UMass Medical School to share how partnerships and self-assessments improve transformation at the 2015 Conference on Practice Improvement

December 01, 2015

Patient-centered medical home experts from UMass Medical School’s Commonwealth Medicine division will present how partnerships and collaborations improve transformation, share results of behavioral health self-assessments and reveal untold stories from the Massachusetts Patient-Centered Medical Home Initiative at the Society of Teachers of Family Medicine (STFM) 2015 Conference on Practice Improvement in Dallas, Texas, Dec. 3-6.

Friday, Dec. 4

A Transformative Collaboration: Duffy Health Center and Commonwealth Medicine Partner to Build Improved Systems of Care
1:45-2:15 p.m., Colonnade B

The collaboration between Duffy Community Health Center, a HRSA 330€ Health Care for the Homeless FQHC since 2002, and UMass Medical School’s Commonwealth Medicine division in the area of practice transformation demonstrates a partnership that relies on data to generate action steps that can be quickly implemented and produce real and measurable short-term improvements that align with long-term sustainability. The presentation will outline how Duffy chose a Practice Transformation Consultant at Commonwealth Medicine to join its Patient-Centered Medical Home Clinical Transformation Team and the way team members worked with the consultant to achieve desired outcomes. Among the team’s process improvements are (1)A work process that resulted in 100% of new patients receiving a PHQ-9 Depression Screen, with patients being directed to appropriate on-site treatment and follow-up, (2) An algorithm to collect data related to cervical cancer screening rates to reconnect with 75% of eligible patients seeking this care elsewhere.

Ruth Aboagye, MBA, Center for Health Policy and Research, Commonwealth Medicine
Sai Cherala, MD, MPH, Center for Health Policy and Research, Commonwealth Medicine
Joan D. Johnston, RN, CIH, CPE, PCMH CCE, Center for Health Policy and Research, Commonwealth Medicine
Anita Morris, MSN, FNP-BC, Center for Health Policy and Research, Commonwealth Medicine
Pamela Senesac, PhD, MS, Center for Health Policy and Research, Commonwealth Medicine
Judith L. Steinberg, MD, MPH, Commonwealth Medicine
Jane de Groot, MPA, Duffy Health Center
Wesley Neal Klein, MD, Duffy Health Center

Behavioral Health Self-Assessment Tool
1:45-2:15 p.m., Spectrum A

A behavioral health self-assessment evaluation tool was an integral component of planning and on-going evaluation in the Primary Care Payment Reform Initiative (PCPR), an effort by the Massachusetts Medicaid’s program to improve access, patient experience, care management/coordination, and clinical quality while integrating behavioral health (BHI) into the primary care setting. This presentation will share the results of a self-assessment, taken by 30 participating practice organizations associated with 47 practice sites. Overall, 66% of the responding practices self-scored at Level B on scale of A-D, reflecting that the basic elements of the key change had been implemented, although the practice still has significant opportunities to improve. Administration of the tool at baseline provides immediate feedback to participating practices on their self-reported strengths and weaknesses, valuable information for planning relevant Initiative-wide opportunities for shared learning and technical assistance, and a baseline for on-going measurement and tracking.

Sai Cherala, MD, MPH, Center for Health Policy and Research, Commonwealth Medicine
Karen Clements, MPH, ScD, Disability and Community Services, Commonwealth Medicine
Joan D. Johnston, RN, CIH, CPE, PCMH CCE, Center for Health Policy and Research, Commonwealth Medicine
Anita Morris, MSN, FNP-BC, Center for Health Policy and Research, Commonwealth Medicine
Judith L. Steinberg, MD, MPH, Commonwealth Medicine

Community and Clinical Partnerships—Lessons From the Field

1:45-2:15 p.m., Crystal VIII

Community health workers (CHWs) can assist in addressing significant health status and access-to-care issues because they have a close understanding of the communities they serve through shared ethnicity, culture, language, and life experiences. This relationship enables them to break down social/cultural barriers among communities and health care, behavioral health, and social service systems. The City of Worcester Division of Public Health was awarded a Prevention Wellness Trust Fund (PWTF) grant through the Massachusetts Department of Public Health. Through the PWTF project, city of Worcester is seeking to improve health and reduce health care costs by preventing and managing chronic conditions: pediatric asthma, hypertension, and events that lead to health decline: elderly falls, by facilitating and supporting systems change. The interventions are focused on linking CHWs across clinical and community systems by standardizing the training and care coordination of CHWs, who will work across the systems. Our approach is to foster linkages between clinical and community partners by supporting community-based partnerships.

Sai Cherala, MD, MPH, Center for Health Policy and Research, Commonwealth Medicine

Saturday, Dec. 5

Transformation Journey of Practices in Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI): Untold Stories

2:15-3:15 p.m., Spectrum A

The Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) was a 3-year multi-payer demonstration designed to promote clinical model transformation in practices across the state and prepare the practices for PCMH recognition. The 45 participating primary care practices practices received technical assistance including learning collaboratives, coaching provided by external facilitators, and feedback of practice-specific and aggregated data. As part of the Initiative, participating practices were required to develop a new clinical workflow to follow-up with patients immediately post hospitalization. A review of the qualitative narratives reveals aspects of the common experience shared by many practices in their efforts to establish this new workflow. This includes inconsistent staffing and the challenges of information-sharing across various sites of care, and crucial ingredients for success, such as prioritizing high volume hospital systems for information-sharing, streamlining documentation of the workflow in the electronic health record, focusing on highest risk patients, and clearly identifying the role and function of each care team member in the new process.

Ruth Aboagye, MBA, Center for Health Policy and Research, Commonwealth Medicine
Sai Cherala, MD, MPH, Center for Health Policy and Research, Commonwealth Medicine
Joan D. Johnston, RN, CIH, CPE, PCMH CCE, Center for Health Policy and Research, Commonwealth Medicine
Anita Morris, MSN, FNP-BC, Center for Health Policy and Research, Commonwealth Medicine
Pamela Senesac; PhD, MS, Center for Health Policy and Research, Commonwealth Medicine
Judith L. Steinberg, MD, MPH, Commonwealth Medicine
Jaime F. Vallejos, MD, MPH; Center for Health Policy and Research, Commonwealth Medicine

UMass Medical School’s Commonwealth Medicine is a leader in the area of practice transformation, the patient-centered medical home (PCMH) model of care and behavioral health integration. Our team works directly with primary care practices and health care institutions to educate them about new care delivery models, such as PCMH, and alternative payment models. Our practice facilitators are experts in navigating the care delivery transformation process and help practices improve patient experience, meet quality outcome goals and deliver value-based care.

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