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The patient in Dr. Shelly Voet’s examining room was at risk for diabetes: She was obese. Her grandfather had diabetes. Her blood sugar and insulin levels were elevated.
“She was pre-diabetic,” Dr. Voet says. “And obesity is a hard topic to talk about.”
But Dr. Voet knew how to counsel this patient and her family. Her practice, Pediatric Associates in Crestview Hills, Ky., had developed plans for counseling overweight and obese patients as part of their process for earning recognition as an NCQA Patient Centered Medical Home (PCMH).
Now, all pediatricians who can attest that they have participated in quality improvement activities as part of earning NCQA PCMH recognition also can earn Maintenance of Certification (MOC) credit from the American Board of Pediatrics.
As part of earning NCQA PCMH status, Dr. Voet and her partners identified obesity screening and treatment as one of the areas in which their practice could improve. They incorporated evidence based guidelines for obesity management into their EMR templates, developed lists of community resources, and provided training for providers and staff on communication.
Dr. Voet explained to her patient and family about the risks she was facing, and the benefits of exercising and eating healthier. The mother took that advice to heart, signing the girl up for swim team and improving her diet.
“When she came back in for a checkup one year later, her BMI was lower, her blood sugar was normal, and her insulin levels were in the normal range,” Dr. Voet says. “We were able to make a real difference in her health.”
Other improvements that came out of the Pediatric Associates’ NCQA PCMH recognition process included earlier vision and hearing screening for preschoolers, and tobacco use screening for teens.
The idea behind NCQA PCMH is to give patients a personal general pediatrician who will monitor and coordinate care, even to outside subspecialists and other treatment facilities.
A number of PCMH recognition and accreditation programs exist. Dr. Voet and her partners chose the National Committee for Quality Assurance (NCQA) recognition. Quality improvement activities that are part of PCMH recognition by other programs also may qualify for MOC credit. If you participated in QI projets as part of a different PCMH certification process, you can apply for credit through the Small Group project application for ≤ 10 diplomates or through the Quality Improvement Project Application for >10 diplomates.
PCMH is a model of care for general practitioners treating children, adolescents or adults. The program aims to coordinate and improve the quality, effectiveness and efficiency of care. Joint PCMH principles were developed more than eight years ago by the American Academy of Pediatrics, American Academy of Family Medicine, American College of Physicians and American Osteopathic Association. The idea is to allow each patient to develop an ongoing relationship with a personal physician. That physician leads a team of individuals at the practice level who take responsibility for ongoing care of patients. They take a “whole-patient orientation,” which means arranging care for the patient by other qualified professionals, including subspecialists if and when necessary. The aim is to provide patient centered, coordinated care across all parts of the health care system.
Working toward NCQA PCMH recognition, pediatricians and/or practices document their policies and procedures, evaluate their practice, and choose areas in which they think they could improve. They do a baseline assessment of a specific area, develop a plan for improvement, and then measure the results. Activities address not only preventive care and chronic care, but also access to health care and community resources, and management of patient populations.
Dr. Voet said it took her practice about 18 months to earn the highest level of recognition from NCQA. Patients and their families were involved in the process. After families were surveyed about the practice, a family advisory committee was established to explore issues such as access and communication. For example, feedback from families lead to a complete change in the way appointments are scheduled, and spurred the practice to incorporate a new telephone system.
“We understand the problems much better from the family’s perspective,” she says.
So why is NCQA PCMH recognition effective in making quality improvements to a practice?
“It gives you a systematic way to review your practice policies and make improvements,” Voet says. “Quality improvement is important, and you can’t know how well you’re doing until you measure it.”
For example, the practice evaluated their success at vaccinating adolescents for the human papillomavirus (HPV) which may cause cervical cancer and genital warts. When they compared how many patients started the HPV vaccination’s three-dose series with how many actually completed the series within the recommended 6 month period, Dr. Voet’s practice discovered a gap.
“We did not have a reliable system for follow-up,” she says. “We weren’t reminding them about appointments, so they weren’t always coming back in to complete the three-dose series.”
Looking at the whole practice is time-consuming, but every part of the evaluation is useful, she says.
“So much goes into providing coordinated, evidence based, accessible, health care besides the 15 minutes a patient spends with a provider,” she said. “But it does require extra effort, so you have to make sure it’s meaningful.”
Being able to earn MOC credit for all the quality improvement work that goes into NCQA PCMH recognition is a huge benefit, she says.
One of her partners, Dr. Christopher Cunha, says the process leading to NCQA PCMH recognition is “transformational.”
“For example, we’ve been struggling with referrals, especially for mental health issues,” he said. “It’s almost impossible to get a consult letter back. If your patient has come in for anxiety, and there’s no letter in their chart that they’ve seen anyone else about it, you can’t give them the best, coordinated treatment. These are the kinds of challenges we need to overcome.”
Dr. Cunha, chair-elect of the ABP Board of Directors, also is chair of the ABP’s MOC committee. He had helped lead the effort to get MOC credit for NCQA PCMH recognition.
“We’re all being asked to improve, and we all want to improve,” he said. “Those efforts should be rewarded. The more you can get out of it, the more motivation there will be to continue improving. Everybody wins – especially the children.”