PCMH Congress 2017

Learning Objectives
• Discuss the re-engineered model that strengthens NCQA’s commitment to patient-centered care principles
• Describe the practices’ experience enrolled in the new program
• Outline feedback from NCQA staff who support practices pursuing and succeeding in PCMH recognition 

• Learners will identify the need, content and method of collecting a measure of degree of primary care integration.
• Learners will review the development and content of integration  outcomes and process metrics developed by an national expert panel.
• Learners will develop a working use of the methodology for collecting the data and constructing the metrics necessary to be used to support NCQA Behavioral Health Distinction.

• Describe the key components of an effective population management program including team-based care to address health equity.
• Identify opportunities within the patient centered medical home to provide equitable care.
• Implement culturally tailored interventions to promote coordinated, patient-centered care for racial and ethnic populations.

• Determine the challenges when vulnerable populations face accessing and interpreting health information and how this may impact these patients' ability to access needed care and manage their health.
• Identify practical, practice-level improvements to increase patient access to health information that is understandable and actionable particularly for vulnerable populations
• Explain how efforts to increase patient access to understandable and actionable health information can result in patients that are more engaged in their care.

Learning Objectives

• Identify methods to strengthen primary care and to advance behavioral health integration in the primary care setting
• Apply lessons learned from PCPR in the transition from FFS to alternative payment models that increase providers' accountability for care and quality
• Determine optimal resources to deploy to support clinical transformation

• Leverage MIPS as a framework for PCMH practice facilitation.
• Utilize PCMH process to ease providers into VBP.
• Develop strategies to align PCMH with other VBP initiatives.
  
  

• Recognize the benefits of pre-visit planning in various office settings and how quality and patient engagement will improve when utilized consistently and effectively.
• Identify the areas in the practice setting where the use of pre-visit planning will increase efficiency and create an environment that maintains and sustains PCMH growth.
• Create innovative ways to apply the use of pre-visit planning as a way to strengthen relationships with the medical neighborhood.

• Describe current policy as it relates to state and federal EHR incentive programs
• Review the impact of health reform and equity on population health
• Outline solutions to improve access to care in under-resourced communities 

Supported by an educational grant from Merck & Co., Inc. 

Complimentary Lunch for all Attendees 

• Understand our networks current model to ensure the PCMH model of care continues post implementation and how we measured that success
• Describe the criteria and resources needed to tackle the more difficult components of how to sustain PCMH at a small practice (1-2 providers, 1-2 staff members)
• Identify how to utilize 2017 PCMH re-design and our current model to continue the goal of PCMH sustainability

Learning Objectives

• Clarify the importance and key components of primary care redesign across the full provider continuum and community, including opportunities, challenges, and repercussions of postponing such changes.
• Brainstorm and develop implementable solutions and potential ROIs relative to primary care redesign, including care management and care coordination of patient populations.
• Share achieved ROIs resulting from primary care redesign, including care team expansion and accountable fee for service efforts.

• Identify common measures shared by UDS and PCMH
• Use the PCMH Quality Improvement and Population Management factors to improve UDS clinical performance measures
• Align factors from PCMH, UDS and MCO incentive programs

• Describe reports utilized to measure quality and utilization in the primary care setting
• List steps taken by the organizations to foster collaboration and enhance likeliness of success
• Identify strategies undertaken to stratify patient health risk from the provider and payer perspectives.

• Understand the impact of integrated behavioral health and primary care on health outcomes, patient and provider satisfaction, and costs of care
• Demonstrate the ability of a health plan to work in partnership with the delivery system to build and sustain a model for integrated behavioral health in primary care
• Define key strategies to engage payers and providers in their own communities to move toward sustainable models of integrated care

• Identify tools that are effective in engaging patients and community partners in a collaborative approach to care management
• Employ SBIRT (Screening, Brief-Intervention and Referral to Treatment) into your Medical Group Practice or Emergency Department
• Choose quality initiatives, chronic conditions for care plans and preventive measures that satisfy NCQA and ACO’s quality metrics

• Discuss challenges faced by PCMH practices and strategies to overcome these challenges as part of the recognition process
• Review best practices and guidelines for optimizing patient care
• Outline the roles of the healthcare team members as they relate to overcoming barriers to patient-centered care 

• Identify the key subject areas covered on the examination
• Develop a strategy to prepare for the test based on best practices discussed during the session
• Review sample examination questions
• Identify resources to aid in successful study efforts 

• Identify patient family support and how the level of support impacts the care delivery
• Understand market resources to leverage coordination to improve patient outcomes
• Discuss how to individualize care based on patient's health literacy

Learning Objectives

• Describe how PCMH practice facilitators can collaborate with primary care practices to help them implement practice transformation efforts so that they are successful and sustainable

• Identify tools, resources, and strategies for transformation projects and how they can be used at different stages of clinical transformation

• Identify common barriers and solutions for identifying transformation leadership, engaging staff and providers, adopting PCMH change concepts, and measuring outcomes throughout the clinical transformation process

Learning Objectives

• Identify a process in your practice that needs to be improved and run a benchmark
• Utilize a Lean Six Sigma tool to implement needed improvement
• Remeasure process after Lean Six tool utilized and monitor improvement

• Discuss how the Patient-Centered Specialty Practice Recognition model can be used to impact care for oncology patients
• Highlight the Oncology Medical Home Recognition program
• Use examples from the PCORI project to develop a roadmap towards recognition

• Understand the Community Centered Health Home model, how it includes patient voices, and how it can support quality improvement efforts
• Describe examples of how the Community Centered Health Home model can be applied in a primary care practice
• List 3 ways the Community Centered Health Home model can include input from patients and align with quality improvement efforts to reduce health disparities

• Define health literacy, health literate organization, and role of health literate advocates. Determine who can participate and why and who benefits from health literate organizations.
• Describe the economic impact, prevalence, and skills needed to be a health literate organization; educate on research findings and initiatives to assist with conceptualization of health literate sites.
• Showcase the 10 Attributes of a health literate organization and tools they use to fulfill PCMH Standards as well as walk them through applicability of those tools to meet the PCMH 2014 or 2017.

• Describe how a Shared Care Plan supports better care coordination in an integrated model of physical and behavioral health.
• Identify how a "Shared Care Plan" promotes client engagement and self -management of physical/behavioral health conditions. 

Learning Objectives

• Review how to use PCMH to create your Value Based Statement
• Discuss how to remove yourself from "Standard Silos" and integrate the intent of the Standards to demonstrate improvement
• Implement practical tools that will assist in truly transforming and practicing the PCMH principles and ultimately be sustainable in a value based system

Supported by an educational grant from Astellas Pharma, US.

Complimentary Lunch for all Attendees 

• Learn how a large ACO and clinically-integrated healthcare delivery system found ROI through NCQA PCMH transformation of aligned independent primary care practices in a value-based environment

• Understand how to successfully scale NCQA PCMH clinical transformation throughout a large ACO primary care network

• Evaluate the impact of NCQA PCMH transformation through an analysis of quality performance from a robust clinical integration program

Learning Objectives

• Review and evaluate the interest of the payor and physician community for practice transformation
• Develop community based practice transformation and achievable educational goals
• Identify how to implement and strategize to receive community-wide interest and acceptance of the PCMH model

Learning Objectives

• Understand the importance of selecting the right quality metrics in multi-specialty group practices.
• Learn how to use PQRS QRUR reports to identify the gaps in MIPS categories.
• Discuss strategy to improve the practice's position for future success with clinician collaboration and buy-in. 

• Identify how to approach educating large communities about NCQA's PCMH, in language they can understand
• Discuss what communication platforms and tools where most effective at helping the targeted community to engage
• Outline the critical components needed for the success of the program

• Identify 3 conversational roadblocks to change
• Define the relational principles and active listening components (OARS) used in BMI
• Identify and understand how to apply each step of the 3-Step CHANGE model

• Describe the unique practice design established by the Center for Elder Care in Huntsville, AL
• Understand the benefit of community-based programs being intertwined with primary practice
• Review the benefit of incorporating educational training partnerships with Nursing and Medical schools

• Review the primary care specific framework of the capitated system in the Veterans Health Administration
• Recognize key processes and tools used in the timely and cost-effective management of primary care provider panels
• Identify key processes and tools that allow on-demand availability of primary care appointments

• Understand basic requirements for nurse Annual Well Visits and Chronic Care Management (non-complex and complex)
• Analyze the business opportunity for new Medicare services in relation to panel size, practice setting, staff scope of practice
• Evaluate various models for delivery of these services by impact on patient care value, access, and experience of care

Learning Objectives

• Assess the current processes of a practice in relationship the NCQA Patient-Centered Medical Home 2017 Standards
• Measure the assessment outcomes and provide feedback on priorities for implementation, identification of care management populations, and improvement on the overall operation of a practice
• Prioritize the needs of a practice and provide recommendations designed to assist the practice in achieving PCMH Recognition through workflow improvement, policy development, reporting, and EHR optimization

Learning Objectives

• Understand best practices in PCMH transformation and sustainability activities in the field
• Apply lessons learned from the presented case studies to their own unique circumstances
• Learn about the PCMH transformation process of different practice settings

Learning Objectives

• Demonstrate functional knowledge of organizational structure and its relationship to developing internal governance
• Identify barriers and potential pitfalls associated with implementing governance change to support PCMH
• Define key members, roles and responsibilities in order to develop a PCMH core team

Learning Objectives

• Discuss how to develop an ambulatory quality program across a multi-specialty medical group
• Review how to use process improvement models and tools to improve clinical quality, safety and patient experience, and to develop and sustain your patient centered medical home
• Identify different ways to display your data to drive improvement and meet the needs of the audience  

Supported by an educational grant from GlaxoSmithKline.

Complimentary Lunch for all Attendees 

Supported by an educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

Complimentary Lunch for all Attendees 

• Understand how PCMH & PCSP can help them succeed in the new CMS payment model
• Understand where they are in regards to MIPS/APM and identify at least one resource they will need to make this transition
• Identify at least two quality measures that align with CMS MIPS measures that they can act to improve during PCMH/PCSP transformation and maintenance

Learning Objectives

• Understand important Health IT features that help and hinder PCMH success
• Apply smart solutions to optimize workflows with limited Health IT resources
• Identify best practices and lessons learned from case studies

• Evaluate process of care outcomes and cost factors that support moving to integrated care
• Describe 3 different models of behavioral health integration
• Outline 3 process of care factors as reasons to integrate behavioral health into primary care

• State how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will affect PCMH and PCSP practices

• Identify how clinicians move up from Fee-For-Service/Merit-Based Incentive Payment Systems to Alternative Payment Models

• Outline tactics that practices can implement to prepare for upcoming policy changes

• Discuss ways that practices can help influence the policy debate