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Maryland Learning Collaborative Update

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

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  1. 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

  2. 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

  3. 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

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

  5. 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

  6. 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

  7. 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

  8. Evidence based methodology to link implementation and outcomes

  9. Maryland Learning Collaborative will provide support for your transformation in the following ways:

  10. MLC Leadership Group • 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

  11. Sheila Laura MaryPractice 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!

  12. Methods of communication • Webinars, Seminars • teleconferences, telephones • Academic detailing techniques • Newsletter • Emails • Practice coaching visits • Selected Practice facilitation

  13. Maryland Learning Collaborative Website • 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

  14. Physician Teleconference • 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

  15. Mental Health • 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

  16. Planning Mental Health Discussion Forum • Live vs Media forum • Insight from Dr Anthony Lehman, Chair, Psychiatry • Being developed ..

  17. Developing Small Mental Health Pilot Project • 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

  18. Implementation challenges • Selection of the coaching/collaborative process for implementing change in primary care • Scanty resources

  19. System based issues • Patient attribution • Implementation of 24/7 access • Care Manager role and implementation • Payment Methodology supporting change • Data management

  20. Example of QA process

  21. July 1st 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

  22. MLC Ongoing program management needs • 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

  23. Establishing Partnerships • SON – Collaboratively Developing novel professional development curriculum to train CARE MANAGERS • MLC will Support the development of care managers’ roles within primary care practices

  24. Exploring partnerships • 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

  25. Next Regional Collaborative • August 2,3,4 • Baltimore north • Annapolis • Frederick • National Harbor

  26. Future Steering Committee dates • July 14th Thursday • August 16th Tuesday or 25th Thursday • September 15th Thursday

  27. Residency Committee • 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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