PCMH Learning Network Northeastern PA 8.13.24

August 13, 2024

SDOH workflows and patient/family advisories are an integral part of the work performed by PCMHs. The session will have peer-to-peer learning and presentations on how to involve patient/family advisors to inform practices on SDOH screening and PCMH processes and team roles for SDOH screening, feedback, documentation, and connection to services. Attendees will also participate in facilitated simulations of SDOH messaging and interactive Knowledge Cafes on connecting patents to employment, transportation, health plan, housing, and transportation services.

Agenda

8:00 a.m. to 8:30 a.m. – Registration and Continental Breakfast

8:30 a.m. to 8:40 a.m. – Welcome and Introduction – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

8:40 a.m. to 9:40 a.m. – Small Group Discussion on Report Out Questions

  • SDOH Screening and Follow-up Discussion: What is your current workflow, team roles (including Community Health Workers), and tools for SDOH screening, warm handoffs, and follow-up? How do you train staff to perform these roles? What improvements (changes) have you made over time and why? What is your process for collecting and reporting SDOH screening and follow-up data?
  •  Family/Patient Input Discussion: What has worked well to identify and engage patients and family members as advisors? What type of feedback on SDOH screening and follow-up have you received from patients and/or formal patient/family advisors? If you haven’t received any feedback, what are the patient/family councils, board members, or advisors at your organization whom you could connect with to receive feedback?          
  •  SDOH Partnership Discussion: Which community agencies has your PCMH developed a working relationship to improve SDOH referrals and to close the loop on those referrals? If your PCMH has CHWs on your team, what is their role in developing these community relationships and following-up on referrals? Which tools, such as PA Navigate (Find Help), are supporting this communication process?

9:40 a.m. to 9:50 a.m. – Break

9:50 a.m. to 10:55 a.m. – Presentation: SDOH Screening and Follow-up based on Feedback from Patient/Family Advisors – Kathleen Barry, Deputy Chief Operating Officer; Kathleen Doyle, Director of Patient Centered Services; Paul Haugland, Manager of Electronic Health Records (EHR) and Health Informatics; Kari Machelli, RN, Associate Vice President of Integrated Primary Health Services; and Kara McDonough Seitzinger, Executive Director of Public Affairs/Advisor Liaison to President & CEO; The Wright Center

10:55 a.m. to 11:10 a.m. – Action Planning Exercise: Involving Patient/Family Advisors to Continuously Improve SODH Screening and Follow-up

11:10 a.m. to 11:20 am – Break

11:20 a.m. to 12:00 p.m. – Part 1 Workshop: Patient-Centered Language for SDOH Screening – Facilitated by Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence

12:00 p.m. to 1:00 p.m. – Lunch

1:00 p.m. to 1:45 p.m. – Part 2 Workshop: Practing Patient-Centered Language for SDOH Screening and Warm Handoffs – Facilitated by Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence

1:50 p.m. to 2:10 p.m. – Break

2:10 p.m. to 3:15 p.m. – Knowledge Cafes: Connecting with SDOH Community Resources

            WIC

  • Erica Bozentka, WIC Director, Maternal and Family Health Services
  • Laurie Waskovich, Nutrition Services Administrator, Maternal and Family Health Services 
  • Nurse-Family Partnership and Maternal Medical Home Programs
  • Cindy Kennedy, Director of Community Impact & Partnerships, Maternal and Family Health Services
  • Ann M. Jones, BSN, RN, Director of Nurse-Family Partnership, Maternal and Family Health Services 
  • MCO Special Needs Units
  • Hosted by Geisinger Health Plan and AmeriHealth
  • PA Navigate (Find Help)
  • Joshua A. Muchler, Business Architect, Keystone Health Information Exchange 
  • Transportation 
  • Carl Albright, Director, Wayne County Transportation System 

3:15 p.m. to 3:50 p.m. – Huddles and Report Outs – Facilitated by Jen Condel, Robert Ferguson, and Lisa Boyd

3:50 p.m. to 4:00 p.m. – Wrap-Up

 

Target Audience

Nurse

Physician

Social Worker

Learning Objectives

  • Discuss how to work with patient/family advisories to develop, use, and continuously improve patient-centered language for SDOH screening and feedback
  • Describe PCMH processes and team roles for SDOH screening, feedback, documentation, and connection to services
  • Describe resources for connecting patients to employment, transportation, health plan, housing, and transportation services
Course summary
Available credit: 
  • 6.00 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 6.00 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 6.00 ASWB
  • 6.00 Attendance
Course opens: 
08/13/2024
Course expires: 
11/30/2024
Event starts: 
08/13/2024 - 8:30am EDT
Event ends: 
08/13/2024 - 4:00pm EDT

SDOH workflows and patient/family advisories are an integral part of the work performed by PCMHs. The session will have peer-to-peer learning and presentations on how to involve patient/family advisors to inform practices on SDOH screening and PCMH processes and team roles for SDOH screening, feedback, documentation, and connection to services. Attendees will also participate in facilitated simulations of SDOH messaging and interactive Knowledge Cafes on connecting patents to employment, transportation, health plan, housing, and transportation services.

Agenda

8:00 a.m. to 8:30 a.m. – Registration and Continental Breakfast

8:30 a.m. to 8:40 a.m. – Welcome and Introduction – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

8:40 a.m. to 9:40 a.m. – Small Group Discussion on Report Out Questions

  • SDOH Screening and Follow-up Discussion: What is your current workflow, team roles (including Community Health Workers), and tools for SDOH screening, warm handoffs, and follow-up? How do you train staff to perform these roles? What improvements (changes) have you made over time and why? What is your process for collecting and reporting SDOH screening and follow-up data?
  •  Family/Patient Input Discussion: What has worked well to identify and engage patients and family members as advisors? What type of feedback on SDOH screening and follow-up have you received from patients and/or formal patient/family advisors? If you haven’t received any feedback, what are the patient/family councils, board members, or advisors at your organization whom you could connect with to receive feedback?          
  •  SDOH Partnership Discussion: Which community agencies has your PCMH developed a working relationship to improve SDOH referrals and to close the loop on those referrals? If your PCMH has CHWs on your team, what is their role in developing these community relationships and following-up on referrals? Which tools, such as PA Navigate (Find Help), are supporting this communication process?

9:40 a.m. to 9:50 a.m. – Break

9:50 a.m. to 10:55 a.m. – Presentation: SDOH Screening and Follow-up based on Feedback from Patient/Family Advisors – Kathleen Barry, Deputy Chief Operating Officer; Kathleen Doyle, Director of Patient Centered Services; Paul Haugland, Manager of Electronic Health Records (EHR) and Health Informatics; Kari Machelli, RN, Associate Vice President of Integrated Primary Health Services; and Kara McDonough Seitzinger, Executive Director of Public Affairs/Advisor Liaison to President & CEO; The Wright Center

10:55 a.m. to 11:10 a.m. – Action Planning Exercise: Involving Patient/Family Advisors to Continuously Improve SODH Screening and Follow-up

11:10 a.m. to 11:20 am – Break

11:20 a.m. to 12:00 p.m. – Part 1 Workshop: Patient-Centered Language for SDOH Screening – Facilitated by Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence

12:00 p.m. to 1:00 p.m. – Lunch

1:00 p.m. to 1:45 p.m. – Part 2 Workshop: Practing Patient-Centered Language for SDOH Screening and Warm Handoffs – Facilitated by Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence

1:50 p.m. to 2:10 p.m. – Break

2:10 p.m. to 3:15 p.m. – Knowledge Cafes: Connecting with SDOH Community Resources

            WIC

  • Erica Bozentka, WIC Director, Maternal and Family Health Services
  • Laurie Waskovich, Nutrition Services Administrator, Maternal and Family Health Services 
  • Nurse-Family Partnership and Maternal Medical Home Programs
  • Cindy Kennedy, Director of Community Impact & Partnerships, Maternal and Family Health Services
  • Ann M. Jones, BSN, RN, Director of Nurse-Family Partnership, Maternal and Family Health Services 
  • MCO Special Needs Units
  • Hosted by Geisinger Health Plan and AmeriHealth
  • PA Navigate (Find Help)
  • Joshua A. Muchler, Business Architect, Keystone Health Information Exchange 
  • Transportation 
  • Carl Albright, Director, Wayne County Transportation System 

3:15 p.m. to 3:50 p.m. – Huddles and Report Outs – Facilitated by Jen Condel, Robert Ferguson, and Lisa Boyd

3:50 p.m. to 4:00 p.m. – Wrap-Up

Radisson Lackawanna Station Hotel
Scranton, PA
United States

Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

Kathleen Barry, Deputy Chief Operating Officer, The Wright Center

Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence

Jen Condel

Lisa Boyd

 

 

In support of improving patient care, this activity has been planned and implemented by the University of Pittsburgh and The Jewish Healthcare Foundation. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

As a Jointly Accredited Organization, University of Pittsburgh is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. University of Pittsburgh maintains responsibility for this course. Social workers completing this course receive 6.0 continuing education credits.

Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 6.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 6.0 contact hours.

Social Work (ASWB)
The maximum number of hours awarded for this Continuing Social Work Education activity is 6.0 contact hours.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Available Credit

  • 6.00 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 6.00 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 6.00 ASWB
  • 6.00 Attendance
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