Core Curriculum Guidelines - Suffolk Care · The Core Curriculum Guidelines for Practice Sites include training requirements for participating practice sites in the Suffolk Care Collaborative

Core Curriculum Guidelines for

Practice Sites Audience: Primary Care Practice Sites Medical & Non-Medical Staff & Care Teams

V.01

PROGRAM TOOL FOR PARTICIPANTS OF THE

SUFFOLK CARE COLLABORATIVE

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM

SUFFOLK CARE COLLABORATIVE | PROJECT MANAGEMENT OFFICE| www.suffolkcare.org | [email protected]

http://www.suffolkcare.org/

mailto:[email protected]

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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788

Table of Contents

Welcome ............................................................................................................................................................... 2

User Guide for Core Curriculum Guidelines .......................................................................................................... 2

Purpose of this Tool .......................................................................................................................................... 2

Train the Trainer Approach ............................................................................................................................... 2

Getting Started .................................................................................................................................................. 3

Core Curricula Learning Modules .......................................................................................................... 3

Required Training Topics ....................................................................................................................... 3

Online Learning Center ..................................................................................................................................... 4

Instructions to Return ....................................................................................................................................... 4

Core Curriculum Modules ..................................................................................................................................... 5

New Models of Care and Healthcare Trends ........................................................................................................ 5

DSRIP 101 .............................................................................................................................................................. 6

Community Orientation ........................................................................................................................................ 7

Cultural Competency & Health Literacy................................................................................................................ 8

Ethics & Professional Boundaries ....................................................................................................................... 10

Patient Centered Medical Home Recognition .................................................................................................... 11

Care Coordination Methodology, Protocol & Treatment Plans.......................................................................... 12

Chronic Disease & Co-morbidities ...................................................................................................................... 13

Primary Care & Behavioral Health Integrated Care Program ............................................................................. 14

Cardiovascular Health & Diabetes Wellness & Self-Management Programs ..................................................... 17

Interventions for Tobacco Cessation .................................................................................................................. 18

Promoting Asthma Self-Management Program ................................................................................................. 19

Performance Reporting & Improvement ............................................................................................................ 20

Health Information Technology, Connectivity & Documentation ...................................................................... 22

Regional Health Information Organization (RHIO) ............................................................................................. 23

HIPAA and Compliance Program ......................................................................................................................... 24

Practice Site Training Attestation Form .............................................................................................................. 25

Practice Site Training/Meeting Sign-in Sheet Template ..................................................................................... 26


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Welcome The Suffolk Care Collaborative (SCC) welcomes you as a participating practice site. You play a key role as we

pursue our commitment to improve the health and well-being of the community we serve through the New York

State’s Delivery System Reform Incentive Payment (DSRIP) Program.

User Guide for Core Curriculum Guidelines

Purpose of this Tool The Core Curriculum Guidelines for Practice Sites include training requirements for participating practice sites in

the Suffolk Care Collaborative (SCC). Most of the curricula was designed based on national literature reviews of

training provided around the country and vetted through appropriate key internal stakeholders. Core Curriculum

Learning Modules described should be considered as a starting point for practice site training, are customizable

and will evolve and grow overtime, some Learning Modules are optional while others are required under

participation in the DSRIP program.

The Core Curriculum Learning Modules represent recommended topics for practice site trainings and will position

your organization for successful participation in the DSRIP program. It will serve as a training foundation to harvest

a consistent base of knowledge on the system transformation, clinical improvement, population-wide programs,

patient education, care coordination, and many more. We believe the completion of this tool will enhance the

effectiveness of the services provided by your practice site.

Train the Trainer Approach Each participating practice site will identify a Practice Champion, as described in more detail in the SCC’s

Implementation Guide for Practice Sites. The SCC will train each Practice Champion on the contents of this tool

through a blended learning approach. Every Practice Champion will coordinate the completion of all required

training requirements by job family as described here.


http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

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Getting Started Once you are comfortable with the Core Curriculum Guidelines described in this tool, you will begin coordinating

practice site trainings with your staff. Some trainings may be in-person and/or facilitated by the SCC, via WebEx or

via the SCC’s online Learning Center. You may engage your staff multiple times in various forums that may work

best for your practice. Each time you host a training, we ask that you document the training on the Practice Site

Training/Meeting Sign-in Sheet Template appended to this tool.

Core Curricula Learning Modules We’ve provided a list of the Core Curriculum Learning Modules below. Each module includes recommended topics,

as well as learning objectives describing key competencies gained from each topic. Lastly, there will be links to all

core curricula to be used to facilitate training in each module.

1. New Models of Care & Healthcare Trends 2. DSRIP 101 3. Community Orientation 4. Cultural Competency & Health Literacy 5. Ethics & Professional Boundaries 6. Patient Centered Medical Home Recognition 7. Care Coordination Methodology, Protocol & Treatment Plans 8. Chronic Disease & Co-morbidities 9. Primary & Behavioral Health Integrated Care Program 10. Cardiovascular Health & Diabetes Wellness & Self-Management Program 11. Interventions for Tobacco Cessation 12. Promoting Asthma Self-Management Program 13. Performance Reporting & Improvement 14. Health Information Technology, Connectivity & Documentation 15. Regional Health Information Organizations (RHIO) 16. HIPAA and Compliance Program

The current list of Core Curriculum Learning Modules may change from time to time, these changes and/or

updates will be communicated to you via email and published in future versions of this tool.

Required Training Topics The training topics outlined in the table below should be completed to

meet DSRIP training requirements. The audience and mode are

provided. The audience is specified by job title or grouped by clinical

or non-clinical staff.

Required Training Modules/Topics Audience Mode

DSRIP 101 Clinical and Non-clinical Online Learning Center

Community Orientation

Clinical and Non-clinical Online Learning Center

Cultural Competency Health Literacy 101

Clinical and Non-clinical Online Learning Center

Understanding the Basic Principles and Core Elements of Care Coordination

Care Manager/Coordinator, Social Workers, Community and Health Worker

Online Learning Center

Understanding the Purpose and Benefits of Successful Patient Hand-offs

Care Manager/Coordinator, Social Workers, Community and Health Worker


When navigating through this tool, you will find required training topics marked with this symbol:


https://suffolkcare.org/aboutDSRIP/projects/3ai

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Cardiovascular Health & Diabetes Wellness & Self-Management Program (full Module)

Primary Care for adult patient population


Interventions for Tobacco Cessation - 5 A’s of Tobacco Cessation Control and Referring to the NYS Quitline

Primary Care for adult patient population


Asthma Home Environmental Trigger Assessment Services Overview

Clinical and non-clinical Coming Soon

The SCC Performance Reporting & Improvement Program

Administration, Health Information Technology, Physicians, PA, NP


Clinical Data Sharing & Interoperability Administration, Health Information Technology, Physicians, PA, NP

Will be facilitated by IT Team

RHIO Connectivity Overview


Will be facilitated by RHIO Representatives

Use of DIRECT Secure Messaging & Alerts


Will be facilitated by RHIO Representatives

HIPAA Privacy, HIPAA Security and Compliance

1 Representative per Practice Site to be completed during on-boarding

Online Learning Center & Self-Directed Learning

Online Learning Center The SCC Online Learning Center can be accessed at https://suffolkcare.org/forpartners/learning-center, where you

can access online health education at your convenience. Many of the Core Curricula Learning Module referenced

in this tool are available online, as indicated on the Required Training Topics table. You may choose to use the

web-based system tool to roll-out all training requirements. Each module is about 15-30 minutes in length,

participants will be required to complete a brief registration form and post-evaluation and test.

Instructions to Return When your practice has fulfilled all training requirements, you will complete the Practice Site Training Attestation

Form and return it to your designated Provider Relations Manager. To accompany this attestation, please provide

all sign-in sheets completed by your staff.


https://suffolkcare.org/forpartners/learning-center

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Core Curriculum Modules

New Models of Care and Healthcare Trends

Module Overview: This module provides an overview of the country’s health care delivery system and the goals of

health reform, both Federal and State levels. It focuses on new models of care, an introduction to care

coordination, and the changes in the way that health care is being paid for and delivered. Participants will gain an

understanding of the Triple Aim and how the system is being transformed in order to reach this goal.

Topic Learning Objectives Core Curriculum

Overview of US Healthcare System and Payment System

Describe the private, governmental, professional, and economic contributions to the development, maintenance, alteration, and operation of the U.S. health care system.

Describe the types and interrelationships among health care facilities, services, and personnel.

Understanding the basics of Medicare and Medicaid and private insurance as well as the basics of payment structures including capitation, value-based payments and their purpose in health care reform.

Understanding how health care reform will impact the delivery of health care services.

Describe the values and assumptions that underline the changing priorities in health planning resource allocation.

1199SEIU TEF and PCDC Care Coordination Fundamentals Module 1 - 2 1

New Models of Care

Understand the basics of the Triple Aim.

Describe new models of care (Health Homes, Patient-Centered Medical Home, ACOs, Clinically Integrated Networks, and DSRIP) and understand similarities and differences.

Understand the basics of PCMH standards as it related to care coordination.

Understand the difference between home care and health homes.

Understand how a value-based purchasing/pay for performance payment model differs from transitional fee-for service.

Understanding the differences between Individual vs. Population Health.

1 1199 SEIU Training and Employment Funds and Primary Care Development Corporation. Care Coordination

Fundamentals Teaching Guide, 2014.


https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf





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DSRIP 101 New York Delivery System Reform Incentive Program

Module Overview: This module provides an overview of the New York State’s Delivery System Reform Incentive

Payment Program (DSRIP). It focuses on the overall goals of the program, provides an overview of the SCC

structure and discusses the SCC Quality Improvement Agenda.


New York Delivery System Reform Incentive Program (DSRIP 101)

Required

Discuss the goals of DSRIP

Identify what a Performing Provider System is and its purpose

Describe the Suffolk Care Collaborative’s Structure

Recognize the 11 SCC DSRIP Projects

Discuss the Suffolk Care Collaborative’s Quality Improvement Agenda and Sustainability Plan






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Module Overview: This module provides an overview of the Suffolk County Community, its needs and Suffolk

Care Collaborative (SCC) initiatives. It explores how the SCC aims to focus multiple initiatives and strategies for the

high priority needs in Suffolk County to prevent chronic disease, promote mental health and prevent substance

abuse. Participants will gain a better understanding of the population characteristics and demographics,

understand and learn about strategies to address areas of need, and also how the Suffolk Care Collaborative is

connecting target populations and families to health and wellness services within the community.



Required

Understand the population characteristics and demographics of Suffolk County

Identify and understand the priority areas/needs in Suffolk County community and the relationship to the chosen clinical projects through our Community Needs Assessment.

Identify areas of need in order to better target the intended recipients

Identify the individuals and communities where avoidable utilization of high-cost health care resources currently exist.

Learn about the SCC and HITE partnership

https://suffolkcare.org/forpartners/learning-center HITE REFERENCE INFORMATION: http://files.constantcontact.com/b450ac0d401/ba317dd2-08c7-401b-acff-0cd56de6de7c.pdf?ver=1485200358000





http://files.constantcontact.com/b450ac0d401/ba317dd2-08c7-401b-acff-0cd56de6de7c.pdf?ver=1485200358000






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Cultural Competency & Health Literacy

Module Overview: This module establishes an overview of concepts used to enhance both patients’ and providers’

understanding of the health care system. It emphasizes the terms cultural competency and health literacy. These

terms enable the differing cultural needs of patients to be recognized while not overlooking a patients’ true

understanding of their overall health and well-being. The social determinants of health will also be analyzed in

order to further patients’ knowledge of their unavoidable risks with in the health care system.


Cultural Competency Health Literacy 101

Required

Define health literacy and cultural competency

Discuss the scope and the challenges of health literacy and cultural competency and why it is important.

Understand how culture, health literacy and language access influence patient-centered care.

Suffolk Care Collaborative: Learning Center: CCHL 101 Module

Cultural Competency

Recognizing patients’ families’ cultural needs/factors that may affect their choices or engagement

Define cultural competency, cultural respect, and cultural diversity.

Learn the factors that influence culture

Identify patients and communities in need including populations facing health disparities

U.S. Department of Health and Human Services National Institutes of Health Agency for Healthcare Research and Quality U.S. Department of Health and Human Services - Office of Minority Health

Communicating with patients and families in a culturally competent manner

Understand the impact of cultural backgrounds on patient decision making in healthcare

Educate partners about culturally appropriate methods to providing services to patients and their families

National Institute for Cultural Competence - Providers U.S. Department of Health and Human Services - Health Resources and Services Administration

Health Literacy

Create understanding for patients and their families in order for them to better understand health information

Define health literacy and the different factors that influence it

Identify and understand the 3 different types of health literacy and how to communicate effectively

Identify ways to educate patients and improve health literacy

Educate partners in linguistically appropriate methods in order to more easily communicate, process, and understand each patients needs

Centers for Disease Control and Prevention U.S. Department of Health and Human Services Health Literacy Partners




http://www.hrsa.gov/culturalcompetence/index.html


https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect

http://effectivehealthcare.ahrq.gov/ehc/products/573/1934/cultural-competence-protocol-140709.pdf

http://effectivehealthcare.ahrq.gov/ehc/products/573/1934/cultural-competence-protocol-140709.pdf

http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=10

http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=10

http://nccc.georgetown.edu/information/providers.html

http://nccc.georgetown.edu/information/providers.html




http://www.cdc.gov/healthliteracy/learn/index.html

http://www.cdc.gov/healthliteracy/learn/index.html

http://health.gov/communication/literacy/

http://health.gov/communication/literacy/

http://www.healthliteracypartners.com/happenings/

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Allowing patients and their families to understand the factors that influence a person’s overall health and wellness

Identify the five key social determinants of health

Identify new interventions and resources to address social determinants of health

Define Health Equity and the relationship to social determinants of health

Healthy People 2020 Centers for Disease Control and Prevention World Health Organization


https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

http://www.cdc.gov/socialdeterminants/

http://www.who.int/social_determinants/sdh_definition/en/

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Ethics & Professional Boundaries

Module Overview: This module reviews general ethics for healthcare workers. It focuses on making sure that

trainees understand ethical decision-making.


Ethical and Responsible Decision-Making

Identify a framework for ethical decision making.

Be familiar with and know the purpose of the patient’s bill of rights.

https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf Modules 2, 23, 24 2

Professional Boundaries

Understand personal and professional boundaries and why they are important.

Describe the role personal and professional boundaries have in creating positive relationships with partners and teammates.

Understand appropriate boundaries with social media while working with patients.

Describe ways to maintain healthy boundaries.

Understand risky behaviors that lead to boundary violations.

Understand the relationship between professional boundaries and burn out.

https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf Modules 23, 24 3 https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf https://www.ncsbn.org/NCSBN_SocialMedia.pdf


Fundamentals Teaching Guide, 2014. 3 Ibid.












https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf



https://www.ncsbn.org/NCSBN_SocialMedia.pdf

https://www.ncsbn.org/NCSBN_SocialMedia.pdf

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Patient Centered Medical Home Recognition

Module Overview: This module provides an overview of the National Committee of Quality Assurance (NCQA)

Patient Centered Medical Home Recognition. It focuses on the recognition process; an introduction to the PCMH

model of care; and the national Standards for practices for PCMH recognition. Participants will gain a better

understanding of the PCMH requirements and the roadmap to recognition submission. For the advanced

participant, a comprehensive look at the new 2014 Standards and Guidelines has been included in the curriculum.


NCQA PCMH Recognition Process: Start to Finish

Participants will gain an understanding of the PCMH recognition the process from start, “Is your practice eligible for PCMH recognition?” to finish, “Maintaining your NCQA recognition status.”

https://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh

Introduction to PCMH and Eligibility

Participants should be able to identity aspects of PCMH recognition including contents, scoring and eligibility as well as the documentation requirements.

https://www.youtube.com/watch?v=YQHHt-cEu4s&feature=youtu.be

Overview of the NCQA PCMH: Understanding the Six Standards

Participants should be able to identify and describe the six PCMH Standards. In addition, they should gain knowledge about the Elements and Factors that support the Standards and their documentation requirements.

Standard 1: Patient - Centered Access

Standard 2: Team-Based Care

Standard 3: Population Health Management

Standard 4: Care Management and Support

Standard 5: Care Coordination & Care Transitions

Standard 6: Performance Measures & Quality Improvement

https://www.youtube.com/watch?v=YQHHt-cEu4s&feature=youtu.be https://www.youtube.com/watch?v=qRSEy1NZruM https://www.youtube.com/watch?v=vI9RrGh0xjk https://www.youtube.com/watch?v=oB-632xbKsU&feature=youtu.be https://www.youtube.com/watch?v=9Sd_eof7q8w&feature=youtu.be https://www.youtube.com/watch?v=wuCitK1-SOk https://www.youtube.com/watch?v=fUPohydorRk https://www.youtube.com/watch?v=I_DwadhQ_T4

NCQA PCMH 2014 Standards and Guidelines

Participants should be able to discuss in detail the six PCMH Standards, their Elements and Factors. This tool will guide the user on documentation requirements to meet PCMH recognition.

http://files.constantcontact.com/b450ac0d401/929d2e83-a8a5-4fa8-82b1-c79659abc903.pdf?ver=1485200937000










https://www.youtube.com/watch?v=qRSEy1NZruM

https://www.youtube.com/watch?v=qRSEy1NZruM

https://www.youtube.com/watch?v=vI9RrGh0xjk

https://www.youtube.com/watch?v=vI9RrGh0xjk

https://www.youtube.com/watch?v=oB-632xbKsU&feature=youtu.be



https://www.youtube.com/watch?v=9Sd_eof7q8w&feature=youtu.be



https://www.youtube.com/watch?v=wuCitK1-SOk

https://www.youtube.com/watch?v=wuCitK1-SOk

https://www.youtube.com/watch?v=fUPohydorRk

https://www.youtube.com/watch?v=fUPohydorRk

https://www.youtube.com/watch?v=I_DwadhQ_T4

https://www.youtube.com/watch?v=I_DwadhQ_T4






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Care Coordination Methodology, Protocol & Treatment Plans

Module Overview: This module provides an overview of Care Coordination and its place in the health care delivery

system. Emphasis is placed on the importance of coordinated care throughout the continuum and how social

determinants of health can impact a patient’s health outcomes. Participants will gain an understanding of who can

coordinate care, how this is accomplished through transitions of care, and the importance of providing patients

with effective, efficient, patient centered care.


Understanding the Basic Principles and Core Elements of Care Coordination

Required

Understand and define what it means to coordinate care

Describe those members of the care team that coordinate care and how they work as in interdisciplinary team

Understand the importance of coordinating care throughout the care continuum

Describe basic barriers to reaching optimal health outcomes and explain ways in which these barriers can be overcome

Understand the difference between care coordination and care management


Understanding the Purpose & Benefits of Successful Patient Handoffs

Required

Understanding a warm hand-off & benefits of warm hand-offs, referrals and transfers

Understand effective and ineffective transitions in care

Describe the root causes of ineffective transitions

Describe various models of transitions of care


Integrated Delivery System (IDS) 101

Understanding the concepts of IDS, Clinical Integration, Clinical Interoperability and Population Health Management.

Understand the definition and meaning of an Integrated Delivery System

Understanding the SCC Clinical Integration Strategy

Describe the various levels of care coordination occurring throughout the care continuum

Understand how the DSRIP projects enhance the ability for care to be coordinated

Identify and differentiate between care coordination and more specialized, complex care management occurring at various levels of the integrated delivery system









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Chronic Disease & Co-morbidities Module Overview: This module reviews the major chronic diseases, co-morbidities and the implications of poor

chronic disease management on patients and the health care delivery system. It teaches students tools and

strategies to help patients thrive by reviewing both chronic disease care and the social determinants that affect

health outcomes. It includes a basic overview of the major chronic conditions. Programs should explore in greater

detail conditions relevant to the students’ occupations, work settings, and rural versus urban settings.


Chronic Disease & Co-morbidities (Part 1)

Understand what a chronic disease is, the prevalence of it in the U.S., and how it relates to our healthcare system.

Understand the basics of diabetes, hypertension, high cholesterol, asthma, heart disease, stroke, Hepatitis, HIV, behavioral health, and substance abuse.

Understand stigmas often associated with these chronic conditions.

1199SEIU TEF and PCDC Care Coordination 4 https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf

Chronic disease and co-morbidities (part 2)

Identify behaviors and risk factors related to diet, exercise and smoking that impact chronic disease.

Know the appropriate team member to report changes in behavior/condition.

American Academy on Communication in Healthcare: Behavior Change http://aachonline.org/dnn/Resources/Academic-Articles/Behavior-Change

Disease Registries: A Powerful Tool to Support Your Practice!

Understand what a disease registries is.

Understand why healthcare organizations and providers use computerized disease registries.

Understand and identify different types of registries.

Disease Registries: A Powerful Tool to Support Your Practice http://files.constantcontact.com/b450ac0d401/5e74f8aa-04af-4bd7-

a030-c6ac47629ad8.pdf?ver=

1488912825000


Fundamentals Teaching Guide, 2014.







http://aachonline.org/dnn/Resources/Academic-Articles/Behavior-Change




http://files.constantcontact.com/b450ac0d401/5e74f8aa-04af-4bd7-a030-c6ac47629ad8.pdf?ver=1488912825000






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Primary Care & Behavioral Health Integrated Care Program

Module Overview: This module provides a comprehensive look at the process of primary and behavioral health

integration. The modules progress though understanding the core concepts related to integrating services, and the

prevailing models on integration and their relation to population health, to preparing for integration, and finally to

full implementation and documentation. Participants will gain a full understanding of the potential of this type of

integration to improve the health outcomes of patients, and what the steps will be to work towards this

integration.

To access the trainings, please contact your project manager or email us at [email protected]

Topic Description Learning Objectives Core

Curriculum

Basics of Integrated Care

This module prepares the audience to understand the core concepts related to integrating behavioral health services into a primary care setting

Describe the population based goals of integrated care

Describe the continuum of integrated care

Name the core competencies for providers in an integrated care approach


Basics of Bidirectional Integrated Care

This module prepares the audience to understand the core concepts related to integrating primary care services into a behavioral health setting

Describe the basic parameters of bidirectional programs

Identify the common goals of bidirectional interventions

Identify the core factors that make bidirectional programs effective


Primer on Evidence Based Models of Integrated Care

This module prepares the audience to understand the current prevailing models of integrated care and their relationship to constructs such as “level of integrated care” and “population penetration.”

Name and describe the three prevailing models of integrated care

Describe the meaning behind the constructs of levels of integration and population penetration

Describe the difference between models and programs


Rating Your Level of Integrated Care Using the MeHAF

This module prepares the audience to learn how to self administer the MeHAF tool which is used to rate a site’s level of integration.

Describe the team members required for self-administering the MeHAF

Describe the core competencies of the MeHAF

Self-administer the MeHAF rating scale


Primer on Screening for Integrated Care

This module provides an introduction to the concept of screening as it pertains to integrated care efforts including the different uses of

Identify the typical tools used in primary care

Describe the concepts of screening, assessment and tracking























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screening tools and key implementation concerns.

Describe implementation considerations for establishing screening pathways

Working with BHCs: The Warm Hand-Off

This module provides primary care providers with basic language and understanding of how to effectively provide a warm handoff of a patient to a behavioral health consultant.

Describe the function of a warm handoff

Describe the strategies often used to manage flow in a primary care setting

Describe a sample introduction that a primary care provider can use to introduce services to a patient


Documentation for Primary Care

This module provides an exemplar of effective standard practices for documenting for the primary care record. Although North Carolina standards are referenced the core concepts are applicable across different state settings.

Describe the components of a primary care specific SOAP note

Describe elements that do not belong in a primary care record

Describe regulatory parameters that may influence the content of a SOAP note


Primer on the Primary Care Consult

This module provides behavioral health consultants with a framework for how to structure consults with patients in primary care in a 15 to 30 minute modality.

Describe the core components of a typical consult

Describe the content of an effective introduction

Describe the content of an effective functional analysis


Primer on the PCBH Model

This module provides an overview of one of the three prevailing models of integrated care, the primary care behavioral health model.

Describe the core attributes of the PCBH model

Describe the goals and core metrics of a PCBH service

Describe the core competencies of a BHC in this model


Registry Basics This module provides the audience an overview of the use of and rationale for registries in managing patient populations.

Describe the difference between a spreadsheet and a database

Describe the way in which registries are used to manage care

Describe considerations for implementing a registry based care pathway


Improving Screening and Identification in Pediatric Practices

This module provides the audience with a strategy for identifying pediatric patients who are at risk of behavioral health issues.

Name the percentage of children who have identifiable behavioral health conditions

Describe the components of the AAP Mental Health Toolkit



























16:


Describe the elements to consider when implementing screening

Primer on Pediatric Consults for Primary Care

This module provides the audience with basic strategies for structuring a pediatric primary care behavioral health consult.

Describe the areas where primary care consultation can be effective

Describe the strategies for engaging pediatric patients

Describe the core competencies of a pediatric behavioral health consultant







17:


Cardiovascular Health & Diabetes Wellness & Self-Management Programs

Module Overview: This module reviews the evidence-based resources and treatment strategies being

implemented to support the Cardiovascular Wellness and Self-Management Program and the Diabetes Wellness

and Self-Management Program. You will learn about the Million Hearts® campaign, tools available to identify

patients in need of follow-up care, how to successfully retrieve accurate blood pressure readings and teach self-

monitoring blood pressure techniques, and methods to reduce tobacco use in patients. You will also learn about

tools available to identify patients with diabetes or “at-risk” of developing diabetes, comprehensive diabetes

testing methods and lifestyle recommendations. Finally, you will learn about documentation of patient self-

management goals and how to refer patients to self-management education.


The Cardiovascular Wellness & Self-Management Program

Required

Demonstrate the elements of the DSRIP Cardiovascular Wellness & Self-Management Program

Recall major strategies, goals, and tools of the Million Hearts® campaign

Recognize how a registry is used to identify and track hypertension patients

Summarize key points from guideline recommendations

https://suffolkcare.org/forpartners/lea

rning-center

Blood Pressure Measurement (practice-based or self-monitored)

Required

Summarize proper techniques and equipment for measuring Blood Pressure

Identify implications of performing blood pressure measurements incorrectly

State the impact of self-monitored BP programs (SMBP) in reducing risk of disability or death due to uncontrolled hypertension

Identify features to consider in guiding patient in selection of SMBP equipment

Review the validation process for automatic blood pressure measurement devices


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Diabetes Wellness & Self-Management Program

Required

Review the impact of diabetes

Define the elements of the Diabetes Wellness & Self-Management Program

Apply the screening and treatment recommendations for patients with diabetes


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Patient Self-identified Goals and Diabetes & Chronic Disease Self-Management Education

Required

Formulate ‘smart goals’ in collaboration with patient

Illustrate Motivational Interviewing techniques to assist patients in setting health goals

Identify benefits of diabetes and chronic disease self-management education, components of self-management programs, and the various programs to which a patients can be referred


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Interventions for Tobacco Cessation

Module Overview: This module is intended to support trainees in understanding interventions for tobacco

cessation to support the SCC’s clinical improvement programs and population-wide wellness initiatives. You will

learn about Tobacco Cessation control methods endorsed by the Million Hearts® campaign as well as

understanding the services provided through the NYS Smokers’ Quitline.


5 A’s of Tobacco Cessation Control and Referring to the NYS Quitline

Required

Summarize the 5 A’s of tobacco cessation counseling

Describe the services of the NYS Smokers’ Quitline and the referral process

Illustrate how Progress Reports are obtained and the information included in the reports

Discuss the role of patient-center communication in providing effective tobacco counseling

Provide evidence-based brief interventions in counseling tobacco users


Tobacco Dependence and Cessation Treatment in Individuals with Mental and/or Behavioral Disorders

Identify strategies that individuals with mental and/or behavioral health disorders may use to support their efforts to quit using tobacco products

Define the 5A’s for treating tobacco dependence as outlined in the US PHS Guidelines Treating Tobacco Use and Dependence

Identify the FDA approved medications used to treat tobacco dependence for patients who use tobacco products and increase the rate of successful quit attempts

Evaluate various resources available to assist patients to quit

Summarize the 5R’s to enhance motivation to quit using tobacco products









19:


Promoting Asthma Self-Management Program

Module Overview: This module reviews the evidence-based resources and treatment strategies being

implemented to support the Promoting Asthma Self-Management Program. You will learn about tools available to

assess and monitor patients with asthma, comprehensive education about asthma self-management, the

importance of controlling environmental exposures that affect asthma patients, medication to treat asthma.


Asthma Home Environmental Trigger Assessment Services Overview

Asthma Home Environmental Trigger Assessment Services Overview.

Values of promoting asthma self-management and learn about the tools and patient education resources available.

https://suffolkcare.org/forpartners/learnin

g-center

The American Lung Association’s Asthma Basics Course

Recognize and manage triggers.

Understand the value of an asthma action plan.

Recognize and respond to breathing emergency.

View the What is Asthma? Animation that shows the three primary changes in the airways during an asthma episode.

Learn about comprehensive resources, including asthma medication devices and demonstration video downloads for patients.

Asthma Basics in English

Asthma Basics in

Spanish





http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/asthma-basics.html?referrer=https://www.google.com/

http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/asthma-basics.html?referrer=https://www.google.com/

http://www.lung.org/espanol/asthma-basics-en-espaol.html



20:


Performance Reporting & Improvement

Module Overview: This module provides an overview of the SCC Performance Reporting and Improvement

Program. It focuses on an introduction to the SCC Performance Reporting and Improvement Program and

describes the Domain 1 Patient Engagement Reporting Requirements. Participants will gain a better

understanding of how to deploy PDSA cycles to conduct tests of change and utilize control charts to understand

data variation.


The SCC Performance Reporting & Improvement Program

Required

Describe the purpose of the SCC Performance Reporting and Improvement Plan

Define the SCC approach to Rapid Cycle Improvement

Discuss the performance reporting organizational structure and stakeholder roles and responsibilities

Identify the 11 DSRIP projects the SCC is implementing across Suffolk County

Explain the performance reporting requirements for Domain 1 Patient Engagement, Domain 1 Project Engagement and Domain II & III Performance Outcomes

Discuss the Pay-for-Performance (P4R) and Pay-for-Performance (P4P) model and associated timeline

Explain the Gap-to-Goal improvement standards

Describe the SCC approach to data aggregation and analysis including the decision support tools used to support the performance reporting program

Explain the SCC action planning process

Describe the SCC recommended model for performance improvement (IHI Improvement Model)


IHI – An Introduction to the Model for Improvement

Describe the Model for Improvement

Discuss how to use the Plan-Do-Study-Act (PDSA) cycle to conduct rapid tests of change

Explain the three questions that can help drive quality improvement work


IHI – Building Skills in Data Collection and Understanding Variation

Describe how to evaluate data variation

Explain common and special causes of variation

Identify data collection strategies


IHI – Using Run and Control Charts to Understand Variation

Describe the history of how statistical process control (SPC) methods evolved over time

Identify three key questions to construct and use a control chart

Explain how to select the appropriate control chart based on the types of data


SCC Domain 1 Patient Engagement

Describe the DSRIP Domain 1 Patient Engagement Reporting Requirements and commitments made to the Department of Health

Identify the SCC data request timeline and DOH reporting

https://suffolkcare.org/forpartners/datarequest

















21:


schedule

Explain the patient engagement data specs needed by DSRIP project

Discuss the temporary strategy for transmitting Protected Health Information (PHI) to the Suffolk Care Collaborative to meet each Patient Engagement Quarterly Reporting Requirements


22:


Health Information Technology, Connectivity & Documentation

Module Overview: This module provides an overview on the SCC’s Clinical Data Sharing & Interoperability plan

and the essential steps defined as “technical on-boarding” which our Information Technology Team will be

engaging with your practice to complete. Upon successful completion of “technical on-boarding” your practice will

have access and interoperability with the SCC’s Population Health Management platform and applications.


Clinical Data Sharing & Interoperability

Required

1. Introductions to the SCC Information Technology Team 2. Introduction to the DSRIP & SCC values and roles 3. Provide a program overview of the SCC’s Building an

Integrated Delivery System, benefits and how “big data” is an essential element in integrated care delivery.

4. Describe the SCC’s Population Health Platform and six applications used in the platform.

5. Understand the 4 steps in the technical on-boarding process, timeline and deliverables at each stage in the process.

6. Preview step 2 of the technical on-boarding process the “technical deep dive”

Please note training will be provided by the

SCC IT Team Representatives

directly. Technical On-boarding

Process Training

Basic Technology documentation requirements in the electronic health record

1. Learn what the SCC’s expectations are for clinical documentation and/or modifications in the electronic medical record

2. Understand the basic technology documentation specifications in the electronic health record.

3. Understand the forms that will need to be returned to the SCC to demonstrate successful completion of documentation requirements.

An Orientation to the Suffolk Care Collaborative: DSRIP Clinical Programs Presentation Slides: 20, 24, 28, 32 http://files.constantcontact.com/b450ac0d401/7fb7e6a6-b88f-4cdb-aa66-54ac6f23cd46.pdf?ver=1485200360000


https://suffolkcare.org/sites/default/files/DSRIP%20Technical%20On-Boarding%20Slides%20v16.pdf

https://suffolkcare.org/sites/default/files/DSRIP%20Technical%20On-Boarding%20Slides%20v16.pdf

http://files.constantcontact.com/b450ac0d401/7fb7e6a6-b88f-4cdb-aa66-54ac6f23cd46.pdf?ver=1485200360000






23:


Regional Health Information Organization (RHIO)

Module Overview: This module provides an overview of Regional Health Information Organization (RHIO)

Connectivity, the ways in which RHIO connectivity can improve and streamline using and accessing patient specific

data, the use of DIRECT secure messaging and receiving alerts. This module will also provide information for

physicians on explaining and obtaining patient consent. At the end of this module, you will be have increased

knowledge on RHIO, the benefit as a provider to accessing the RHIO and knowledge on how best to discuss RHIO

consent with your patient.


RHIO Connectivity Overview

Required

1. Learn the value of a Regional Health Information Exchange

2. Understand why RHIO connectivity is an essential element to improve the quality and efficiency of healthcare for Medicaid eligible patients

3. Understand how RHIO connectivity allows a bi-directional connectivity/communication line between the provider and a Qualified Entity

Please note training will be provided by RHIO

Representatives directly.

Use of DIRECT Secure Messaging & Alerts

Required

DIRECT Secure Messaging: 1. An exchange that occurs through the Qualified Entity

Health Information Service Provider (HISP) and the provider

2. Secured access thru webmail to exchange care summary and other clinical information between providers in the community

3. DIRECT secure messaging supports patient referrals and transitions of care

Alerts: 1. Physician practices, health home providers and health

systems can receive a notification whenever their patients are admitted or discharged from any partner hospital or emergency department.

2. Patient RHIO consent is required to use this feature

Please note training will be provided by RHIO

Representatives directly.


24:


HIPAA and Compliance Program

Module Overview: This module presents essential information about the SCC’s HIPAA and Compliance Program

including information privacy and security, ethics, Code of Conduct, confidential reporting, the legal framework for

compliance, and how to get more information when you need it. Attention is also given to the relationship

between Coalition Partners and the SCC in the implementation of the Compliance Program.


HIPAA Privacy

Required

Describe the Health Insurance Portability and Accountability (HIPAA) Privacy Rule

Describe Individually Identifiable Health Information (PHI)

Describe Protected Health Information (PHI)

Understand the basic responsibilities of Business Associates (BAs)

Understand Patient Rights under HIPAA

http://files.constantcontact.com/b450ac0d401/f9d8c75c-1e84-42e3-999b-5109e66ee5ec.pdf?ver=1485200421000

HIPAA Security

Required

Understand the Health Insurance Portability and Accountability (“HIPAA”) Security Rule and e-PHI

Describe the Health Information Technology for Economic and Clinical Health Act (“HITECH”)

Understand the basic responsibility of Business Associates (BAs)

Understand Administrator Requirements of the HIPAA Security Rule

Describe a Breach Notification/Assessment/Impact

Understand the basic responsibilities of Subcontractors

Understand investigations and consequences of HIPAA violations

Describe HIPAA case studies

http://files.constantcontact.com/b450ac0d401/6f11f159-1058-4e7f-9e03-4a5c974a6196.pdf?ver=1485200421000

Compliance

Required

Understand the scope and requirements of the SCC Compliance Program and how to get information when you need it

Read and acknowledge the SCC Code of Conduct

Understand the duty to report compliance concerns and how to do so confidentially

Know that retaliation against good faith reporters is prohibited

For SCC personnel only: complete a Conflict of Interest disclosure form

SCC Compliance Training Video














https://suffolkcare.org/compliance/training

https://suffolkcare.org/compliance/training

25:


Practice Site Training Attestation Form Practice Information

[Practice Name ] [Address Location]

[Practice Site Primary Contact Name & Title]

[Practice Site Primary Contact Phone Number] [Practice Site Primary Contact Email Address]

Attestation of Training Completion The purpose of this Practice Site Training Attestation Form is to document completion of the training which occurs at practice sites. Please print this page, complete and sign this attestation when your staff has been trained on all required DSRIP training requirements as outlined in the Core Curriculum Guidelines for Practice Sites. It is recommended that you keep a copy of this completed form for your reference as it will be submitted to the New York State Department of Health as documentation your staff has been trained.

I attest the office of _____________________________________________________ has successfully completed all required DSRIP Training requirements.

[Practice Site Primary Contact/Administrator (Print)]

[Practice Site Primary Contact/Administrator Title]

[Practice Site Primary Contact/Administrator Signature]

Instructions to Return Once all training requirements are complete, please attach the corresponding Practice Site Training Sign-In Sheets. Please use the SCC Practice Site Training Sign-In Sheet Template, provided on the next page. You may have multiple sign-in sheets. If your staff utilized the SCC Online Learning Center to complete any of the DSRIP required training modules, you do not need to attach sign-in sheets, as participation is automatically captured. Please return all materials to demonstrate the completion of all required DSRIP training requirements to your designated Provider Relations Manager at the Suffolk Care Collaborative.


26:


Practice Site Training/Meeting Sign-in Sheet Template

Instructions to return: Please print when completing this template, once complete please return to your designated Provider Relations Manager at the Suffolk Care Collaborative.

[Practice Site Name ]

[Address Location]

[Training Module and Training Topic Name]

[Training Facilitator Name & Title (if applicable)]

[Format/Mode of Training]

[Date]

[Time]

Frist Name Last Name Suffix Title Email Initial


Documents

Core Curriculum Guidelines - Suffolk Care · The Core Curriculum Guidelines for Practice Sites include training requirements for participating practice sites in the Suffolk Care Collaborative