protected time
Training programs
Commitment
statements
Current PCMH Status: Transformation, Progress, and Measurement
12. Please select below, your current PCMH practice transformation focus points (check all that
apply):
Preventive health care services
Chronic disease management
Care management services
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
13. In regard to PCMH transformation in your practice, what technical assistance or other
support would be most useful at this time?
14. Does your practice have a formal quality improvement strategy or use formal quality
improvement methodologies?
Yes
No
14b. Are you using one of the following methods/strategies?
Lean management principles
Six Sigma
Plan-Do-Study-Act (PDSA) cycles
Institute for Health Improvement's (IHI) model for improvement
Consulting firm such as TransforMed
Other
15. Does your practice have a staff person who has dedicated quality improvement
responsibilities?
Yes
No
If yes, please provide the following
information on the staff person:
Name: Title:
E-mail: Number of hours spent on QI per week:
16. Does your practice involve patients in the PCMH transformation process?
Yes
No
16b. Does your practice utilize the following?
Patient advisory council
Patient surveys
Other
17. Has your practice enhanced access to care/improved health for patients?
Yes
No
17b. Please select the ways in which your practice has enhanced access to care and/or patient
self-management. Check all that apply.
Electronic communication
Expanded office hours
Same day appointments
Clinical advice system available when office is not open
Patient portal
Other
18. What chronic disease measures are you currently tracking for your PCMH recognition?
Blood pressure control in adults 18-85 with diagnosed hypertension.
Poor A1C control in adults with diagnosed diabetes.
Other
19. What preventive measures are you currently tracking for your PCMH recognition?
Identification of tobacco use and counseling for cessation in adults 18 years and older.
Age-appropriate immunization for children who were aged 3 years during the reporting
period.
Other
20. Has your practice incorporated care coordination and/or disease management into care
delivery yet?
Yes
No
20b. What elements of care coordination/disease management are parts of your care delivery?
Collaborate and assist patients in personal goals for their improved health (self-
management 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 contacts 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
21. 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.
22. 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 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
23. What version of your EHR system is your practice currently using?
24. When did your practice 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
Other
25. For each EHR system function listed below, please check whether it is available in your
practice's EHR system AND whether if it has been used by your staff.
Chronic disease registry
Available
Unavailable
Used
Unused
Unknown
Clinical Decision Support System
Available
Unavailable
Used
Unused
Unknown
Patient Portal
Available
Unavailable
Used
Unused
Unknown
Ability to document patient
referral
Available
Unavailable
Used
Unused
Unknown
Ability to document patient reminder
or follow-up
Available
Unavailable
Used
Unused
Unknown
Ability to pull custom
reports
Available
Unavailable
Used
Unused
Unknown
Ability to provide electronic data exchange (HL7)
Available
Unavailable
Used
Unused
Unknown
26. Do you have an EHR technical lead or professional IT support person on staff?
Yes
No
27. Does your practice use a standardized depression screening tool (such as PHQ-2, PHQ-9,
etc.)?
Yes
No
28. If yes, please describe.
28. Is your practice able to electronically report on the percentage of patients over age 12 who
are screened for depression using this standardized tool?
Yes
No
29. For those who screen positive for depression, is your practice able to report on the
percentage of patients who have a follow-up plan documented on the date of the positive screen?
Yes
No
30. Questions or comments for CSI?
Resources to Support Quality Improvement
1. The CSI partners with the Montana Department of Public Health and Human Services
(DPHHS) in regard to collecting and analyzing quality measures (questions 18 & 19). 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)?
Yes
No
2. If yes, please specify which of these are of interest to your practice.
NQF 0018 -- The Cardiovascular Health Program can provide assistance on collecting
complete and quality data for NQF 0018 and support quality improvement initiatives for
hypertension.
NQF 0059 -- The Montana Diabetes Program can provide assistance on collecting
complete and quality data for NQF 0059 and support quality improvement initiatives for
A1c control.
NQF 0027 -- The Montana Tobacco Quit Line provides free cessation services to all
Montanans. A fax referral system is in place for providers. The Montana Tobacco Use
Prevention Program can provide education and assistance for both resources.
NQF 0038 -- The Montana Immunization Program can provide assistance on collecting
complete and quality immunization data for quality assurance purposes.
From 2014 to 2018, the Cardiovascular Health Program and Diabetes Program will offer
two annual funding opportunities involving: 1) collection of NQF 0018 and 0059, 2)
blood pressure and diabetes control quality improvement, 3) team-based care, 4)
promoting self-measured blood pressure monitoring, and/or 5) addressing undiagnosed
hypertension.
Other
If yes, please provide the contact information below:
Name: E-mail
Phone number:
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Monica J. Lindeen Commissioner of Securities & Insurance (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 13 August 2020

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