Population Health Learning Activities

 


Diversity and Health Literacy

IP Student Learning Activity related to Factors 1, 2, 4 within Element C, Standard 2:

An IP student team develops a report assessing language composition and diversity (including racial, ethnic, and at least one other meaningful characteristic of diversity), of the practice’s patient population. NCQA defines diversity as “a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. These characteristics of a group may include, but are not limited to, race, ethnicity, gender identity, sexual orientation and disability.”

The report should include:

  • A review and assessment of the practice’s materials in languages other than English
  • Recommendations for possible further assessments or strategies to address the practice’s materials in languages other than English
  • A brief literature review of disparities faced by at least one underserved population of the practice
  • Recommendations to help reduce such disparities

This activity should include the students, preferably as a team, interacting with (e.g., interviewing) sufficient numbers of patients from the practice who meet the NCQA definition of “diverse” in order to inform their assessment and/or to obtain feedback on their preliminary assessment and recommendations. (See details Standard 2, Element C, NCQA PCMH Standards.)

The student team will utilize health literacy tools such as AHRQ’s Health Literacy Universal Precautions Toolkit. Relevant tools may include: Tool 9 “Address Language Differences,” Tool 10 “Consider Culture, Customs, and Beliefs” and Tool 11 “Access, Select, and Create.” 

A draft of the report will be reviewed by the practice and student teams in a group meeting in order to discuss, make revisions and agree on next steps. This meeting should include at least one other health profession from the practice team than is represented in the student team, and if possible, include practice team members whose work is focused on the patient populations concentrated on in the student report.

Learning Objectives (letters/numbers after each objective reference the specific IPEC competency):

  • Recognize the impact of language needs and diversity characteristics on health care and on health.  
  • Develop and demonstrate at least two health literacy skills such as are found in AHRQ’s Health Literacy Universal Precautions Toolkit.
  • Assess the health disparities for group of the population served by the practice;
  • Assess patient education materials.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Embrace the cultural diversity and individual differences that characterize patients, populations, and the health care team. (IPEC VE3)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible (IPEC CC2)
  • Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT3)

Standard 2, Element C: Culturally and Linguistically Appropriate Services

The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by:

  • Factor 1: Assessing the diversity of its population
  • Factor 2: Assessing the language needs of its population
  • Factor 4: Providing printed materials in the language of its population

Note: According to NCQA: “Diversity is a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. These characteristics of a group may include, but are not limited to, race, ethnicity, gender identity, sexual orientation and disability.”


Population Health Profile

IP Student Learning Activity related to Standard 3, Elements A and B:

An IP student team develops a health profile of the practice’s patient population or a profile of a subset of the population based on such factors as a health risk, a demographic category, or a diagnosis.

Using as many of the factors in Elements A and B as is possible and is relevant, the team compiles and analyzes the data, formats into a population profile, includes some comparisons with existing community health profiles, and identifies some challenges faced by the patient population.. Data from Elements A and B are also used in a number of other student learning activities, so this health profile learning activity can also be an introductory and foundational one for students who are new to the practice.

Student teams should become familiar with the community health assessment and population health improvement processes, including the most commonly used metrics. Resources include:

Learning Objectives:

  • Using health informatics, develop a population health profile that can be effectively used to manage the health of the practices’ patient population.
  • Describe a community health assessment process and some of the most commonly used metrics and data sources.
  • Compare and contrast the patient population of the practice compared with that of the community, county, region, and/or state.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Use available evidence to inform effective teamwork and team-based practices. (IPEC T10)

Standard 3, Element A: Patient Information

The practice uses an electronic system to record patient information, including capturing information for factors 1-13 as structured (searchable) data for more than 80% of its patients:

  • Factor 1: Data of birth+
  • Factor 2: Sex+
  • Factor 3: Race+
  • Factor 4: Ethnicity+
  • Factor 5: Preferred language+
  • Factor 6: Telephone numbers
  • Factor 7: Email addresses
  • Factor 8: Occupation (NA for pediatrics)
  • Factor 9: Dates of previous clinical visits
  • Factor 10: Legal guardian/health care proxy
  • Factor 11: Primary caregiver
  • Factor 12: Presence of advance directives (NA for pediatrics)
  • Factor 13: Health insurance information

+ Stage 2 Core Meaningful Use Requirement

Standard 3, Element B: Clinical Data

The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1 – 5 and 8 – 11 as structured (searchable) data.

  • Factor 1: An up-to-date problem list with current and active diagnoses for more than 80% of patients. +++
  • Factor 2: Allergies, including medication allergies and adverse reactions, for more than 80% of patients. +++
  • Factor 3: Blood pressure, with the data of update, for more than 80% of patients 3 years and older. +
  • Factor 4: Height/length for more than 80% of patients. +
  • Factor 5: Weight for more than 80% of patients. +
  • Factor 6: System calculates and displays BMI. +
  • Factor 7: System plots and displays growth charts (length/height, weight, and head circumference) and BMI percentile (0-20 years) (NA for adult practices) +
  • Factor 8: Status of tobacco use for patients 13 years and older for more than 80% of patients. +
  • Factor 9: List of prescription medications with date of updates for more than 80% of patients. +
  • Factor 10:  More than 20% of patients have family history recorded as structured data. ++
  • Factor 11:  At least one electronic progress note created, edited, and signed by an eligible professional for more than 30% of patients with at least one office visit. ++

+ Stage 2 Core Meaningful Use Requirement

++Stage 2 Menu Meaningful Use Requirement

+++CMS Meaningful Use Requirement


Population Health Management Review

IP Student Learning Activity related to Element D:

An IP team of students reviews the current strategies used by the practice to comply with Element D (population health management strategies), identifies areas of effectiveness and possible gaps, and makes recommendations for improvement. In doing so, the team will incorporate data from Standard 3 Elements A and B (Population Health Profile) to determine if the outreach required in Element D matches with the needs identified in the Profile. Students will then write a draft of their review, meet with, and report their findings and recommendations to the appropriate members of the practice team, who will then determine appropriate course of action.

Student teams should become familiar with the community health assessment and population health improvement processes, including the most commonly used metrics. Resources include:

Learning Objectives:

  • Develop a report reviewing the practice’s compliance Standard 3 Element D and present findings and recommendations to a practice team.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care.  (IPEC TT7)

Standard 3, Element D: Use Data for Population Health Management (a MUST PASS element):

At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines, including:

  • Factor 1: At least two different preventive care services +
  • Factor 2: At least two different immunizations +
  • Factor 3: At least three different chronic or acute care services +
  • Factor 4: Patients not recently seen by the practice
  • Factor 5: Medication monitoring or alert

+ Stage 2 Core Meaningful Use Requirement


Health Communication and Shared Decision-Making

IP Student Learning Activity related to Standard 3 Element E and Standard 4 Element E:

An IP student team identifies a common health issue in the practice, determined by the needs identified in the Population Health Profile (i.e., data in Standard 3, Elements A and B) that also fit into one of the factors listed in Standard 3 Element E, (e.g., opioid addition, diabetes, obesity, tobacco, depression, etc.).

The team reviews the practice’s clinical decision support materials (e.g. point-of-care reminders), other educational materials, self-management tools, decision-making aids, practice or community education programs (including group classes and peer support), and lists of community resources available from the practice for that health issue.

The team then reviews available resources that are best practices and evidence-based, and chooses some for the practice to consider adopting. During this process:

  • A review of the data generated in Standard 3 Elements A, B, and C associated with the health issue should be informative to this process. For instance, patient information, clinical data, health assessment data and qualitative information for and from the patients with the specific health issue may help inform the team of the challenges faced by these patients, and therefore help determine what resources are needed.
  • If patient or family advocates are available, students should meet with them to review and obtain feedback on the current practice resources and to provide input on plans.
  • Student teams should also obtain feedback and input from practice staff who have relevant expertise.
  • This process should include the students meeting with community partners such as public health, health system, and other non-profit organizations to determine if other community resources are appropriate to add.
  • Student teams may also use the practice’s current materials or ones being considered with patients in order to learn about their efficacy. Some practice with shared decision-making strategies is optimal.
  • The utility of the current and proposed materials should be measured based on national guidance for health literacy, design, and shared decision-making.

Students will then write a draft of their findings and recommendations, meet with and report to the appropriate members of the practice team, who will then determine adjustments to the practice’s resources.

Suggested Resources:

Learning Objectives:

  • Develop a review of, assessment of, and recommendations for decision-support tools, self-care and decision-making aids for a particular health issue to assist the practice in meeting its patients’ needs.
  • Demonstrate shared decision-making skills. 
  • Demonstrate health literacy skills when evaluating written materials and when communicating with patients and colleagues.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members. (IPEC 6, CIHC 2010)
  • Manage ethical dilemmas specific to interprofessional patient/population centered care situations. (IPEC VE8)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Develop consensus on the ethical principles to guide all aspects of patient care and team work. (IPEC TT2)
  • Engage other health professional – appropriate to the specific care situation – in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)

Standard 3, Element E: Implement Evidence-Based Decision Support

The practice implements clinical decision support (e.g., point-of-care reminders) following evidence-based guidelines for:

  • Factor 1: A mental health or substance use disorder (CRITICAL FACTOR)+
  • Factor 2: A chronic medical condition +
  • Factor 3: An acute condition +
  • Factor 4: A condition related to unhealthy behaviors +
  • Factor 5: Well child or adult care +
  • Factor 6: Overuse/appropriateness issues +

Standard 4, Element E: Support Self-Care and Shared Decision Making

The practice has, and demonstrates use of, materials to support patients and families/caregivers in self-management and shared decision making. The practice:

  • Factor 1: Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients.
  • Factor 2: Provides educational materials and resources to patients.
  • Factor 3: Provides self-management tools to record self-care results.
  • Factor 4: Adopts shared decision-making aids.
  • Factor 5: Offers or refers patients to structured health education programs, such as group classes and peer support.
  • Factor 6: Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates.
  • Factor 7: Assesses usefulness of identified community resources.

Quality Improvement (QI)

IP Student Learning Activity related to QI on:

  • Clinical Quality Measures
    • Standard 6, Element A, Element D Factors 1, 2; Element E Factors 1, 2
  • Resource Use and Care Coordination
    • Standard 6, Element B, Element D Factors 3, 4; Element E Factors 1, 3
  • Patient/Family Experience
    • Standard 6, Element C, Element D Factors 5, 6; Element E Factors 1, 4
  • Health Disparities in Care for Vulnerable Populations
    • Standard 6, Element D Factor 7

Also relates to Standard 2, Element D Factors 9 and 10 (care team staff and patients are involved with QI)

An IP student team, working with the practice’s QI team, will compile data to meet the requirements for one of the following:

  • Clinical Quality Measures: Standard 6, Element A (e.g., data on immunizations, other preventive care measures, chronic or acute care clinical measures, and/or data stratified for vulnerable populations), as well as relevant factors in Elements D (set goals and act to improve the measures from Element A) and Element E (use QI strategies to measure the effectiveness of actions taken to improve the metrics chosen from Element A);
  • Resource Use and Care Coordination: Standard 6, Element B (measures on care coordination such as when patients are in transition between inpatient and outpatient settings, and utilization measures affecting health care costs such as avoidable ER or hospital admissions), as well as relevant factors in Elements D (set goals and act to improve the measures from Element B) and Element E (use QI strategies to measure the effectiveness of the actions taken to improve the metrics chosen from Element B);
  • Patient/Family Experience: Standard 6, Element C (feedback from patients and/or families from a practice survey, the CAHPS survey, feedback from vulnerable populations, or qualitative feedback), as well as relevant factors in Elements D (set goals and act to improve the measures from Element C) and Element E (use QI strategies to measure the effectiveness of the actions taken to improve the metrics chosen from Element C);or
  • Health Disparities in Care for Vulnerable Populations: Standard 6, Element D Factor (set goals and address at least one identified disparity in care/service for identified vulnerable populations).

The team will analyze the metrics chosen longitudinally (over a time period designated by the practice and appropriate for the measure), note any current strategies underway by the practice to improve the measures and their effectiveness, and provide evidence-based recommendations for further improvements. A review of the data generated in Standard 3 Elements A, B, and C (patient information, clinical data, comprehensive health assessments) associated with the chosen measure may be informative to this process. This QI process should involve engaging with, in a meaningful way, to learn from, obtain input and feedback from, members of the practice team who work to improve the chosen metrics and patients and their families/caregivers who are affected by them. Students are strongly encouraged to use the resources listed in this activity. The student team’s recommendations will include proposed goals and strategies to improve the measures. This analysis and recommendations will be presented to the appropriate members of the practice team, who will then determine next steps.

For the purpose of addressing the health disparities topic, vulnerable populations are defined by the PCMH standards as “those who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability,” and include people with multiple comorbid conditions or who are at high risk for frequent hospitalization or ER visits. A review of the data generated in Standard 3 Elements A, B, and C associated with the chosen measure and/or vulnerable patient population may be informative to this process, for instance, to identify vulnerable populations to focus on and to determine other barriers they may face.

If time allows, the student team will participate in implementing and studying the QI strategies to complete one cycle of Plan-Do-Study-Act.

This activity should include the student IP team understanding the basics of QI through the following activities, as is appropriate:

  • Complete the St. Louis University TeamSTEPPS Mutual Support Module as a team since QI work can involve complex communications on challenging topics:
  • Complete either the:
    • HRSA QI Methodology modules
    • Institute for Healthcare Improvement (IHI) Open School QI Practicum
    • Another training module for a QI methodology used by the practice site
  • Work with others to address the chosen topic, following QI principles and practices found in either the HRSA QI modules, the IHI QI Open School, or another QI methodology used by the practice site.

Resources:

Learning Objectives:

  • Develop a review of, assessment of, and plan for quality measures.
  • Demonstrate the basic principles and skills of healthcare QI as is defined by the Institute of Medicine (IOM): QI consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The IOM defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.
  • Articulate some common measures, challenges, impacts on health and healthcare, and strategies related to the chosen QI topic, such as on the chosen quality measures and their uses; resource use and/or care coordination; patient/family experiences; and health disparities.
  • Define mutual support as per TeamSTEPPS;
  • Demonstrate common types of feedback, advocacy, assertion, and conflict resolution TeamSTEPPS tools.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members (IPEC VE6).
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Forge interdependent relationships with other professions to improve care and advance learning. (IPEC RR7)
  • Engage in continuous professional and interprofessional development to enhance team performance. (IPEC RR8)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. (IPEC CC2)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. (IPEC CC6)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Reflect on individual and team performance for individual, as well as team, performance improvement. (IPEC TT8)
  • Lead a quality improvement activity to increase the effectiveness of interprofessional teamwork and team-based care. (IPEC TT9)
  • Use available evidence to inform effective teamwork and team-based practices. (IPEC TT10)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)

Standard 2, Element D: The Practice Team

  • Factor 9: Involve care team staff in the practice performance evaluation and quality improvement activities.
  • Factor 10: Involve patients/families/caregivers in quality improvement activities or on the practice’s advisory council.

Standard 6, Element A: Measure Clinical Quality Performance

At least annually, the practice measures or receives data on:

  • Factor 1.  At least 2 immunization measures.
  • Factor 2.  At least 2 other preventive care measures.  
  • Factor 3.  At least 3 chronic or acute care clinical measures.
  • Factor 4.  Performance data stratified for vulnerable populations (to assess disparities in care).

Standard 6, Element B: Measure Resource Use and Care Coordination

  • At least annually, the practice measure or receives quantitative data on:
  • Factor 1. At least 2 measures related to care coordination.
  • Factor 2. At least 2 utilization measures affecting health care costs.

Standard 6, Element C: Measure Patient/Family Experience

At least annually, the practice obtains feedback from patients/families on their experiences with the practice and their care.

  • Factor 1: The practice conducts a survey to evaluate patient/family experiences on at least 3 of the following categories: access; communication; coordination; and whole person care/self-management support.
  • Factor 2: The practice uses the PCMH version of the CAHPS Clinician and Group Survey Tool.
  • Factor 3: The practice obtains feedback on experiences of vulnerable patient groups.
  • Factor 4: The practice obtains feedback from patients/families through qualitative means.

Standard 6, Element D: Implement Continuous Quality Improvement (MUST-PASS)

The practice uses an ongoing QI process to:

Factor 1: Set goals and analyze at least 3 clinical quality measures from Element A.

Factor 2: Act to improve at least 3 clinical measures from Element A.

Factor 3: Set goals and analyze at least one measure from Element B.
Factor 4: Act to improve at least one measure from Element B.

Factor 5: Set goals and analyze at least one patient experience measure from Element C.

Factor 6: Act to improve at least one patient experience measure from Element C.

Factor 7: Set goals and address at least one identified disparity in care/service for identified vulnerable populations.

Standard 6, Element E: Demonstrate Continuous Quality Improvement

The practice demonstrates continuous quality improvement by:

  • Factor 1: Measuring the effectiveness of the actions it takes to improve the measures selected in Element D.
  • Factor 2: Achieving improved performance on at least 2 clinical quality measures.
  • Factor 3: Achieving improved performance on one utilization or care coordination measure.
  • Factor 4: Achieving improved performance on at least one patient experience measure.

Public Health Uses For Electronic Health Records

IP Student Learning Activity related to Element G:

An IP student team will: review a subset or all of the data reflected in Factors 3 – 10 for an appropriate time period (1 – 2 years); assess for any challenges, including quality issues or gaps with the reporting; and familiarize themselves with the agencies to whom the data are reported, including how the data are used. A case study of an outbreak, possible cancer cluster, a vaccine-preventable outbreak, or a public health problem solved with the help of the health information exchange should be considered. IP student teams should consider interviewing the relevant agency the information is submitted to. This process should involve engaging with, in a meaningful way, to learn from, obtain input and feedback from, members of the practice team whose work intersects the data studies, the agency staff to whom the data are submitted, and appropriate patients and their families. Findings, including any recommendations, will be presented to the appropriate members of the practice team for further action.

Resources:

Learning Objectives:

  • Develop a review of, assessment of, and plan for public health uses for EHRs.
  • Explain the goals and objectives of Meaningful Use and how practices participate.
  • Articulate a case study of how Meaningful Use has improved health. (optional)
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members. (IPEC 6, CIHC 2010)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. (IPEC CC2)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. (IPEC CC6)
  • Develop consensus on the ethical principles to guide all aspects of patient care and team work. (IPEC TT2)
  • Engage other health professional – appropriate to the specific care situation – in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)

Standard 6, Element G: Use Certified EHR Technology

The practice uses a certified EHR system.

  • Factor 3: The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically. ++
  • Factor 4: The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
  • Factor 5: The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically. ++
  • Factor 6: The practice reports clinical quality measures to Medicare or Medicaid agency, as required for Meaningful Use. +++
  • Factor 7: The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically. +
  • Factor 8: The practice has access to a health information exchange.
  • Factor 9: The practice has bidirectional exchange with a health information exchange.
  • Factor 10: The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10 percent of patients/families/caregivers about needed preventive/follow-up care.+

+Stage 2 Core Meaningful Use Requirement

++Stage 2 Menu Meaningful Use Requirement

+++Meaningful Use Requirement 


Review of Any Standard

IP Student Learning Activity related to Any Standard:

An IP student team can review any standard or sets of elements within a standard, review how the practice implements them, develop recommendations for more fully implementing them, and present to the appropriate members of the practice team. This process can involve: interviewing practice team members to obtain their input; conducting a literature review; researching strategies suggested by NCQA, IHI, AHRQ, and other organizations; and discussing issues with patients.

Resources:

Learning Objectives:

  • Develop a review of, assessment of, and plan for the implementation of an NCQA standard or element for achieving PCMH recognition.
  • Articulate how PCMH standards and strategies fit into the overall federal health quality initiatives.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members. (IPEC 6, CIHC 2010)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. (IPEC CC2)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. (IPEC CC6)
  • Develop consensus on the ethical principles to guide all aspects of patient care and team work. (IPEC TT2)
  • Engage other health professional — appropriate to the specific care situation — in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)