6th Annual Texas Primary Care and Health Home Summit April 5-6, 2018 Renaissance Austin Hotel, Austin, Texas Draft Agenda

Transcription

1 6th Annual Texas Primary Care and Health Home Summit April 5-6, 2018 Renaissance Austin Hotel, Austin, Texas Draft Agenda Time: Session: Objective: Speaker(s): Session Track: Thursday, April 5 7:30AM 8:30AM 8:30AM -11:30AM Registration and Breakfast Pre-Summit Sessions (additional fee) P1) We Are All On The Same Team- Strategies for Successful Patient- Provider Partnerships P2) TeamSTEPPS From the Basics to a Model of Interprofessional Team Collaboration: The Health For All Huddle Patient Family Engagement is an essential element of the Patient Centered Medical Home and a key strategy to support meaningful patient-provider partnerships, team based care, and shared decision making. A growing body of evidence demonstrates engagement and collaboration with the entire care team, including patients and families, will foster improved health outcomes, better communication and improved patient experience. This workshop will examine core principles and provide strategies of successful patient/family engagement and partnering with patients/families. There is a growing body of evidence to support team based care and effective communication within these teams can optimize patient care. TeamSTEPPS is an evidence-based, comprehensive teamwork training system designed to improve quality and safety in health care and is rooted in more than three decades of research in high-stress, high-risk industries. This session will open with an introduction to several TeamSTEPPS tools and strategies that can improve communication within a team. There will be active audience participation to practice with these strategies. The session will then transition over to a model of effective teamwork, the huddles at Health For All. These huddles uniquely integrate behavioral health into a primary care clinic using telehealth and interprofessional meetings. Health For All is a free primary care clinic that treats over 1500 low-income, uninsured patients annually. Staff noted the complexity of some patients and identified a need to provide more holistic care. The Health huddle was created to address challenging patient cases by coordinating care across Hala Durrah, Patient Family Engagement Consultant and Advocate; Renee Turchi, MD, St. Christopher s Hospital for Children Philadelphia Bree Watzak, PharmD; Carly McCord, Texas A&M University School of Public Health; Elizabeth Dickey, Health For All 1

2 P3) Readiness for Value-Based Payment: Sustaining the PCMH Model Through Change and Payment Policy P4) Implementing Patient-Centered Medical Homes for Transgender Patients and Families, and other members of the LGBTQ+ Community the various health professions. Representatives from medicine, nursing, pharmacy, public health, behavioral health, and nutrition regularly attend these 90 minute meetings. As a result of Huddle discussions, patient treatments are often augmented with medication adjustments, mental health counseling, and referral to community services. Care is increasingly coordinated between providers who treat the same patients. Trainees knowledge of diverse health professions and perspectives has also improved. Effective strategies are needed for supporting providers to be successful at shifting their practices and then sustaining the new model of patient-centered primary care. Assessing readiness and applying data to drive care coordination impacts are key to success with the new alternative payment approaches that transition from volume to value. The presenters will provide an overview of key tools and approaches for patient-centered medical homes based on their experiences in three different state environments, Oregon, Idaho and North Carolina. From their roles as providers, state officials, director of clinical care coordination network and as advisors to providers and systems, the presenters will discuss how both payment policies and practice changes can sustain the patientcentered medical home. They will review tools to assess clinical readiness and describe approaches for initiating key core capabilities towards success in the new world of paying for value, particularly in rural settings. PCMHs improve healthcare and outcomes for lesbian, gay, bisexual, and transgender patients and families. Transgender individuals are highly marginalized; experience significant victimization, mental health issues, suicide, and HIV/STDs; are less likely to have health insurance, and face unique healthcare needs. Fenway Health is the largest healthcare center serving the LGBT population with 3,000 transgender people. Equitas Health, one of the largest community health centers, is committed to performance measurement ensuring service delivery supporting health and wellness. WPATH establishes internationally accepted Standards of Care for transgender health. People s Community Clinic provides care for 13,000 uninsured and medically underserved patients. Kind Clinic offers full service sexual health and wellness services including HIV prevention treatment and gender-affirming care. Dr. Angela Sturm provides surgical and non-surgical care for transgender Jeanene Smith MD, MPH, Health Management Associates (HMA); L. Allen Dobson MD, Community Care of North Carolina (CCNC) John Oeffinger, Texas Health Institute; Lou Weaver, Equality Texas Foundation; Celia Neavel MD, FSAHM, FAAFP, Center for Adolescent Health and GOALS, People s Community Clinic FQHC; Angela Sturm, MD, Facial Plastic Surgery Associates and 2

3 12:00PM-1:30PM 1:45PM-2:45PM Luncheon Keynote: Eliminating Mental Health Disparities through a Culturally and Linguistically, Patient-Centered, Integrated Health Care Approach; Camille D. Miller, MSSW, Honorary Lecture Breakout Sessions I I.1) Optimizing Chronic Care Management to Improve Access and Reduce Emergency Department Utilization patients and promotes LGBT-positive PCMHs in Texas. TransForward helps create culturally-competent transgender healthcare. Participants will learn emerging practices, resources, and lessons learned in applying the PCMH framework from national and Texas organizations serving transgender patients and the LGBTQ community. The presenters will discuss two virtual care initiatives they developed in their Primary Care Center and describe the outcomes those initiatives produced. One, streamlining Home Health Care Coordination by changing clinic workflow and collaborating with selected Home Health agencies that patients preferred reduced staff and clinician workload, increased revenue, and enhanced patient experiences. Two, optimizing chronic care management by collaborating with their information technology (IT) team to create new workflows in the electronic health record reduced unnecessary face-to-face visits, improved access to care, and increased revenue for time spent in chronic care management. These initiatives enhanced patient-centered-care; decreased unnecessary Emergency Department visits; and improved satisfaction among patients, Harris County Medical Society - Central Branch; Mikayla Avery, MS, Kind Clinic; Jamison Green, PhD, WPATH (World Professional Association for Transgender Health); Kelly Wesp,PhD, Equitas Health; Julie Thompson, Fenway Health Katherine Sanchez, LCSW, PhD, Baylor Scott and White Neela Patel, UT Health San Antonio; Herlinda McFarlin, UT Health San Antonio Improvement 3

4 I.2) Improving Clinical Performance Through Youth Voice and Data I.3) Health Plans and Primary Care s: Partnerships Yield Benefits for Both family members, and members of the clinical team. Participants will form small groups to discuss their current Home Health and Chronic Care Management practices and define strategies to enhance chronic care management and Home Health coordination. The Improving Clinical Performance through Youth Voice & Data session will provide an understanding of how youth voice and perspective impacts program planning, development, and evaluation. This session will describe how a health insurer has worked with primary care clinicians to advance person centered, team based high value care. The session will delineate health plan and tools, reports and learning activities to support primary care. The session will also highlight work with sub specialtists in the context of episodes of Care / bundled payments and the Medical neighborhood. Melissa Bing, Houston Health Department; Tia Johnson, Houston Health Department Steven R. Peskin, MD, MBA, FACP, Horizon Blue Cross Blue Shield New Jersey Transitions of Care Public Policy/Payment I.4) Achieving Behavioral Health Integration in Primary Care: a Project ECHO Approach I.5) A Simplified highly Effective PCMH Model To improve behavioral health access and quality care, CMS awarded a two-year contract to TMF Health Quality Institute, in partnership with Arkansas and Missouri subcontractors, to focus on treatment of depression and alcohol use disorder and the integration of behavioral health into primary care through Project ECHO (Extension for Community Healthcare Outcomes) and the Mental Health Integration (MHI) model. In partnership with Dell Medical School at UT Austin, behavioral health subject-matter experts mentor clinicians and give feedback on patient cases. This approach teaches primary care providers how to integrate behavioral health treatment into their practice beyond just screening patients for behavioral health needs. The project aims to help primary care providers achieve behavioral health integration promoting essential primary practice changes including improving detection, monitoring, stratification and management of behavioral health conditions, reinforcing relations with patients and families and managing behavioral health treatment. This session will focus on the core elements of a Patient Centered Medical Home (PCMH) utilizing by an operationally driven, simplified method. Attendees will learn a unique, proven model to incorporate PCMH into their routines. Focus will be on reducing ED visits, reducing hospital re-admissions and generic medications. Patient Care in the United States is quickly moving Caitlin Fenerty- Moore, MPH, CPHQ, TMF Health Quality Institute; Paulette Blanc, MPH, TMF Health Quality Institute Kate Hill, The Compliance Team Integrated Care PCMH Model 4

5 2:45PM 3:00PM 3:00PM 4:00PM Break Breakout Sessions II II.1) Practical Tips for Creating a Population Health Program in Your Primary Care II.2) The Texas 1115 Waiver: the Impacts of Projects and the Systematic Improvement Opportunities Moving Forward II.3) Transitioning Youth with Special Healthcare Needs in a towards a value-based system. This PCMH model of healthcare offers a holistic approach to traditional medicine by taking into account more of the patient s needs than just his/her immediate health issue. A key element of this program is "What Matters Most" to the patient. PCMH is gradually becoming one of the standards for measuring value-based healthcare in the clinic environment. Taking the step to attain PCMH accreditation puts clinics in the position of being better tuned to our evolving health care system. This PCMH model also improves the fundamental operations of the clinic, both in terms of practitioner satisfaction and business improvement. We will explore the core challenges in adding a population health focus to your primary practice and how to address each of them with a mix of options. We start with do-it-yourself analytics and how to make both payer information and your patient data work for you. Then on to crafting a program to use staff you already have to round up care gaps and schedule visits proactively. Next, we show you how to take full advantage of Medicare Wellness Visits to help patients receive more complete care while meeting payer quality metrics at the same time. Finally, tips for helping clinical staff make the mental switch from a volume to value and what to look for in a potential population health employee. We can help you solve for common population health challenges to help you design or refine your practice. The Texas 1115 Waiver, initially approved in 2011, has supported over 300 projects across the state in numerous care settings; those projects have increased capacity and quality of care. The infrastructure through the Regional Health Partnership structure has developed a growing culture of collaborative learning amongst diverse organizations. As the 1115 Waiver transitions to an organizational approach to systematic improvements, this session will cover the changes to the protocols as well as the potential for further alignment with the Triple Aim (improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care). In 2015 the University of Texas at Austin School of Social Work along with Texas CSHCN and MCHB began to create a curriculum to teach graduate-level learners about transitioning Winonah Hoffman, Austin Regional Clinic, Mitch Goldman, MSN, MSIS, Austin Regional Clinic Craig Kovacevich, MA, University of Texas Medical Branch Kendra Koch, The University of Texas Steve Hicks Improvement Public Policy/Payment Transitions of Care 5

6 4:30PM 6:00PM Friday, April 6 Medical Home: Teaching and Doing II.4) Integrated Care Benefits Seen from the Creation of an Intensive Medical Home Clinic II.5) Lessons Learned: Medical Home and Value Based Payment Models Reception with Sponsors and Exhibitors youth with special healthcare needs (YSHCN) from pediatric to adult care. This curriculum is complete and was built on data from focus groups of stakeholders, a targeted assessment of learners, and a systematic review of literature. In addition, this curriculum was evaluated in class sessions in the Spring of One portion of this curriculum is called "Two types of readiness," and it looks a three major areas: 1) are youth ready to transition? 2) are professionals ready to facilitate that transition? and, 3) how do professionals facilitate that transition. This presentation would present this module looking at both how to teach transition skills and problem solving to staff and providers and also at how to transition YSHCN. A large, multispecialty, integrated health system saw impressive reductions in ER visits and hospitalizations from high risk patients by utilizing an integrated intensive medical home containing multidisciplinary services powered to address social determinants of health and behavioral health needs. This clinic has provided over three years of consistent high quality results and cost reductions. This clinic utilizes an embedded nurse navigator, physician, advanced practice provider, pharmacist, and licensed social worker. There has also been access to continuity, telephonic counseling services. Supported by an 1115 Medicaid waiver, this service was available to patients with reduced financial resources, and led to financial benefits to the organization in the form of reduced low acuity ER visits. Conditions were managed more comprehensively, and social barriers were addressed, such that patients required fewer hospitalizations. Interactive discussion related to Lessons learned on implementing PCMH and Value Based Payment model. School of Social Work Janet Hurley, CHRISTUS Trinity Clinic Julie Schilz, BSN, MBA, Anthem, Inc. PCMH Model 7:30AM 8:30AM Breakout Sessions III III.1) Project ECHO: Enhancing Community Medical Care with PCPs frequently refer patients for specialty consultation because they lack expertise in specific areas of practice. Project ECHO uses case-based learning to educate PCPs about complex Norman L. Sussman, MD, FAASLD, Baylor College of Medicine 6

7 Video Enhanced Consultation and Monitoring III.2) PREVENT Disease NOW! III.3) A Financial Tool to Plan PCMH Support by Key Functions III.4) How to Use a Chronic Disease medical conditions that can be safely and appropriately managed in the patient's medical home. Using hepatitis C as an example, this workshop will discuss our success in setting up a treatment network and will encourage audience participation in shaping future needs in primary care. Woven Health Clinic is turning the traditional health care model completely upside down by focusing the majority of its resources on disease prevention, as opposed to treatment. PREVENT Disease NOW! implements evidence-based medical best practices to reduce modifiable risk factors related to chronic disease. The program is a comprehensive approach to assessing lifestyle risks, giving immunizations, medications, cancer screenings and patient education for physical and mental health. Additionally, it employs nutrition therapy, CBT, behavior change, goal setting, exercise prescriptions and counseling sessions. This program addresses traditional disease prevention and management, but also focuses on weight management, customized healthy diet, physical activity, stress management, tobacco cessation and sleep hygiene. Woven Health's patients are all low income, uninsured, allowing the true costs of care to be captured and analyzed. Their patientcentered team-based approach is resulting in physically and mentally healthier patients at an efficient and affordable cost. Delivering patient-centered care requires some functions that are not traditionally included in most primary care practices. Understanding these functions and providing the right level of financial support is essential for delivering the type of team care that the PCMH demands. We describe a functional model that isolates 6 key functions: 1) welcome/front door, 2) clinical processes/refills/triage, 3) same day access support, 4) patient coaching/navigation/transitions of care, 5) outreach/population health, and 6) finance/administrative support. We show examples of how this model can identify necessary investment for each of the components for a network of 5 primary care clinics in San Antonio, TX. We demonstrate how expenses related to each of the functions can be compared using an expense per MD ratio. The tool may be used for calibrating investments in each function and to improve resource utilization across clinics in a network or to identify areas that need further resources. This case report will highlight a major population health initiative put forward at the Internal Medicine Clinic of the Lisa Rigby, EMBA, Woven Health Clinic; Poonam Misra, BSN, FNP, Woven Health Clinic Carlos Jaen, UT Health San Antonio: La-Keisha Harrell, UT Health San Antonio Physicians, Primary Care Center; Ramon Cancino, MD, MSc, UT Health San Antonio Diego De la Mora, Improvement 7

8 8:45AM-9:45AM Management Registry: Case Report From an Academic Internal Medicine III.5) Low Cost Tools to Improve Immunization Rates in a Community Health Center Plenary Session: The State of Telemedicine in Texas Texas Tech University Health Sciences Center (TTUHSC) of El Paso. We will also seek to make light of useful tips on how to use a chronic disease management registry. TTUHSC of El Paso is a large multispecialty practice and part of the largest medical school in the US-Mexico Border. As part of the DSRIP project the institution sought to implement a Chronic Disease Management Registry which was rolled out initially in the Internal Medicine (IM) clinics for both Faculty and Residents. Since its implementation, we have been able to implement workflow changes including the development of a more structured Pre- Visit planning process, limit the number of point-of-care alert burden for physicians, empower quality improvement across the organization and set the platform for powerful outreach capabilities. According to the National Immunization Survey of 2015, vaccinations rates for Texans have been improving but are still lower than the national average. In an effort to improve the vaccination rates in our clinic and ultimately in our city, county, and state, we enlisted several changes over the past few years that have led to an improvement in our clinic. This hour long workshop will discuss low cost tools and how to utilize your existing staff members to ultimately improve your clinic immunization rates. These tools include identifying an immunization champion, providing low cost vaccine education for staff, developing and utilizing standing delegated orders for vaccines, and employing vaccine pre-visit planning and coupling vaccines to improve vaccination rates. Paul L. Foster School of Medicine Frene Lacour- Chestnut, MD, Baylor College of Medicine Nora Belcher, Texas e-health Alliance; Billy Philips, PhD, Taxa Telehealth Resource Project; Tom Banning, Texas Academy of Family Physicians (moderator) 10:00AM 11:00AM Breakout Sessions IV 8

9 IV.1) Using Data Analytics to Improve Clinical Performance IV.2) Working Together to Improve Primary Care Oral Health Across Texas - a Multidisciplinary Evidence Based Approach IV.3) Strategies for Staying Independent in Primary Care IV.4) Transitions of Care: Knowledge is power. Data analytics allows physicians and providers to achieve improved quality and patient outcomes at lower costs using information to highlight areas of suboptimal performance. Medicare and private payers mandate reduction in quality variations and cost variations. Implementing data collection and robust analytics can be challenging as it requires technology, collection and analysis of data, process improvement, and evaluation in a continuous cycle. Lack of knowledge and economic incentive, along with personal preferences, concerns about malpractice risk, and inadequate decision-support tools, further complicates this endeavor. However, the improvement in clinical performance is well worth working through the challenges. Patient outcomes improve, and patients are healthier and happier. Physicians and providers are able to identify evidence-based interventions that positively affect the patient population. Data can help streamline workflow processes for greater efficiency at lower cost. Knowledge can empower and guide clinical decisionmaking that is effective and patient-centered. Since 2000, the national call to improve oral health care via partnerships across Family Medicine, Pediatrics, Nursing, Physician Assistants and the Dental communities has come from the U.S. Surgeon General's 2000 report, Oral Health in America, the CDC s 2010 Healthy People 2020 Goals and the Institute of Medicine (IOM) 2011 report, Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Here in Texas, the Texas Health Institute (THI) and Texas Oral Health Coalition (TxOHC) have developed a collaborative initiative to unite provider groups and advance the oral health across the state. As part of the TxOHC s Advancing the Oral Health Movement in Texas (ATOHMIT) goal for Oral Health Integration into Primary Care, we have developed the Oral Health Tip Sheets for easy access to evidence based oral health information for all primary care providers and their patients. Many Primary Care Physicians know what the problems that cause independent physicians to decide to become employed or retire. Let's talk about the strategies that can keep physicians INDEPENDENT The presenters will discuss how they used QI tools and specific interventions to develop an effective transitions of care program. They will review QI tools like process mapping and Yvonne Mounkhoune, RN, BSN, MA, PCMH CCE, Texas Medical Association Stephanie Rowan, RN, MSN, UT Health San Antonio, Dental School Luis Benavides, Seventh Flag ACO; Greg Fuller, MD, Catalyst Health Chandana Tripathy UT Health San Antonio; Ruby Improvement Integrated Care Public Policy/Payment Transitions of Care 9

10 Management Strategies and Tools IV.5) Community Collaboration to Implement Social Determinants of Health Screening in Patient Centered Medical Homes IV.6) Integration of Behavioral Health Into Primary Care Settings, Lessons from the UT Southwestern Vital Sign6 Program fish bone) and describe interventions (e.g., tracking hospitalizations and discharges) that produced measurable outcomes like reduced readmissions by aggressively followingup on discharged patients. After describing two different practice management strategies for transitions of care (i.e., Case Manager Led Model and Nurse Practitioner Led Model), they will divide participants into small groups to outline the transitions of care processes in their practices. Participants will then describe how they will improve transitions of care in their practices. Presenters will provide a packet with online resources attendees can access to improve their transitions of care. This workshop highlights methods for implementing social determinants of health screening. The Centers for Children and Women are two NCQA level III patient centered medical homes in Houston who serve over 24,000 patients with Texas Children s Health Plan, a Medicaid and CHIP managed care organization. Both Centers offer obstetrics-gynecology, behavioral health and pediatric departments with a multitude of ancillary services. In accordance with recent recommendations from the American Academy of Pediatrics, our pediatric departments implemented food insecurity screenings. Recent data shows 26% of children in Southeast Texas live with food insecurity. The development of our screening tool occurred through collaboration with community and institutional partners. This input allowed us to overcome barriers to screening methods and ensure the clinics were capturing our food insecure patients and offering appropriate resources. This workshop will explore the collaboration, interventions and challenges of initiating social determinants of health screening to an underserved population. The U.S. Preventive Services Task Force recommends depression screening for the general adult population, with adequate systems in place to accurately diagnose, treat and provide follow-up. The VitalSign6 Program strives to enhance healthcare access and the standard of care for those affected by depression. Through the utilization of VS6, an innovative web-based application, community partners have access to validated depression screening, assessment tools, curbside consultation, teletherapy and clinical decision support as part of measurement-based care treatment for depression. VitalSign6 is dedicated to improving the quality of care for patients by: Matthew, UT Health San Antonio Sydnee Lucas, DNP, RN, APRN, FNP-BC, The Center for Children and Women; Stephanie Marton, MD, MPH, The Center for Children and Women- Greenspoint; Brittany Richardson, MD, The Center for Children and Women Robert Kinney, Ph.D., UT Southwestern Center for Depression Research and Clinical Care 10

11 11:00AM- 11:15AM 11:30AM 12:30PM Break Breakout Sessions V V.1) Community Centered Health Homes: Operationalizing the Community Clinic s role in Advancing Health, Not Just Health Care V.2) From Patients to Policy: Improving Transition From Adolescent to Adult Medicine Through Interprofessional Collaboration Improving access to mental health care and contributing to overall patient wellness through the implementation of universal screening and depression treatment Reducing stigma and empowering patients to discuss mental health by making depression screening part of routine care or the sixth vital sign Achieving full and sustained remission of depressive symptoms through the implementation of measurement-based care treatment Community Centered Health Homes (CCHH s) are clinics that take an active role in addressing the community conditions affecting health and health equity. EHF has funded 13 community based clinics to advance this work in Texas in Austin, Waco, Tyler, and the greater Houston area. This session will use a talk-show format with a panel of 3-4 CCHH practitioners in Texas to describe their accomplishments along with the benefits and challenges of becoming a CCHH. The session will also highlight opportunities for new clinics to come on board with EHF s next cohort of grant-funded CCHH s and how to prepare. Ample time will be given for the audience to ask the panel and presenter questions about the CCHH model, how it is related to value based care and population health, early signs of impact and changes in practice, and features of the current or next cohort of clinics supported by EHF. In an era of healthcare transformation, where practitioners seek tools to improve population health, our interprofessional approach provides a framework for health care teams to identify and address individual health harming non-clinical needs and effect change. This session will describe this patientsto-policy approach through the example of the transition from adolescent to adult medicine. We consider transition not only from an organizational perspective, but from the patient s lived experience. Through this view of transition as an opportunity to address medical needs and mitigate select root causes of poor Kenneth D. Smith, University of Texas Medical Branch; Rhonda Mundhenk, Lone Star Circle of Care; Valerie Smith, St Paul Children's Foundation; Jackson Griggs, Heart of Texas Family Health Center; Robert Nnake, Memorial Hermann; Lexi Nolen, Episcopal Health Foundation (moderator) Celia Neavel MD, FSAHM, FAAFP, People s Community Clinic; Keegan Warren Clem; People's Community Clinic; Sula Coria- Garza, People s Community Clinic; PCMH Model Transitions of care 11

12 V.3) Achieving Population Health Goals Using the PCMH Model V.4) Supporting the Medical Home through Effective BH Integration in Primary Care Settings: An Overview of the Collaborative Care Model health in adults, we created a universal screening tool and improved our ability to accurately document patients relevant statuses. Presenters will (1) share strategies for incorporating a community health perspective into CHC practice to support system change through holistic interventions, and (2) facilitate discussion of best practices and challenges in building crosssector partnerships that bridge the various providers of care and support for vulnerable populations. Population health management strives to address individuals health needs at all points along the continuum of care, including the community setting, through participation, engagement and targeted interventions for a defined population. Population health is not static because a patient s risk, disease state or social situation can change at any time. Because the patient-centered medical home model leverages population health data for targeted treatment and clinical interventions, it is an ideal model to use as a building block for effective population health strategies. This session will identify concepts of population health management and how the patient-centered medical home model can be used to build a strong population health management program, as well as how PCMH can help you manage patients as they move through the continuum of care to ultimately deliver better health outcomes for the patients. The Medical Home model seeks to improve engagement and care for all patients. Effective strategies for engaging and serving those with behavioral health conditions are needed to attain successful outcomes and recoup treatment costs with this population. Access to mental healthcare is also of concern given the national psychiatric workforce shortage. Presenters will provide an overview of the Collaborative Care Model, an evidence-based approach to integrating primary and behavioral health care with proven positive impact on access to care, health outcomes, and return on investment. This presentation includes the evidence base for this team-based care model that promotes the medical home and standardized strategies and tools for overcoming challenges inherent in merging primary care and behavioral health to develop successful and effective collaboration. Implementation of the new CPT codes for collaborative care that enhance reimbursement for provision of coordinated, integrated care in a medical home model will also be discussed. Araceli Ramos, People s Community Clinic Patricia Marine Barrett, MHSA, National Committee for Quality Assurance (NCQA) Bren Manaugh, LCSW-S, CPHQ, Health Management Associates, Lori Raney, MD, Health Management Associates Improvement 12

13 12:45PM 2:00PM V.5) Implementation of the Medical Home Model for Children with Special Needs Closing Plenary and Luncheon This session will be highly interactive with audience participation expected. The session will open with a brief presentation of the Driscoll Health Plan (DHP) Health Home Model followed by a series of questions that have been prepared by the moderator that will help to bring greater clarity to how this model of health home functions in a two physician, suburban medical practice. The panel is composed of individuals very familiar with the conceptualization, development as well as implementation of the DHP Health Home Model. There will be ample time allotted allowing for a robust dialogue between the panel members and the audience. Mary Dale Peterson, MD, MSHCA; Fred McCurdy, MD, PhD, MBA; Carmen Rocco, MD; Maria Mata, RN, Driscoll Health Plan Evan Saulino, MD, PhD, Providence Medical Group 13