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 CMSCE@cms.hhs.gov 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 atCPCPlus@telligen.com 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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