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ForwardPCMH Lehigh Capital PA Learning Session 5.5.21
The Patient Centered Medical Home (PCMH) practices are well on their way to screening patients for Social Determinants of Health issues that could affect patient health but they continue to have challenges around effective techniques for these screenings, documentation, referral after SDOH concerns raised and follow up. The PCMHs are not aware of the Integrated Care Plans (ICPs) that exist at the Managed Care Organization level and these may be helpful to the practices in the care and treatment of their patients with complex care issues.
Agenda
8:30 - 8:45am Welcome and Overview of Agenda including PCMH requirement focus
8:45 - 9:30am Report outs by PCMH practices:
Facilitator: Laura Line, Health Federation.
PCMH Questions:
- What have been your successes recently in collecting and reporting SDOH data, and what have been your major challenges?
9:30am – 10am Q & A: Resource Information and Services Enterprise (RISE) PA
Facilitator: Suzanne Cohen, Health Federation
Speaker: Nora Carreras, Special Advisor to the Secretary, PA Department of Human Services
10am - 10:40am Social Determinants: Assessment, Coding, Reporting and Closing the Loop with Referrals
Facilitator: Suzanne Cohen, Health Federation
Panelists:
Heather Goshorn, Manager of Enabling Services, Keystone Health
Tom Michaels, Manager, Integrated Care Coordination, Lehigh Valley Health Network
10:40am – 11:25am Integrated Care Plans: What are ICPs and how can you support your patients with ICPs?
Facilitator: Laura Line, Health Federation
Speaker: Bridget Gill-Gibson, Acting HSPS Supervisor, Quality Accountability
Panel of ICP representatives from each MCO
- Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan
- Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You
- Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
- Matthew Skokowski, RN, CCM, Manager, Population Health Management, AmeriHealth Caritas
- Michelle Kercher Hawley, LSW, Manager of Quality Department, PerformCare
- Lauren Keane, MS, LPC, Director, Integrated Health, Magellan Healthcare, Inc
- Stacy Anthony, LSW, Associate Clinical Manager, CCBH
- Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan
- Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare
11:25 - 11:30am Wrap-up
Target Audience
Nurse
Physician
Social Worker
Learning Objectives
1. Identify effective practices for SDOH screening, documentation, referral, and follow-up.
2. Describe how your practice can engage with the state-wide resource and referral tool, RISE PA.
3. Describe how each MCO develops Integrated Care Plans and how your practice can engage with the plans for your patients.
Additional Information
| Attachment | Size |
|---|---|
 ICP Presentation - Bridget Gill Gibson.pdf | 224.64 KB |
| Keystone Health SDOH Panel Presentation 2021.pdf | 1.42 MB |
| Lehigh Valley Health Network presentation.pdf | 913.74 KB |
Agenda
8:30 - 8:45am Welcome and Overview of Agenda including PCMH requirement focus
8:45 - 9:30am Report outs by PCMH practices:
Facilitator: Laura Line, Health Federation.
PCMH Questions:
- What have been your successes recently in collecting and reporting SDOH data, and what have been your major challenges?
9:30am – 10am Q & A: Resource Information and Services Enterprise (RISE) PA
Facilitator: Suzanne Cohen, Health Federation
Speaker: Nora Carreras, Special Advisor to the Secretary, PA Department of Human Services
10am - 10:40am Social Determinants: Assessment, Coding, Reporting and Closing the Loop with Referrals
Facilitator: Suzanne Cohen, Health Federation
Panelists:
Heather Goshorn, Manager of Enabling Services, Keystone Health
Tom Michaels, Manager, Integrated Care Coordination, Lehigh Valley Health Network
10:40am – 11:25am Integrated Care Plans: What are ICPs and how can you support your patients with ICPs?
Facilitator: Laura Line, Health Federation
Speaker: Bridget Gill-Gibson, Acting HSPS Supervisor, Quality Accountability
Panel of ICP representatives from each MCO
- Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan
- Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You
- Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
- Matthew Skokowski, RN, CCM, Manager, Population Health Management, AmeriHealth Caritas
- Michelle Kercher Hawley, LSW, Manager of Quality Department, PerformCare
- Lauren Keane, MS, LPC, Director, Integrated Health, Magellan Healthcare, Inc
- Stacy Anthony, LSW, Associate Clinical Manager, CCBH
- Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan
- Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare
11:25 - 11:30am Wrap-up
Nora Carreras, Special Advisor to the Secretary, PA Department of Human Services
Heather Goshorn, Manager of Enabling Services, Keystone Health
Tom Michaels, Manager, Integrated Care Coordination, Lehigh Valley Health Network
Laura Line, Health Federation
Bridget Gill-Gibson, Acting HSPS Supervisor, Quality Accountability
Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan
Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You
Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
Michelle Kercher Hawley, LSW, Manager of Quality Department, PerformCare
Lauren Keane, MS, LPC, Director, Integrated Health, Magellan Healthcare, Inc
Lyndra Bills, MD, Senior Medical Director, CCBH
Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan
Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare
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 3.0 continuing education credits.
Available Credit
- 3.00 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.
- 3.00 ANCCUPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
- 3.00 ASWB
- 3.00 Attendance