PCMH Southeastern PA Learning Session 2.7.23

February 7, 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 & Overview – Suzanne Cohen, MPH, Senior Director of Population Health, The Health Federation of Philadelphia

8:45 a.m. to 9:30 a.m. – PCMH Report Outs: Reflecting on PCMH requirement progress – Facilitated by Laura Line, Health Federation 

Please share:

·   Areas of work related to the PCMH requirements where you made the most progress in 2022

·   One area you will particularly focus your efforts on in 2023

Possible examples include:

·   Screen, coding, and follow-up for SDOH

·   Address health disparities through a quality improvement initiative

·   See 75% of patients within 7-days of hospital discharge with an ambulatory sensitive condition

·   Include patient advocates or family members to support the patients’ health goals and advise practices

·  Deploy a Community-Based Care Management team:

o   Incorporate behavioral health integration

o   Depression screening and follow-up

·  Provide tobacco cessation counseling services (TCC) or demonstrate referral of patients seeking TCC services

9:30 a.m. to 10:25 a.m. – Breakouts: PCMHs and MCOs share best practices

Attendees will join small group discussions based on their interest.

Topics include:

·   Identifying and reaching high-risk patients with lapsed care and/or no shows

·   Follow-up on patients within 7 days post-hospital discharge

·   Reducing avoidable Emergency Department visits

10:25 – 10:30 am Wrap up

 

Target Audience

Nurse

Physician

Social Worker

Learning Objectives

1. Describe examples of, and best practices for, meeting the PCMH requirements, such as screening for social determinants of health, behavioral health integration.
2. Describe best practices for identifying and reaching high risk patients with lapsed care, reducing avoidable ED visits, and follow-up with patients within 7 days post hospital discharge.

Additional Information

AttachmentSize
File Audience Disclosure slides (002).pptx459.3 KB
File PCMH Southeast 2.7.23 Agenda.docx333.33 KB
File Discussion framework for 7-day follow up winter 2023.docx14.54 KB
Course summary
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 ANCC
    UPMC 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
Course opens: 
02/07/2023
Course expires: 
05/31/2023
Event starts: 
02/07/2023 - 8:30am EST
Event ends: 
02/07/2023 - 10:30am EST
Add to calendar: 

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 & Overview – Suzanne Cohen, MPH, Senior Director of Population Health, The Health Federation of Philadelphia

8:45 a.m. to 9:30 a.m. – PCMH Report Outs: Reflecting on PCMH requirement progress – Facilitated by Laura Line, Health Federation 

Please share:

·   Areas of work related to the PCMH requirements where you made the most progress in 2022

·   One area you will particularly focus your efforts on in 2023

Possible examples include:

·   Screen, coding, and follow-up for SDOH

·   Address health disparities through a quality improvement initiative

·   See 75% of patients within 7-days of hospital discharge with an ambulatory sensitive condition

·   Include patient advocates or family members to support the patients’ health goals and advise practices

·  Deploy a Community-Based Care Management team:

o   Incorporate behavioral health integration

o   Depression screening and follow-up

·  Provide tobacco cessation counseling services (TCC) or demonstrate referral of patients seeking TCC services

9:30 a.m. to 10:25 a.m. – Breakouts: PCMHs and MCOs share best practices

Attendees will join small group discussions based on their interest.

Topics include:

·   Identifying and reaching high-risk patients with lapsed care and/or no shows

·   Follow-up on patients within 7 days post-hospital discharge

·   Reducing avoidable Emergency Department visits

10:25 – 10:30 am Wrap up

Webinar
Pittsburgh, PA
United States

Suzanne Cohen, MPH, Senior Director of Population Health, The Health Federation of Philadelphia

Laura Line, Health Federation

 

 

 


 

            

 

 

 

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 ANCC
    UPMC 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
Please login or register to take this course.