PCMH Western PA Learning Session 5.18.21

May 18, 2021

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

  • Rachel Lee-Price, LSW, Manager, Clinical Services, Beacon Health Options of Pennsylvania, Inc.
  • Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan
  • Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You
  • Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
  • Harriet Phillips, Clinical Manager, CCBH
  • Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan
  • Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare
  • Kim Gatten, Coordinator Clinical Liaison/Special Needs and Venus Heckman, Manager Integrated Care Management, AmeriHealth Caritas

 

 

Target Audience

Nurse

Physician

Social Worker

Learning Objectives

1. Describe how to document and report SDOH assessments based on the 2021 HealthChoices PCMH Expectations

2. Discuss the challenges and successful strategies for documentation and reporting SDOH assessments across your PCMH colleagues

3. Describe how PA RISE will support SDOH assessment tracking, referrals, and closing the loop the referrals

4. Discuss how to collaborative with Integrated Care Plan teams to help meet patients’ physical, behavioral, and social needs

Additional Information

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.
  • 3.00 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: 
05/18/2021
Course expires: 
07/31/2021
Event starts: 
05/18/2021 - 8:30am
Event ends: 
05/18/2021 - 12:00pm

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

  • Rachel Lee-Price, LSW, Manager, Clinical Services, Beacon Health Options of Pennsylvania, Inc.
  • Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan
  • Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You
  • Patrice Faust, MA, LPC, Manager, Clinical Health Services, Aetna
  • Harriet Phillips, Clinical Manager, CCBH
  • Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan
  • Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare
  • Kim Gatten, Coordinator Clinical Liaison/Special Needs and Venus Heckman, Manager Integrated Care Management, AmeriHealth Caritas

 

Virtual Meeting
Pittsburgh, PA
United States

Robert Ferguson, MPH, Chief Policy Officer, Pittsburgh Regional Health Initiative

Pauline Taylor, CQIA, Program Specialist, PRHI

Nora Carreras, MPA, Special Advisor to the Secretary, PA Department of Human Services

Bridget Gill-Gibson, Acting HSPS Supervisor, Quality Accountability Bureau Of Managed Care Operations, PA Department of Human Services

Rachel Lee-Price, LSW, Manager, Clinical Services, Beacon Health Options of Pennsylvania, Inc.

Ann Giazzoni, MSW, LCSW, MBA, Senior Program Manager, UPMC Health Plan

Nicholas Degregorio, MD, MMM, Senior Medical Director, UPMC for You

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

Harriet Phillips, Clinical Manager, CCBH

Jennifer Conti MSW, LSW, Sr. Clinical Project Manager, Gateway Health Plan

Kristina Fox, RN, Manager of Medical and Clinical Operations and Qiana Rash, Behavioral Health Service Coordinator, UnitedHealthcare

 

 

 

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.
  • 3.00 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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