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Maryland Learning Collaborative Update. Niharika Khanna , MBBS,MD,DGO Program Director, Maryland Learning Collaborative Multi-Payer Program for Patient Centered Medical Home Associate Professor Family and Community Medicine. Acknowledgements.

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Maryland learning collaborative update l.jpg

Maryland Learning CollaborativeUpdate

NiharikaKhanna, MBBS,MD,DGO

Program Director, Maryland Learning Collaborative

Multi-Payer Program for Patient Centered Medical Home

Associate Professor Family and Community Medicine


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Acknowledgements

  • We are grateful to the State of Maryland Leadership for…

    • Creating a platform for Primary Care Clinicians to advance Health Care delivery to improve the health of all our patients

    • Fostering a unique partnership between the University of Maryland and the Johns Hopkins University

    • Supporting/guiding the Maryland Learning Collaborative

    • Devising a reimbursement structure that enables carriers to support practice infrastructure development

    • Directing the Maryland Health Care Commission to manage the Program

    • Enabling the Community Health Resource Commission to fund the learning collaborative.

  • Physician and clinical leaders -- David Stewart, MD and Norman Poulsen, MD, Scott Feeser, MD, and Kathy Montgomery, PhD, RN

  • All our advisors


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Mission

  • Innovation: to develop a model of advanced patient centered primary care in the State of Maryland which builds capacity within primary care practices to provide accessible, continuous, comprehensive, coordinated, and high quality health care

  • Implementation and Dissemination: uses a Learning Collaborative and within practice coaching of existing staff by expert Practice Transformation Coaches, and introduces an additional Care Manager to implement the new model of primary care with rigorous outcomes evaluation of process, systems of care, physician/clinician, patient related and disease outcome measures


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Vision

  • The Maryland Learning Collaborative will be the “implementation leader” for advancing primary care practice in the State of Maryland.


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Implementation and Dissemination ModelPatient Centered Intervention Strategy

Innovative Payment Methodology to support Care Management and Shared Savings

Multi-Insurance Carrier Supported

Maryland Learning Collaborative

All Teach All Learn Community

Transformations Coaches to Support Practice Self Learning

NCQA recognition for Patient Centered Medical Home

Care Manager integration into Primary Care Practices to enhance chronic disease management, disease prevention and patient engagement

Multi-disciplinary Leadership and Collaboration from University of Maryland, Johns Hopkins and State of Maryland


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Large Group Collaborative Meeting

  • SUCCESS!

  • Amazing turnout – 51 practices represented

  • health care staff and physician/ clinician community + organizing staff/MHCC/UM

  • Presentations by leadership group and participating physicians/clinicians

  • MHCC representation and participation

  • NCQA and CRISP presentation


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Feedback from Steering committee

  • What we did well

  • What we could do better

  • Where we should spend most time next time

  • HOW TO STAY PATIENT CENTERED

  • Physician feedback- in next few slides



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Maryland Learning Collaborative outcomeswill provide support for your transformation in the following ways:


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MLC Leadership Group outcomes

  • Synergy

  • Complimentary skill set with variety of experiences and willingness to share opinions

  • Brainstorming is fun

  • Implementation has been challenging due to resource scarcity leading to yet more innovations


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Sheila Laura Mary outcomesPractice Transformation Coaches

  • Sheila is a wonderful team leader for the coaches and a meticulous methodologist

  • The Coaches, Laura,Mary under her guidance are doing a fabulous job

  • Team work is exemplary with each coach taking responsibility for themselves and each other

  • Positive energy!


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Methods of communication outcomes

  • Webinars, Seminars

  • teleconferences, telephones

  • Academic detailing techniques

  • Newsletter

  • Emails

  • Practice coaching visits

  • Selected Practice facilitation


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Maryland Learning Collaborative Website outcomes

  • https://mhcc.maryland.gov/pcmh/portal/index.aspx

  • Working on a public Face of the Maryland Learning Collaborative as a sub page of the School of Medicine, Department of Family and Community Medicine website

  • We will link these two websites


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Physician Teleconference outcomes

  • June 2nd 7-8am

  • Focus area Mental Health

  • 27 physicians participated

  • Problems identified: screening, referrals, SMI management

  • Several expressed concerns with shortage of psychiatry community in the counties

  • Consider within practice capacity building

  • Referral centers with mental health personnel regionally

  • Unique FQHC challenges


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Mental Health outcomes

  • Developing committee

  • Agenda: Screening, Developing internal capability for early intervention within practices

  • Consider Care manager role as pivotal

  • Referrals process

  • SMI care coordination

  • Role of Psychiatrists training PCP


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Planning Mental Health Discussion Forum outcomes

  • Live vs Media forum

  • Insight from Dr Anthony Lehman, Chair, Psychiatry

  • Being developed ..


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Developing Small Mental Health Pilot Project outcomes

  • Considering training Care Managers in identification of Multi-morbidity in patients

  • To select high risk patients: heart disease with recent ER visit or hospitalization for care management, care coordination and referrals as needed with enhanced communication between specialty and PCP

  • Screen each hi-risk patient for Depression and Anxiety

  • Study systems, provider, patient and disease outcomes in 10 practices


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Implementation challenges outcomes

  • Selection of the coaching/collaborative process for implementing change in primary care

  • Scanty resources


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System based issues outcomes

  • Patient attribution

  • Implementation of 24/7 access

  • Care Manager role and implementation

  • Payment Methodology supporting change

  • Data management



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July 1 outcomesst deadline

  • Care Manager role definition

  • Access to care 24/7

  • MLC developed data gathering forms for distribution to practices

  • Sent letter with incentive to turn in this data by June 30th

  • Incentive is $15/- towards the AAFP/JHU PCMH modules if July 1 data is turned in by June 30th , QA queries for this data gathering being referred to MHCC


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MLC Ongoing program management needs outcomes

  • Quality assurance activities of the MLC essential for data management

  • Tools and resources to support the MLC practices

  • Transformation trending, tracking, monitoring the impact of interventions

  • Matching resources to needs and reactions from practices

  • Supporting MHCC with data gathering and QA

  • Reporting quality measures, deadlines


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Establishing Partnerships outcomes

  • SON – Collaboratively Developing novel professional development curriculum to train CARE MANAGERS

  • MLC will Support the development of care managers’ roles within primary care practices


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Exploring partnerships outcomes

  • FHA- hypertension focus

  • Center for Prevention of Injury and Policy, Shock trauma

  • CHIP- ? Suggestions welcome

  • SOP- data analysis support

  • SSW- Mental health committee

  • Lipitz Center, JHU - Exploring IT project


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Next Regional Collaborative outcomes

  • August 2,3,4

  • Baltimore north

  • Annapolis

  • Frederick

  • National Harbor


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Future Steering Committee dates outcomes

  • July 14th Thursday

  • August 16th Tuesday or 25th Thursday

  • September 15th Thursday


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Residency Committee outcomes

  • University of Maryland Family Medicine and Pediatrics

  • Johns Hopkins Internal Medicine and Med/Peds

  • Good Samaritan Internal Medicine

  • Franklin Square Family Medicine

  • Minutes distributed


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