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Transcript of Patient and Caregiver Engagement Webinar - Constant...
Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Patient and Caregiver Engagement
March 16, 2017
Bryant Campbell, Amy Gibson, Barbara Doyle
Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Continuing Education
• To receive Continuing Medical Education/Continuing Education Unit credit:
– Go to https://learner.mlnlms.com/– Enter your login ID and password and then click "Log In."
NOTE: You may need to create an account if you have not done so in the past.
• Specific instructions are available for download during the webinar or from CPC+ Connect.
• For questions regarding the continuing education credit, please contact [email protected] via email.
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Introductions
Barbara DoyleNational Learning Team
for CPC+
Amy GibsonNational Learning Team
for CPC+
Bryant CampbellNational Learning Team
for CPC+
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Objectives
At the end of this session, you will be able to:
• Identify effective strategies to partner with patients and caregivers to improve quality
• Describe strategies to integrate self-management support into your practice
• Describe ways to engage patients and caregivers through shared decision making
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Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus
CPC+ Driver Diagram
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Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus
Function 4: Patient and Caregiver Engagement
• Engage patients and caregivers to guide improvement in the system of care
• Integrate self-management support into usual care across conditions
• Engage patients in shared decision making
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Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus
Key Questions
Your work to enhance Patient and Caregiver Engagement starts by asking:
How can we can effectively engage patients, families, and caregivers in
improving the system of care?
What roles, responsibilities, and activities can my staff take on to
help patients achieve their health goals?
How can we balance risks and expected outcomes with patients’
preferences and values?
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Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus
Care Delivery Requirements: Patient and Caregiver Engagement
Track 2 capabilities are inclusive of and build upon Track 1 requirements.
Track 1
Assess practice capability and plan for support of patients’ self-management
Requirements for
Track 2Requirements for
Convene a Patient and Family Advisory Council at least once in PY2017, and integrate recommendations into care as appropriate
Implement self-management support for at least 3 high risk conditions
Convene a Patient and Family Advisory Council in at least two quarters in PY2017 and integrate recommendations into care as appropriate
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Polling Question
At what stage are you in developing your PFAC?
a. Not started yet
b. Started planning with practice staff
c. Have a identified a few potential patients to serve on PFAC
d. Planning for first PFAC meeting
e. PFAC meets regularly and involved in making practice improvements
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Patients as Partners in Improvement
Our patients and their families are an abundant source of wisdom as we navigate the stormy seas of healthcare delivery. To go it alone without their partnership is foolish and unwise.
Joseph Bianco, MD, FAAFPDirector of Primary Care, Essential Health.
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Benefits of Patient and Family Advisory Council (PFAC)
• Bring patient and family perspective to practice operations
• Improve patient safety, quality and care delivery
• Provide insight about community resources and supports
• Share unique patient experiences influenced by culture and environment
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Starting your PFAC
• Work with members to determine best day and time to meet
• Get to know one another
• Provide orientation to practice and goals of PFAC
• Work collaboratively to develop agenda and goals going forward
Meeting
Composition
Collaborate
• Identify a staff liaison
• Determine the composition of your PFAC
• Recruit and invite patients and family caregivers to the meetings
Identify
Key Steps for Creating PFACS in CPC Practices document is available for download
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Western Wayne Physicians
• Located in: Allen Park, MI
• Physician-owned, primary care practice
• EHR: Allscripts/KPN
Robert Jackson, MD Primary Care Physician
Laurie GroesbeckComplex Care
Manager
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Providence Medical Group North Portland
• Located in: Portland, OR
• Large health system
• Patients: 9,336
• EHR: EPIC/Healthy Planet
Chantell Fitz-AmadoProgram Coordinator
Bryant Campbell PFAC Member
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
What is Self-Management Support?
Self-management support gives your patients with chronic conditions the tools to manage their health on a day-to-day basis and take an active role in their health care
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Shift in the Process of Care
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Essential Activities in Self-Management Support
Collaborating with patients
Teachingdisease-specific skills
Negotiating healthybehavior change
Providing training inproblem-solving skills
Assisting with theemotional impact
of having achronic condition
Providing regularand sustained
follow-up
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Utica Park Clinic – Owasso
• Located in: Oklahoma
• Large Multi-specialty practice
• EHR: Next Gen and
IBM Watson Health for
population management
Jeffrey Galles, D.O.Chief Medical Officer
Primary Care Physician
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Shared Decision Making
Identify preference sensitive conditions
Decide on a uniform approach to shared
decision making including the use of
decision aids
Determine the process for the care
team to support shared
decision making
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Additional Learning Support
CPC+ Change Package
CPC+Requirements
CPC+Roadmap
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Engage with the CPC+ Learning Community
• Review the Change Package and Care Delivery Requirements
• Find tools and resources in your Implementation Guide
• Join Action Groups
• Ask questions and share best practices on CPC+ Connect
• Join Affinity Groups
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Upcoming CPC+ Learning EventsCheck the CPC+ Community’s Weekly Update for registration details as they become available.
Learning Event Scheduled Date
CPC+ Monthly Office Hour April 27 at 4:00 PM ET
Access & Continuity on–demand webinar series Coming in April
Action Group 001 Implementing Risk Stratification and Longitudinal Care Management
Session 1: April 11 at 12:00 PM ETSession 2: April 25 at 12:00 PM ETSession 3: May 9 at 12:00 PM ET
Action Group 002 Implementing Risk Stratification and Longitudinal Care Management
Session 1: April 11 at 3:00 PM ETSession 2: April 25 at 3:00 PM ETSession 3: May 9 at 3:00 PM ET
Using Your Comprehensive Primary Care Payment for Non-Visit Based Care webinar May 3 at 4:00 PM ET
Action Group 003 Two-Step Risk Stratification and Enhanced Longitudinal Care Management
Session 1: April 27 at 12:00 PM ETSession 2: May 11 at 12:00 PM ETSession 3: May 25 at 12:00 PM ET
Action Group 004 Two-Step Risk Stratification and Enhanced Longitudinal Care Management
Session 1: April 27 at 3:00 PM ETSession 2: May 11 at 3:00 PM ETSession 3: May 25 at 3:00 PM ET
Financial Forecasting and Reconciliation on-demand webinar Coming in May
CPC+ Monthly Office Hour May 25 at 4:00 PM ET
Refer to the CPC+ Master Calendar on
CPC+ Connect for the latest
information and details!
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Question & Answer
Additional Questions?
Contact CPC+ Support [email protected] or 1-888-372-3280
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Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Thank You
We appreciate your feedback on this learning event. Please take a minute to complete our survey.
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