PCMH Western PA Learning Session 10.21.20

October 21, 2020

PCMH Regional Session for Western PA

Wednesday, October 21

8:30 a.m. to 11:30 a.m.

Register Here

 

Agenda:

8:30 a.m. to 8:35 a.m. – Welcome and Introductions – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

8:35 a.m. to 9:35 a.m. – PCMH and MCO Report Outs: Collecting and Stratifying Data by Race/Ethnicity – Facilitated by Pauline Taylor, CQIA, Program Specialist, PRHI

1. The facilitators will frame the reports by: (1) emphasizing the rationale for accurately collecting race/ethnicity data and looking at measures by race/ethnicity (the “why”); (2) defining race and ethnicity; and (3) connecting it to the HealthChoices PCMH expectations to: “collect and report annual quality data and outcomes pertinent to their patient population…” and “conduct internal clinical quality data reviews on a quarterly basis, report results, and discuss improvement strategies with the PH-MCO”

2. Each PCMH and MCO will be asked to respond to the following questions. And prior to the learning session, each PCMH and MCO will be asked to run a report on PCMH-related quality measure by race/ethnicity.

  • How does your PCMH/MCO collect information about race and ethnicity?
  • Which PCMH-related quality measures has your PCMH/MCO looked at by race/ethnicity (e.g., SDOH screening and follow-up rates, patient satisfaction, blood pressure < 140/90, A1c < 9, well-child visit rates, 7-day hospital follow-up, etc.)
  • When you ran a report by race/ethnicity for one of your quality measures, what did you find and learn (e.g., lack of data about race/ethnicity, health disparities, etc.)?
  • If you were not able to run a report, what got in your way?

3. After the report outs, the facilitators will poll the participants about what topics related to racial disparities they would like future learning sessions to focus on (e.g., implicit bias, best practices for collecting race/ethnicity data, analyzing data by race/ethnicity, engaging patient and family advocates from communities of color, collaborating with community resources in communities of color, analyzing the impact of practice policies on racial disparities, etc.)

4. Each PCMH will also be asked to report out on their current SDOH screening rate (% of patients screened in the past year with a validated SDOH screening tool).

9:35 a.m. to 10:25 a.m. – SDOH Screening and Follow-up During COVID-19: Examples and Workflows for Incorporating SDOH Screening into Telehealth Pre-Visits and Visit Workflows & Using EHR Functionality to Order and Track SDOH-Related Referrals – Alison Williams, CCP Project Coordinator, Community Wellness Department, Reading Hospital, Tower Health

1. 30-minute presentation of workflows, tactics for completing screens before a virtual visit, EHR screen shots, patient portal screen shots, etc.

CMS Accountable Health Communities site

2. 20-minute Interactive peer-to-peer learning discussion:

  1. How has your team continued SDOH screening during COVID-19?
  2. What barriers did you encounter? How did you problem-solve these challenges?

10:25 a.m. to 11:25 a.m. – Working Across the Care Continuum: Expanding Your PCMH Team to Include SNUs and MCO Care Managers

1. HFP/PRHI facilitators introduce the SNU MCO-specific virtual breakouts, reviewing the role of SNUs and the goals of the breakouts

2. The PCMH, SNU, and MCO attendees go into their 25-minute virtual breakouts with 2 rotations, totaling 50 minutes.

  1. A MCO-specific SNU representative provides examples of how their SNU care coordinators coordinate care across the continuum in partnership with the PCMHs by responding to the following questions:
    1. What criteria do the SNU care coordinators use to determine which patients the SNU care coordinators contact? What triggers this contact?
    2. What services do SNU care coordinators provide to these patients (e.g., assessments, assistance with navigating services/benefits, connecting members to services, etc.)?
    3. Which types of PCMH team members/providers do the SNU care coordinators interact with and when? In other words, what are the common points of interaction with the PCMHs?
    4. How can certain information be shared between the PCMH providers and SNU coordinators?
    5. How has the SNU team fostered effective working relationships with PCMHs? What worked well to form these effective team relationships? (e.g., outreach to PCMH teams, meet and greets, presentations to PCMH/SNU providers, etc.)
  2. After the SNU’s responses to these questions, the HFP/PRHI facilitators will moderate an interactive discussion with the SNUs and PCMHs:
    1. What is your PCMH team’s experience with working with a MCO SNU team?
    2. What worked well in terms of forming this SNU-PCMH team?
    3. How and when do your PCMH and SNU teams communicate with each other?

SNU lead contacts:

  • Chelsey Cleveland, LSW, Supervisor, Case Management, Behavioral Health, & Jamie Smith, RN, BSN, Special Needs Unit Case Management Supervisor and Special Needs Unit Coordinator, Gateway Health Plan
  • Patrice Faust, MA, LPC, Supervisor, Clinical Health Services, Aetna
  • Lindsay Carter, LPC, Medicaid Clinical Coordinator, and Michelle Capper, SNU, UPMC Health Plan (confirmed)
  • Tami Barker, PA Special Needs Unit, UnitedHealthcare Community Plan

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

Target Audience

Nurse
Physician
Social Worker
 

Learning Objectives

  1. Discuss why and how PCMHs and MCOs are collecting and stratifying PCMH-related quality measures by race/ethnicity
  2. Describe how to apply telehealth best practices to SDOH screening and follow-up activities
  3. Describe the roles of the MCOs’ Special Needs Units (SNUs)
  4. Describe how PCMHs have formed teams and communication pathways with MCO SNUs and care managers
Course summary
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.
  • 3.90 ANCC
    UPMC 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
Course opens: 
10/21/2020
Course expires: 
12/30/2020
Event starts: 
10/21/2020 - 8:30am
Event ends: 
10/21/2020 - 12:00pm

PCMH Regional Session for Western PA

Wednesday, October 21

8:30 a.m. to 11:30 a.m.

Register Here

 

Agenda:

8:30 a.m. to 8:35 a.m. – Welcome and Introductions – Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

8:35 a.m. to 9:35 a.m. – PCMH and MCO Report Outs: Collecting and Stratifying Data by Race/Ethnicity – Facilitated by Pauline Taylor, CQIA, Program Specialist, PRHI

1. The facilitators will frame the reports by: (1) emphasizing the rationale for accurately collecting race/ethnicity data and looking at measures by race/ethnicity (the “why”); (2) defining race and ethnicity; and (3) connecting it to the HealthChoices PCMH expectations to: “collect and report annual quality data and outcomes pertinent to their patient population…” and “conduct internal clinical quality data reviews on a quarterly basis, report results, and discuss improvement strategies with the PH-MCO”

2. Each PCMH and MCO will be asked to respond to the following questions. And prior to the learning session, each PCMH and MCO will be asked to run a report on PCMH-related quality measure by race/ethnicity.

  • How does your PCMH/MCO collect information about race and ethnicity?
  • Which PCMH-related quality measures has your PCMH/MCO looked at by race/ethnicity (e.g., SDOH screening and follow-up rates, patient satisfaction, blood pressure < 140/90, A1c < 9, well-child visit rates, 7-day hospital follow-up, etc.)
  • When you ran a report by race/ethnicity for one of your quality measures, what did you find and learn (e.g., lack of data about race/ethnicity, health disparities, etc.)?
  • If you were not able to run a report, what got in your way?

3. After the report outs, the facilitators will poll the participants about what topics related to racial disparities they would like future learning sessions to focus on (e.g., implicit bias, best practices for collecting race/ethnicity data, analyzing data by race/ethnicity, engaging patient and family advocates from communities of color, collaborating with community resources in communities of color, analyzing the impact of practice policies on racial disparities, etc.)

4. Each PCMH will also be asked to report out on their current SDOH screening rate (% of patients screened in the past year with a validated SDOH screening tool).

9:35 a.m. to 10:25 a.m. – SDOH Screening and Follow-up During COVID-19: Examples and Workflows for Incorporating SDOH Screening into Telehealth Pre-Visits and Visit Workflows & Using EHR Functionality to Order and Track SDOH-Related Referrals – Alison Williams, CCP Project Coordinator, Community Wellness Department, Reading Hospital, Tower Health

1. 30-minute presentation of workflows, tactics for completing screens before a virtual visit, EHR screen shots, patient portal screen shots, etc.

CMS Accountable Health Communities site

2. 20-minute Interactive peer-to-peer learning discussion:

  1. How has your team continued SDOH screening during COVID-19?
  2. What barriers did you encounter? How did you problem-solve these challenges?

10:25 a.m. to 11:25 a.m. – Working Across the Care Continuum: Expanding Your PCMH Team to Include SNUs and MCO Care Managers

1. HFP/PRHI facilitators introduce the SNU MCO-specific virtual breakouts, reviewing the role of SNUs and the goals of the breakouts

2. The PCMH, SNU, and MCO attendees go into their 25-minute virtual breakouts with 2 rotations, totaling 50 minutes.

  1. A MCO-specific SNU representative provides examples of how their SNU care coordinators coordinate care across the continuum in partnership with the PCMHs by responding to the following questions:
    1. What criteria do the SNU care coordinators use to determine which patients the SNU care coordinators contact? What triggers this contact?
    2. What services do SNU care coordinators provide to these patients (e.g., assessments, assistance with navigating services/benefits, connecting members to services, etc.)?
    3. Which types of PCMH team members/providers do the SNU care coordinators interact with and when? In other words, what are the common points of interaction with the PCMHs?
    4. How can certain information be shared between the PCMH providers and SNU coordinators?
    5. How has the SNU team fostered effective working relationships with PCMHs? What worked well to form these effective team relationships? (e.g., outreach to PCMH teams, meet and greets, presentations to PCMH/SNU providers, etc.)
  2. After the SNU’s responses to these questions, the HFP/PRHI facilitators will moderate an interactive discussion with the SNUs and PCMHs:
    1. What is your PCMH team’s experience with working with a MCO SNU team?
    2. What worked well in terms of forming this SNU-PCMH team?
    3. How and when do your PCMH and SNU teams communicate with each other?

SNU lead contacts:

  • Chelsey Cleveland, LSW, Supervisor, Case Management, Behavioral Health, & Jamie Smith, RN, BSN, Special Needs Unit Case Management Supervisor and Special Needs Unit Coordinator, Gateway Health Plan
  • Patrice Faust, MA, LPC, Supervisor, Clinical Health Services, Aetna
  • Lindsay Carter, LPC, Medicaid Clinical Coordinator, and Michelle Capper, SNU, UPMC Health Plan (confirmed)
  • Tami Barker, PA Special Needs Unit, UnitedHealthcare Community Plan

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

Zoom Meeting
Pittsburgh, PA
United States

Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative (PRHI)

Pauline Taylor, CQIA, Program Specialist, PRHI

Alison Williams, CCP Project Coordinator, Community Wellness Department, Reading Hospital, Tower Health

Chelsey Cleveland, LSW, Supervisor, Case Management, Behavioral Health

Jamie Smith, RN, BSN, Special Needs Unit Case Management Supervisor and Special Needs Unit Coordinator, Gateway Health Plan

Patrice Faust, MA, LPC, Supervisor, Clinical Health Services, Aetna

Lindsay Carter, LPC, Medicaid Clinical Coordinator, and Michelle Capper, SNU, UPMC Health Plan (confirmed)

Tami Barker, PA Special Needs Unit, UnitedHealthcare Community Plan

 

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.
  • 3.90 ANCC
    UPMC 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
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