Applicable to PCPs and specialists. When patient is co-managed by PCP and specialist, roles must be clearly defined regarding who is responsible for ensuring patients receive needed community services.
10.1
PO has conducted a comprehensive review of community resources for the geographic population that they serve, in conjunction with Practice Units
PCP and Specialist Guidelines:
- The review may take place within the context of a multi-PO effort
- Review should include health care, social, pharmaceutical, mental health, and rare disease support associations
- If comprehensive community resource database has already been developed (e.g.,by hospital, United Way) then further review by PO is not necessary
- Review may include survey of practice units to assist in identifying local community resources
10.2
PO maintains a community resource database based on input from Practice Units that serves as a central repository of information for all Practice Units.
PCP and Specialist Guidelines:
- The database may include resources such as the United Way’s 2-1-1 hotline, and links to online resources.
- At least one staff person in the PO is responsible for conducting a semiannual update of the database and verifying local resource listings (PO may coordinate with Practice Unit staff to ensure resource reliability)
- During the update process, consideration may be given to including new, innovative community resources such as Southeast Michigan Beacon Community’s Text4Health program
- It is acceptable for staff to not verify aggregate listings (such as 2-1-1) if they are able to document how often the listings are updated by the resource administrator
- Resource databases are shared with other Pos, particularly in overlapping geographic regions
- Portion of database includes self-management training programs available in the community
10.3
PO in conjunction with Practice Units has established collaborative relationships with appropriate community-based agencies and organizations
PCP and Specialist Guidelines:
- PO is able to provide a list of organizations in which collaborative relationships are directly established
- Collaborative relationships must be established with selected agencies with relevance topatients’ needs
- Collaborative relationships need to be established directly with the individual agencies (notvia 2-1-1) and involve ongoing substantive dialogue
10.4
All members of practice unit care team involved in establishing care treatment plans have received training on community resources so that they can identify and refer patients appropriately
PCP and Specialist Guidelines:
- Training may occur in collaboration with community agencies that serve as subject-matter experts on local resources
- PO or Practice Unit administrator assesses the competency of Practice Unit staff involved in the resource referral process at least annually. This may occur in conjunction with community agencies.
- For example, practice unit staff are able to explain process for identifying and referring patients to relevant community resources
- Practice Unit is able to demonstrate that training occurs as part of new staff orientation
10.5
Systematic approach is in place for educating all patients about community resources and assessing/discussing need for referral
PCP and Specialist Guidelines:
- Systematic process is in place for educating new patients and all patients during annual exam (or other visits, as appropriate) about community resources and assessing/discussing need for referral
- For example, Practice Units may develop an algorithm (or series of algorithms) to guide the referral process
- Information about available community resources may be disseminated via language added to patient-provider partnership documents, PO or Practice Unit website, brochures or county booklets at check-out desk
10.6
Systematic approach is in place for referring patients to community resources
PCP and Specialist Guidelines:
- Practice Unit must be able to verbally describe or provide written evidence of systematic process for referring patients to community resources.
- For example, systematic process may consist of standardized patient referral materials such as a “prescription form”, computer-generated printout that details appropriate sources of community-based care, or other documented process or tools.
- Patients should have access to resources that are appropriate for their ethnicity,gender orientation, ability status, age, and religious preference, including resources that are available in other languages such as Spanish, Arabic, and American Sign Language, and resources available both locally and nationally.
- For example, if Practice Units within a PO have a great deal of diversity within their patient population, the PO may amass specific information about services for those diverse patient groups. Practice Units may also share information about resources for diverse groups.
10.7
Systematic approach is in place for tracking referrals of high-risk patients to community resources made by the care team, and making every effort to ensure that patients complete the referral activity
PCP and Specialist Guidelines:
- Practice units have the responsibility to identify those patients who are at high risk of complications/decompensation for whom referral to a particular agency is critical to reaching established health and treatment goals.
- Referrals to community resources should be tracked for high-risk patients. Practice Units are encouraged to create a hierarchy to ensure that vital services (such as referrals to mental health providers) are being tracked appropriately. Specialists must ensure that PCPs are notified about referrals to community resources for high-risk patients.
- The purpose of tracking the referrals is to ensure that these high-risk patients receive the services they need.
10.8
Systematic approach is in place for conducting follow-up with high-risk patients regarding any indicated next steps as an outcome of their referral to a community-based program or agency.
PCP and Specialist Guidelines:
- Patients may be held partially responsible for the tracking process. For example, Practice Units may use technology such as Interactive Voice Response (IVR) for patients to report initial contact and completion, develop a “passport” that patients can have stamped when they complete trainings or attend a support group, or use existing disease registries such as Well Centive to track community-based referral activities.
- Process includes mechanism to track patients who decline care and obtain information about reasons care was not sought.
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Expand the PCMH-Neighborhood to include community resources. Incorporate use ofcommunity resources into patients’ care plans and assist patients in accessing community services.
No reference links associated with this module.
PGIP - Physician Group Incentive Program
An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.
PO - Physician Organization
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
PHO - Physician Hospital Organization
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.
MPP - Physician Partners
An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".
SRD - Self Reporting Data
Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.
PU - Practice Unit
The identification of a practice within the PGIP program.
PCMH Nomination
An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.
Denominator
Total number of "current" patients in the practice.
Numerator
Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past
4P or Pay for Performance
Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)