PCMH Regional Session for Lehigh Capital

Tuesday, October 20

8:30 a.m. to 11:30 a.m.

Register here

Agenda:

8:30 a.m. to 8:35 a.m. – Welcome and Introductions – Suzanne Cohen, MPH, Health Federation of Philadelphia (HFP)

8:35 a.m. to 9:35 a.m. – PCMH and MCO Report Outs: Collecting and Stratifying Data by Race/Ethnicity – Facilitated by Laura Line, Health Federation of Philadelpia

 1. The facilitators will frame the reports by: (1) emphasizing the rationale for accurately collecting race/ethnicity data and looking at measures by race/ethnicity (the “why”); (2) defining race and ethnicity; and (3) connecting it to the HealthChoices PCMH expectations to: “collect and report annual quality data and outcomes pertinent to their patient population…” and “conduct internal clinical quality data reviews on a quarterly basis, report results, and discuss improvement strategies with the PH-MCO”

2. Each PCMH and MCO will be asked to respond to the following questions. And prior to the learning session, each PCMH and MCO will be asked to run a report on PCMH-related quality measure by race/ethnicity.

• How does your PCMH/MCO collect information about race and ethnicity?
• Which PCMH-related quality measures has your PCMH/MCO looked at by race/ethnicity (e.g., SDOH screening and follow-up rates, patient satisfaction, blood pressure < 140/90, A1c < 9, well-child visit rates, 7-day hospital follow-up, etc.)
• When you ran a report by race/ethnicity for one of your quality measures, what did you find and learn (e.g., lack of data about race/ethnicity, health disparities, etc.)?
• If you were not able to run a report, what got in your way?

3. After the report outs, the facilitators will poll the participants about what topics related to racial disparities they would like future learning sessions to focus on (e.g., implicit bias, best practices for collecting race/ethnicity data, analyzing data by race/ethnicity, engaging patient and family advocates from communities of color, collaborating with community resources in communities of color, analyzing the impact of practice policies on racial disparities, etc.)

4. Each PCMH will also be asked to report out on their current SDOH screening rate (% of patients screened in the past year with a validated SDOH screening tool).

9:35 a.m. to 10:25 a.m. – SDOH Screening and Follow-up During COVID-19: Examples and Workflows for Incorporating SDOH Screening into Telehealth Pre-Visits and Visit Workflows & Using EHR Functionality to Order and Track SDOH-Related Referrals

 1. 30-minute presentation of workflows, tactics for completing screens before a virtual visit, EHR screen shots, patient portal screen shots, etc.

2. 20-minute Interactive peer-to-peer learning discussion:

1. How has your team continued SDOH screening during COVID-19?
2. What barriers did you encounter? How did you problem-solve these challenges?

10:25 a.m. to 11:25 a.m. – Working Across the Care Continuum: Expanding Your PCMH Team to Include SNUs and MCO Care Managers

1. Introduce the SNU MCO-specific virtual breakouts, reviewing the role of SNUs and the goals of the breakouts

2. The PCMH, SNU, and MCO attendees go into their 25-minute virtual breakouts with 2 rotations, totaling 50 minutes.

1. A MCO-specific SNU representative provides examples of how their SNU care coordinators coordinate care across the continuum in partnership with the PCMHs by responding to the following questions:
   1. What criteria do the SNU care coordinators use to determine which patients the SNU care coordinators contact? What triggers this contact?
   2. What services do SNU care coordinators provide to these patients (e.g., assessments, assistance with navigating services/benefits, connecting members to services, etc.)?
   3. Which types of PCMH team members/providers do the SNU care coordinators interact with and when? In other words, what are the common points of interaction with the PCMHs?
   4. How can certain information be shared between the PCMH providers and SNU coordinators?
   5. How has the SNU team fostered effective working relationships with PCMHs? What worked well to form these effective team relationships? (e.g., outreach to PCMH teams, meet and greets, presentations to PCMH/SNU providers, etc.)
2. After the SNU’s responses to these questions, the HFP/PRHI facilitators will moderate an interactive discussion with the SNUs and PCMHs:
   1. What is your PCMH team’s experience with working with a MCO SNU team?
   2. What worked well in terms of forming this SNU-PCMH team?
   3. How and when do your PCMH and SNU teams communicate with each other?

 11:25 a.m. to 11:30 a.m. – Wrap-up & Next Steps – Laura Line, Health Federation of Philadelphia