8:30 a.m. to 8:40 a.m. – Welcome and 2021 HealthChoices PCMH Expectations – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

8:40 a.m. to 9:30 a.m. – MCO and PCMH Report Outs – Facilitated by Pauline Taylor, Program Specialist, PRHI

1. MCOs report out on:

Among your MCO members’ who were discharged from the hospital with an ambulatory sensitive condition, what % have been seen within 7 days of discharge? 
How does this vary by race/ethnicity?
Is this measure included in the gaps in care or P4P reports that your MCO sends to PCMHs? If not, could it be included?
What has been the impact of telehealth visits on the 7-day post-hospital follow-up percentages?

2. PCMHs report out on:
 
When you receive the gaps in care and P4P reports from your MCOs, how does this feed into your quality improvement (QI) work and help you set QI priorities?
Among your PCMH’s patients who were discharged from the hospital with an ambulatory sensitive condition, what % has your PCMH seen within 7 days of discharge?
How does this vary by race/ethnicity (e.g., NH white, NH black, Hispanic, and other)?
What has been the impact of telehealth visits on the 7-day post-hospital follow-up percentages?

3. Polling questions
Among the 2021 PCMH Expectations, which topics would you like to focus on during the future learning sessions?
What methods are the most useful in these sessions? 
Panels of peer practices
Panels of experts
Breakouts tailored to specific groups
Virtual TA office hours
Statewide webinars

9:30 a.m. to 10:30 a.m. – Health Equity Roadmap – Marshall Chin, MD, MPH, Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine, University of Chicago and Co-Director of the National Program Office for Advancing Health Equity; 
Amy Reid, Director, Institute for Healthcare Improvement (Amy directs the IHI Pursuing Health Equity Collaborative) 

The national speakers will review the “why” and provide a roadmap with strategies, with a focus on one or more of the following health equity learning opportunities identified during the November sessions:
understanding the impact of racism and racial disparities on health outcomes
collaborating with community resources in racial/ethnic communities 
analyzing the impact of practice policies on racial disparities
shifting the mindset/narrative from “we care for all patients the same across the board” or “we don’t have a lot of diversity” to “we looked at our data to understand our population and identified changes that reduced disparities”
knowing how to help patients self-select their race/ethnicity during registration who may not feel comfortable selecting one of the OMB/UDS-defined race/ethnicity categories 

10:30 a.m. to 11:25 a.m. – Peer-to-Peer PCMH Panel and Virtual Breakouts: Health Equity Journey and Emerging Best Practices  

Lynda Nester, BSN, MS, NE-BC, Executive Director, Community Care Network, Monongahela Valley Hospital - Vale-U-Health, will present why and how they created a health coaching program for African American communities. 

11:25 a.m. to 11:30 a.m. – Wrap-Up & Next Steps – Pauline Taylor