Practice Newsletter - July 24, 2014

Rhode Island Chronic Care Sustainability Initiative

Upcoming Meetings:

August 5, 7:30-9am

(Memorial Hospital, Pawtucket): Data and Evaluation Committee

August 7, 7:30-9am

(301 Metro Center Blvd., Warwick): PCMH-Kids Stakeholder meeting (committee members only)

August 8, 7:30-9am

(RIQI): Steering Committee

August 8, 9:30-11am

RIQI): Community Health Team Planning meeting (committee members only)

August 12, 8-9:30am

(RIQI): Nurse Care Manager Best Practice Sharing Committee

August 14, 8-9:30am

(RIQI): Practice Reporting Committee (REQUIRED meeting for all CSI sites to review Quarter 2 data)

August 21, 7:30-9am

RIQI): Practice Transformation Committee

August 21, 3:30-5pm

(RIQI): Integrated Behavioral Health Workgroup

August 22, 7:30-9am

(BVCHC): Executive Committee (committee members only)

August 22, 9:30-11am

(BVCHC): Community Health Team Planning meeting (committee members only)

August 28, 7:30-9am

(RIQI): Contracting Committee (CSI practices and health plans only)

Upcoming Events

Free Webinar on Health Behavior Change

Thursday July 31, 1:00 - 2:00pm

This webinar will look at brief approaches to behavior change that can help patients find their own solutions, resolve ambivalence and address barriers to change. For more information or to register for this event, click here.

Free Introductory Webinar on Motivational Interviewing and Evidence Based Approach

Tuesday July 29, 2014 11:00am - 12:00pm

A free introduction to Motivational Interviewing, a critical skill for healthcare providers who wish to encourage patients to set and achieve goals for health maintenance and disease management. For more information or to register for this event, click

here.

CSI-Rhode Island

508-421-5919

csi-ri@umassmed.edu

www.pcmhri.org

Rhode Island Foundation

One Union Station

Providence, RI 02903

Welcome to the Rhode Island Chronic Care Sustainability Initiative Practice Newsletter, where CSI-RI shares exciting updates, news, milestones, meeting information and more with our CSI-RI practices.

Save the Date for CSI-RI's Annual Learning Collaborative!

What:

CSI-RI's Annual Learning Collaborative:

"The Primary Care Team: The Future is Now"

When:

Thursday, October 9, 2014

1:00 - 7:30pm

Who:

Physician champion
Organizational leader
Nurse care manager
Office manager / person leading practice transformation

Where:

TBD

Stay tuned!

A confirmed agenda will be circulated later this month - stay tuned for more details! We look forward to seeing you and your practice team participate in this exciting learning opportunity.

Update on the Nurse Care Manager Measurement Project

The CSI-RI Pilot sites (together with Anchor Medical and WellOne) have been working hard on the Nurse Care Manager measurement project. Practices have been asked to develop team based systems to support the nurse care manager focus on high risk patients, and to test and determine the feasibility of the high risk definitions and reporting systems.

Health plans have been working behind the scenes to distribute weekly reports to practices on patients who utilize the ER and/or have an inpatient admission, and to distribute quarterly predictive risk reports to CSI-RI practices.

As part of this project, the participating practice sites completed a self-assessment tool to identify what systems they had in place for receiving, processing, and data entering ER/IP utilization information into the electronic health record to create real time utilization registries. The self-assessment tool also identifies what systems practices are using to capture and report on nurse care manager encounters and interventions.

While work is still being done to finalize the definitions of high risk patients, all CSI-RI practice teams are encouraged to complete the self-assessment tool and start looking at how the team can work together to focus on addressing the needs of high risk patients.

Practice Spotlight: Two More CSI-RI Practices Achieve NCQA

University Internal Medicine and Memorial Hospital of RI Family Care Center have achieved recognition through the National Committee of Quality Assurance as Level 3 Patient Centered Medical Homes. This is the highest level of recognition offered by NCQA for PMCH.

NCQA Patient-Centered Medical Home Recognition is the most widely-used way to transform primary care practices into medical homes and is considered the current "gold standard" in the field.

CSI-RI congratulates both practices for all of the hard work and dedication it took to receive this recognition.

Job Opening: Community Health Team Behavioral Heath Clinician

Thundermist Health Center is actively looking for a full time Behavioral Health Clinician to join the Community Health Team at their Woonsocket office.

The Behavioral Health Clinician is a member of the Community Health Team (CHT); a multi-disciplinary team comprised of Nurse Care Managers, Community Health Workers, Care Management Outreach Workers, and Behavioral Health Clinicians. The CHT supports patients of Thundermist Health Center who are dealing with complex medical and behavioral health and/or substance issues and require a more intensive home and community-based intervention. Behavioral Health clinicians are an integral part of the Community Health Team as they conduct behavioral health assessments, provide intensive case management, provide community based clinical interventions, contribute to the development of individual care plans, collaborate with staff, and make referrals as needed.

For more information and details on this posting, click here.

Mather LifeWays Institute on Aging Wants You to Share Your Most Innovative Practice

If your practice serves older adults in innovative and exciting ways please consider submitting an entry to Mather LifeWays Institute on Aging's 2014 Promising Practice Award. This award highlights organizations that work with older adults in a variety of settings that develop and implement new approaches to help this population age well. Each winning organization will receive an award plaque, a mention in Mather LifeWays' monthly news letter InvestigAge, recognition on the Mather LifeWay's website and a press release to send to local media.

Any organization that works with older adults is invited to apply (there is no submission fee). The deadline for application entries is September 15, 2014. To view the application form click here.

CurrentCare - Breaking Through Information Silos

As CurrentCare continues to emerge as a standard of care in Rhode Island, so does the number of people who continue to enroll (now over 401,000).

The RI Regional Extension Center, a service of the RI Quality Institute, assists practices with incorporating CurrentCare services into the office workflow and trains practices how to enroll patients. CurrentCare joins health information from across care settings, giving physicians and care teams the information they need to deliver the best possible care, avoid medical errors and duplicate tests, identify gaps in care, prevent avoidable hospitalizations and ED visits, and better coordinate care.

The CurrentCare enrollment process is transitioning from a paper-based system to a more efficient online enrollment process that will enable providers to easily enroll patients in CurrentCare and will provide additional benefits to the practice. Enrollment partners currently receive $1.00 for each successful paper enrollment, and can receive a $5.00 subsidy payment for all successful online enrollments through September 16, 2014. After September 16, the subsidy for all successful online enrollments will be $2.00, and subsidies for all successful paper enrollments will remain at $1.00.

For more details, please click here. If you are interested in becoming an enrollment partner, or learn about how to adopt CurrentCare services at your practice, please contact the RI Regional Extension Center by emailing CurrentCare@riqi.org, calling (888) 858-4815 or visiting www.CurrentCareRI.org.