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 a.m. to 8:40 a.m. – Welcome & Introductions – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative

8:40 a.m. to 9:10 a.m. – SDOH Assessments: Documentation and Using Data for QI – Robert Ferguson

9:10 a.m. to 10:00 a.m. – PCMH Report Outs & Discussion – Report Outs by PCMHs moderated by Pauline Taylor, CQIA, Program Specialist, PRHI

 PCMHs report out on the following:

• What have been your successes with documenting SDOH assessments, results, and referrals and with tracking SDOH screening rates and positive rates by domain?
• What documentation and reporting challenges have you faced or do you anticipate facing?

10:00 a.m. to 10:40 a.m. – Q&A: Resource Information and Services Enterprise PA (RISE PA) –
Nora Carreras, MPA, Special Advisor to the Secretary, PA Department of Human Services

10:40 a.m. to 11:25 a.m. – Integrated Care Plans (ICP): What are ICPs and How Can You Support Your Patients with ICPs? – Overview by Bridget Gill-Gibson, Acting HSPS Supervisor, Quality Accountability Bureau Of Managed Care Operations, PA Department of Human Services; Panel of ICP Representatives from the HealthChoices MCOs

Panel of ICP Representatives from the HealthChoices MCOs

• Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
• Amie Hoffman, LCSW, Director of Behavioral Health, Geisinger Health Plan
• Michele Magda, LCSW, CCBH
• Kim Gatten, Coordinator Clinical Liaison/Special Needs