The PCMHs are searching for ways to integrate tobacco screening and counseling into their workflows.
The increase in mental health concerns is overwhelming the PCMHs resources so they are looking to improve the structures and processes for knowing when and how to connect patients to the MCO SNU care teams and how to maintain communication with the SNU team to coordinate care and ensure engagement in mental health services and supports.

Agenda:

8:30 a.m. to 8:45 a.m. – Welcome & Overview – Suzanne Cohen, MPH, Senior Director of Population Health, The Health Federation of Philadelphia

8:45 a.m. to 9:45 a.m. – Presentation: Tobacco Cessation Counseling Services – Regional Primary Contractors: Philadelphia Department of Public Health, Health Promotion Council of Southeastern PA, Inc.

The regional primary contractors:
·    Present a workflow describing the certification/registry process and the billing process
·    Mention any implications or differences for FQHCs
·    Provide an example of a primary care workflow, showing how tobacco screening and counseling is built into standard work (noting the similarities with depression screening and follow-up and SBIRT workflows)
·    Show a map of the certified providers in the region for referrals 

9:45 a.m. to 10:00 a.m. – Break 

10:00 a.m. to 10:45 a.m. – Panel: Examples of How PCMHs, MCO Special Needs Units (SNUs), and the Behavioral and Physical Health Integrated Care Plan (ICP) Program Collaborate to Improve Whole Person Health – Panel of PCMHs, SNUs, and ICP coordinators with successful examples of collaboration (which would be identified via the “PCMH and MCO SNU/ICP Collaboration Survey”)

10:45 a.m. to 11:00 a.m. – Transition to Breakouts

11:00 a.m. to 12:00 p.m. – Breakouts: How to Refer Patients to Special Needs Units (SNUs) and Coordinate Whole Person Care with Integrated Care Plans (ICPs) to Improve Outcomes – Facilitated by PRHI and Health Federation of Philadelphia Facilitators

Pre-work prior to the session: each MCO SNU/ICP Team will be asked to bring information to the session about their current processes in response to the following questions:
·    How does the MCO send the ICP Plan to PCMHs, and who receives it at the PCMH?
·    If this process involves obtaining consents at the MCO-level to share information for care coordination purposes, which consent forms are used and for what purposes?

Pre-work prior to the session: each PCMH will be asked to bring information to the session about their current processes in response to the following questions:
·    When the PCMH receives the ICP Plan, what actions and roles does this trigger at the PCMH-level to help patients follow-up on referrals to behavioral health treatment and community services?
·    How and when do PCMHs call the SNU hotlines for their patients. What has been the experience of PCMHs when they make this referral and how have the SNUs helped patients?

During the breakout: each PCMH and MCO is asked to report out on these questions, describing their current process/experience, including what is working well and what is not working well. The PRHI/HFP facilitators capture their processes (including the differences, successes, and challenges) on a process map using butcher paper or an electronic process mapping tool).

12:00 p.m. to 1:00 p.m. – Lunch & Networking 

1:00 p.m. to 1:45 p.m. – Presentation: Why and How to Establish Roles and Competencies within Primary Care Settings to Follow-up and Care for Mental Health – The PCMH with the best Depression Screening and Follow-up Workflow from the Spring Regional Sessions would be invited to present a deeper dive, explaining why and how they implemented and standardized these roles and processes 

1:45 p.m. to 2:00 p.m. – Transition to Breakout

2:00 p.m. to 3:00 p.m. – Breakouts: How to Integrate Mental Healthcare in Primary Care Offices

Pre-work prior to the session: each PCMH will be asked to bring their current Depression Screening and Follow-up Workflow, building on their workflows that they presented during the Spring Regional sessions. For any PCMHs without a Depression Screening and Follow-up workflow, they will be asked to describe their plans for implementing depression screening and follow-up services and any remaining questions they have to inform their plans and protocols.  

Pre-work prior to the session: each PCMH will be asked to bring information to the session about their current processes in response to the following questions, supplementing the information in their Depression Screening and Follow-up Workflows. 
·    How does your PCMH introduce and describe the depression screen to patients either verbally, on the electronic screening form, or on the paper screening form?
·    What key messages and patient education materials do your providers use when reviewing positive depression screening results with patients?
·    What is your PCMH’s process and protocols for screening for and responding to suicide risk? Based on the regional sessions in the spring, what changes is your team considering?
·    If your PCMH team includes a behavioral health consultant or care manager, what is their standard work? 
·    If your PCMH teams includes a consulting psychiatrist, what is their standard work?
·    How does your PCMH team track the outcomes of the mental health treatment plan to inform adjustments to the care plan (e.g., contact frequency, treatment type such as psychotherapy and/or pharmacotherapy, medication changes, community services/supports, etc.). As a follow-up to the spring sessions, how is your team incorporating the Response and Remission measures into this process?

During the breakout: each PCMH is asked to report out on these questions, describing their process, including what is working well and what is not working well. The PRHI/HFP facilitators offer feedback based on best practices, facilitate peer-to-peer learning, and capture their processes (including the differences, successes, and challenges) on a flip chart.

3:00 p.m. to 3:15 p.m. – Transition to Main Room for Next Steps and Wrap Up

3:15 p.m. to 4:00 p.m. – Key Takeaways, Next Steps, and Wrap up

During the session:

• Each PCMH team reflects on the key takeaways and tactics they would like to take back to their team and then verbally reports out on these next steps. 
• Each team also completes the session evaluation and spends time completing the PCMH Depression Screening and Follow-up Survey for their processes as of July (due by the end of August). 
• Each PMCH will also have a copy of their most recent PCMH Depression Screening and Follow-up Survey at their team’s table for reference.