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12/11/2018
Quarterly Claims And Operations Meeting

12/18/2018
Member Forum: Health Center: Episodes of Amazing Care

IQIN Oct Face- 2-Face
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  Focus on Population Health and High Risk/ High Cost Patients
 
 
 
 
 
     
                           

Candace Chitty, Quality First Healthcare Consulting, Inc., will be the featured speaker and facilitator for the IQIN Face-to-Face Meeting on October 4th from 8:30 AM – 4:00 PM at the Embassy Suites North in Indianapolis. The purpose of the training is to give participants an understanding of the systems and tools necessary to work successfully with population health models, processes, staffing, training, patient engagement, and reporting. This new model of care will require health center personnel acquire the knowledge and skills necessary to move from an episodic orientation to a population health model. This training covers the essentials of PHM: managing transitions of care, managing high-risk complex populations, engaging patients in self-care, and measuring performance. Skills required to achieve these goals include but are not limited to cultural change, coaching, empowerment, motivating behavior change, advocacy, and mastering continuous quality improvement principles. Other speakers will include Azara Healthcare, Purdue Healthcare Advisors and Participating Health Center staff.


 
 
AGENDA & RESOURCES

 MORNING
                                   8:30 AM                 REGISTRATION AND BREAKFAST                                                                                                                        
     
9:00 AM                 Main Meeting Room- Candace Chitty, LuAnn Kimker    
                                                 Welcome and Overview, Introduction of Speakers
                                                                          Population Health Management: Background and Overview, Candi Chitty resources
                                                                             10:30 AM                Break   
              Panel on Risk Stratification, LuAnn's slide deck
  1. Tools to support Risk Stratification:
      1. Behavioral Risk Factor Surveillance System (BRFSS) Questionnaire https://www.cdc.gov/brfss/questionnaires/index.htm
      2. PHQ-9 https://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf
      3. Diabetes Distress Scale http://www.diabetesed.net/page/_files/diabetes-distress.pdf
      4. NACHC Risk Stratification http://www.nachc.org/wp-content/uploads/2018/02/Action-Guide_Pop-Health_Risk-Stratification-Sept-2017.pdf
      5. AAFP Risk Stratification Rubric https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric
      6. SF-12 Questionnaire https://www.hss.edu/physician-files/huang/SF12-RCH.pdf Scoring https://campaign.optum.com/optum-outcomes/what-we-do/health-surveys.html?s=PPC&pstc=optum:ppc:LS_4.1_2018:g:ls:Frm:18wd1fk01rr23&ppcid=sf%2012&adid=247796573650&adgroupid=52618954298&campaignid=1036340767&o=optum:ppc:LS_4.1_2018:frm:ls:Frm:18wd1fk01rr23&gclid=Cj0KCQjw9NbdBRCwARIsAPLsnFbAzM53Z8l7SHxStSr5ItPiZH3OaTOYkRzj2c3q8sXBck8KD0uoP98aArZ3EALw_wcB
      7. Patient Activation Measure https://www.insigniahealth.com/products/pam-survey

 
     Care Coordination & Care Management: Principles and Practice  
 Candi Chitty - for resources, please refer to Candi Chitty above  
   
                                                          12:00 PM                  LUNCH              Madrid Room  
   
AFTERNOON     
   
                                          1:00 PM                  Main Meeting Room - Candi Chitty - for resources, please refer to Candi Chitty above   
                                                                                               Care Coordination & Care Management: Principles and Practices (continued)  
                                                                    2:00 PM                  Breakout Sessions
                  Breakout 1: Candace Chitty  
                                                                    Action Planning - an Interactive session on Self management  
                                  Breakout 2: Allison Bryan Jungels, PHA,   

                                                                                                   Medicare CCM slide deck - An Interactive Session to explore implementing new CCM
                                                                                      codes to  reduce health center costs for diabetes and other care.

3:00 PM                   Main Meeting Room  

Models

    1. HI Care Coordination Model  www.IHI.org
    2. CareOregon  Care Support www.careoregon.org
    3. Guided Care Nurse  www.guidedcare.org
    4. Geisinger ProvenHealthâ„¢ Navigator www.geisinger.org
    5. BOOST Care Transitions www.hospitalmedicine.org IHI Care Coordination Model  www.IHI.org
    6. CareOregon  Care Support www.careoregon.org 
    7. Guided Care Nurse  www.guidedcare.org
    8. Geisinger ProvenHealthâ„¢ Navigator www.geisinger.org
    9. BOOST Care Transitions www.hospitalmedicine.org