PCMH Learning Network Western PA 7.16.24
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 Discussion: What is your current workflow and tools for SDOH screening and follow-up? What improvements have you made over time and why? What hasn’t worked well or what barriers have you encountered?
Family/Patient Input Discussion: 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? 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 – Kristen Macey, Project Manager - Extended Care Teams, Primary Care Institute, Allegheny Health Network and Laurie Weidner, Director, Practice Transformation
AHN Value-Based Care
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
Staci L. Bose, MS, Operations Manager WIC, Allegheny County Health Department
MCO Special Needs Unit
Jessica Rhodes, Director of Clinical Programs, UPMC for You
Katie Rose LSW, CCM, Community Based Supervisor, Clinical Operations, Highmark Wholecare
Diana Lowry MSW, LSW, CCM, Medical Case Manager and SNU Coordinator, Clinical Services, Highmark Wholecare
PA Navigate
Laura A. Mosesso, Client Services Manager, ClinicalConnect
Carly Pasinski, System Analyst, ClinicalConnect
Housing
Cheryld Emala MSW, LCSW, Chief Operating Officer, Executive of CONNECT Inc.
Community Action Agencies
Pamela Jeneé Wilbon, Chief Operating Officer, Pittsburgh Community Services Inc
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 patents to employment, transportation, health plan, housing, and transportation services
Additional Information
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 Discussion: What is your current workflow and tools for SDOH screening and follow-up? What improvements have you made over time and why? What hasn’t worked well or what barriers have you encountered?
Family/Patient Input Discussion: 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? 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 – Kristen Macey, Project Manager - Extended Care Teams, Primary Care Institute, Allegheny Health Network and Laurie Weidner, Director, Practice Transformation
AHN Value-Based Care
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
Staci L. Bose, MS, Operations Manager WIC, Allegheny County Health Department
MCO Special Needs Unit
Jessica Rhodes, Director of Clinical Programs, UPMC for You
Katie Rose LSW, CCM, Community Based Supervisor, Clinical Operations, Highmark Wholecare
Diana Lowry MSW, LSW, CCM, Medical Case Manager and SNU Coordinator, Clinical Services, Highmark Wholecare
PA Navigate
Laura A. Mosesso, Client Services Manager, ClinicalConnect
Carly Pasinski, System Analyst, ClinicalConnect
Housing
Cheryld Emala MSW, LCSW, Chief Operating Officer, Executive of CONNECT Inc.
Community Action Agencies
Pamela Jeneé Wilbon, Chief Operating Officer, Pittsburgh Community Services Inc
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
Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)
Kristen Macey, Project Manager - Extended Care Teams, Primary Care Institute, Allegheny Health Network
Laurie Weidner, Director, Practice Transformation
Mae Reale, MA, Health Education Specialist, Pennsylvania Coalition Against Domestic Violence
Staci L. Bose, MS, Operations Manager WIC, Allegheny County Health Department
Jessica Rhodes, Director of Clinical Programs, UPMC for You
Katie Rose LSW, CCM, Community Based Supervisor, Clinical Operations, Highmark Wholecare
Diana Lowry MSW, LSW, CCM, Medical Case Manager and SNU Coordinator, Clinical Services, Highmark Wholecare
Laura A. Mosesso, Client Services Manager, ClinicalConnect
Carly Pasinski, System Analyst, ClinicalConnect
Cheryld Emala MSW, LCSW, Chief Operating Officer, Executive of CONNECT Inc.
Pamela Jeneé Wilbon, Chief Operating Officer, Pittsburgh Community Services Inc
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 ANCCUPMC 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