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ForwardPCMH Northeastern PA Learning Session - February 15, 2023
The webinar will allow the PCMH teams to share ideas and best practices, on PCMH goals, by highlighting their successes from the previous year in areas such as Social Determinants of Health and Behavioral Health integration.
We are also aware that many changes due to COVID and managed care organization realignment, have created the circumstances for needing to reengage with patients especially for hospital follow up and high risk patients. The activity will assist the PCMH teams in learning the various ways that the healthcare team can connect with patients after a hospital stay, identify high risk patients and complete appropriate follow ups.
Agenda:
8:30 a.m. to 8:45 a.m. – Welcome and Review of the 2023 HealthChoices PCMH Goals – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)
8:45 a.m. to 9:30 a.m. – PCMH Report Outs on 2022 Highlights and 2023 Goals – facilitated by Pauline Taylor, CQIA, Program Specialist, PRHI
Each PCMH will report out on the following:
1. Looking back on 2022, please describe your quality improvement initiative that had the greatest impact on patient outcomes related to the HealthChoices PCMH goals.
2. For 2023, which HealthChoices PCMH goals is your team planning to prioritize with a quality improvement initiative?
9:30 a.m. to 10:25 a.m. – Strategies to Identify and Engage High-Risk Patients
Presentations by:
⦁ Jennifer Remetta, DNP, RN, CNS, AGCNS-BC, Director of Care Coordination and Integration, Geisinger Health Plan
⦁ Diana Jackson, RN, CCM Director, Care Coordination and Integration, Geisinger Health Plan
Facilitated peer-to-peer discussion on:
1. How PCMHs pull and display data to identify at-risk patient populations (e.g., those with chronic conditions, elevated clinical indicators, lapsed care, and/or recent hospitalizations)
2. PCMHs’ workflows to prioritize and conduct the outreach to the patient populations
3. The tactics that have worked well to problem-solve common challenges with reaching and engaging the patients
4. How this data-driven outreach impacts the HealthChoices PCMH goal to see 75% of patients within seven days of discharge from the hospital with an ambulatory sensitive condition
10:25 a.m. to 10:30 a.m. – Wrap Up – Pauline Taylor, Program Specialist, PRHI
Target Audience
Nurse
Physician
Social Worker
Learning Objectives
• Describe the 2023 HealthChoices PCMH Expectations and focus areas for the Learning Network
• Discuss examples of PCMHs’ quality improvement projects for improving patient outcomes
• Describe best practices for identifying and engaging high-risk patients, including the impact on seeing patients within 7 days of hospital discharge
Additional Information
| Attachment | Size |
|---|---|
 Audience Disclosure slides (002)_1.pptx | 460.14 KB |
 PCMH NEPA 2.15.23 Agenda.doc | 57.16 KB |
The webinar will allow the PCMH teams to share ideas and best practices, on PCMH goals, by highlighting their successes from the previous year in areas such as Social Determinants of Health and Behavioral Health integration.
We are also aware that many changes due to COVID and managed care organization realignment, have created the circumstances for needing to reengage with patients especially for hospital follow up and high risk patients. The activity will assist the PCMH teams in learning the various ways that the healthcare team can connect with patients after a hospital stay, identify high risk patients and complete appropriate follow ups.
Agenda:
8:30 a.m. to 8:45 a.m. – Welcome and Review of the 2023 HealthChoices PCMH Goals – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)
8:45 a.m. to 9:30 a.m. – PCMH Report Outs on 2022 Highlights and 2023 Goals – facilitated by Pauline Taylor, CQIA, Program Specialist, PRHI
Each PCMH will report out on the following:
1. Looking back on 2022, please describe your quality improvement initiative that had the greatest impact on patient outcomes related to the HealthChoices PCMH goals.
2. For 2023, which HealthChoices PCMH goals is your team planning to prioritize with a quality improvement initiative?
9:30 a.m. to 10:25 a.m. – Strategies to Identify and Engage High-Risk Patients
Presentations by:
⦁ Jennifer Remetta, DNP, RN, CNS, AGCNS-BC, Director of Care Coordination and Integration, Geisinger Health Plan
⦁ Diana Jackson, RN, CCM Director, Care Coordination and Integration, Geisinger Health Plan
Facilitated peer-to-peer discussion on:
1. How PCMHs pull and display data to identify at-risk patient populations (e.g., those with chronic conditions, elevated clinical indicators, lapsed care, and/or recent hospitalizations)
2. PCMHs’ workflows to prioritize and conduct the outreach to the patient populations
3. The tactics that have worked well to problem-solve common challenges with reaching and engaging the patients
4. How this data-driven outreach impacts the HealthChoices PCMH goal to see 75% of patients within seven days of discharge from the hospital with an ambulatory sensitive condition
10:25 a.m. to 10:30 a.m. – Wrap Up – Pauline Taylor, Program Specialist, PRHI
Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)
Pauline Taylor, CQIA, Program Specialist, PRHI
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 2.0 continuing education credits.
Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 2.0 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 2.0 contact hours.
Social Work (ASWB)
The maximum number of hours awarded for this Continuing Social Work Education activity is 2.0 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
- 2.00 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.
- 2.00 ANCCUPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
- 2.00 ASWB
- 2.00 Attendance