Regional Care Collaborative Webinar Session

"Medicare Chronic Care Management: An Emerging Opportunity for FQHCs"


Jack Millaway, MS, CPHQ, Senior Data Analyst, Louisiana Public Health Institute

Stacey Curry, MPH, Director of Clinical Quality Management, Coastal Family Health Center

Alvin Baker, MSW, LMSW, Team Leader, University of Southern Mississippi

Webinar Description: Beginning in January, the Medicare Chronic Care Management (CCM) program will pay FQHCs over $60 PMPM for providing non face-to-face services such as medication reconciliation, patient communication, referral tracking and follow-up to Medicare patients. While this program alone is an excellent opportunity for community health centers, its alignment with other value-based care programs or ACO models also makes it an important tool for success. This webinar will review the requirements of the CCM program, best practices for beginning these services at your organization, and a review of the LPHI Chronic Care Management tool, which can be used to estimate revenue and staff time and serve as a tracking tool as you begin this program.

Webinar Recording

Webinar Slides

LPHI Chronic Care Management Toolkit

Regional Care Collaborative Webinar Session"Community-Centered Health"

Speaker Rich Bell: As a Senior Project Officer for Active Living By Design, Rich Bell provides guidance and support for clients, community partnerships and their leaders on all aspects of their work, including strategic planning and prioritization, community engagement and partnership development, capacity building, project implementation, assessment, evaluation and sustainability of efforts to increase active living and healthy eating in communities. He represents ALBD with national partners concerning his primary areas of expertise in planning and urban design, transportation, housing and community development, urban ecology and community gardening. Rich earned a B.A. in economics from Brown University and a master’s in city planning from the University of California at Berkeley.

Webinar Description: The Community-Centered Health Home (CCHH) model is a framework for health centers and their community partners to address the upstream factors that influence health, such as housing or employment. Over the last two years, five health centers across the Gulf Coast received funding from the Primary Care Capacity Project to implement the CCHH model, which produced promising results in their communities. In addition, the Blue Cross Blue Shield Foundation of North Carolina and Active Living By Design have worked with health centers and community groups in North Carolina to draw from the CCHH model and build strong clinical-community partnerships capable of improving community conditions. This webinar provides a refresher on the CCHH model and feature Active Living By Design staff expertise on community engagement and program planning. The presentation highlights actionable strategies, including: engaging hard-to-reach residents, building trusting relationships with your community, selecting priorities with a diverse set of partners, and building sustainable programs.

Webinar RecordingWebinar Slides

Regional Care Collaborative Webinar Session "MACRA Doesn't Matter - Or, Does It?"
Speaker Adele Allison: As the director of provider innovation strategies, Adele Allison monitors healthcare reform for DST System’s health solutions division, a leading provider of health IT solutions for payers, providers and pharmacies dedicated to improving the delivery and administration of healthcare in terms of clinical, financial and patient health outcomes.
Webinar Description: Six years post-Affordable Care Act (ACA) we have a plethora of value-based payment programs entering mainstream healthcare economics. In April 2015, this transformation accelerated when Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) establishing two data-driven payment tracks to purchase value over volume. Commercial and Medicaid payers are deploying such payment reform programs, as well. In this webinar, Adele Allison explores payment transformation through the use of data. With the proper infrastructure and knowledge, providers and their communities can create tremendous value and become strong contenders to accept emerging risk-based contracts being demanded by payers and employers. Learn the fundamentals of health IT associated with alternative payment model (APM) risk-bearing arrangements and incentive-based programs. This session will provide insight into growing trends, opportunities and administrative challenges.

Objectives: By the end of the presentation, attendees will be able to:
  1. Identify strategies to implement in your practice that will prepare you for the transformations coming your way as a result of MACRA legislative mandated changes.
  2. Describe the role of effective data capture to determine the value of services and healthcare reimbursement under emerging population-based payment (PBP) models.
  3. Implement changes in improved data capture that aligns with essential documentation within the primary care group practice and among organizational leaders including coding staff.

Webinar Recording
Webinar Slides

Regional Care Collaborative Webinar Session "Collecting Social Determinants of Health Data Using PRAPARE"
In this webinar, Ms. Michelle Jester, MA discusses "The Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences" (PRAPARE). PRAPARE is a national effort to help health centers and other providers collect and apply the data they need to better understand their patients' social determinants of health, transform care to meet the needs of their patients, and ultimately improve health and reduce costs. PRAPARE is a standardized patient risk assessment tool as well as a process and collection of resources to identify and act on the social determinants of health. This webinar describes how PRAPARE was developed, lessons learned from implementation, and how health centers can use PRAPARE. Find more information on the tool at:

Webinar Recording
Webinar Slides

Regional Care Collaborative Webinar Session "Provider Recruitment & Retention"

In today's competitive health care market, it is imperative that you not only have an excellent recruiting program but that you also continually work on keeping the highly skilled staff that you currently have in place.

During this webinar, Ann Hogan, an experienced Human Resources expert, discusses the elements of a recruitment plan and the importance of "thinking outside the box" by getting creative with recruiting techniques. Additionally, she talks about ways to retain your current staff and the importance of conducting a stay interview. Lastly, she shares an important resource from the Star2 Center where you can get additional guidance and resources.

Webinar Recording

Webinar Slides

Example Stay Interview Guide (from Gonzaga University)

Regional Care Collaborative Webinar Session "5 Steps to Better Transitions of Care"
Experiencing a transition of care increases the chance that a patient will suffer from a medication error or other mistake by 140%. But primary care providers can act to reduce that risk. This webinar supports community health centers and other primary care practices in identifying and addressing common challenges that providers face in coordinating transitions.
The webinar will address such questions as: What can we do today to improve transitions of care? How can the patient be engaged in achieving positive outcomes? What role can Health Information Technology play, and what does HIT fail to address?
Finally, the webinar discusses the ways in which effective management of transitions of care can prepare your organization for Value-Based Payment arrangements and other new reimbursement models. The webinar is presented by Primary Care Development Corporation, and includes the perspective of your peers in community health who have faced these challenges and developed solutions that work.
Webinar Recording
Webinar Slides

Regional Care Collaborative Webinar Session "Building a Culture of Service Excellence"

"Patient Experience: it's not about making patients happy over quality. It's about safe care first, high quality care, and then satisfaction."- James Merlino, MD, President And Founder, Association For Patient Experience Service Excellence and the Patient Experience are more important than ever! Today, patients have more choices about where to receive healthcare and providers have more choices of where they refer their patients. At the same time, reimbursement is becoming increasingly tied to quality, timeliness of care and the overall patient experience. As competition in the healthcare industry continues to escalate we must further distinguish ourselves as a provider of choice or risk losing market share and revenue. Lori Hinga, Clinical Nurse Consultant, presents "Building a Culture of Service Excellence." Learn more about what is required to provide the exceptional service that will set your health center apart as 'The Community's Premier' provider.

Webinar RecordingWebinar Slides

Regional Care Collaborative Webinar Session
“National Models & Success Factors for Accountable Care Readiness”

In this webinar Julie Peskoe and Daniel Lowenstein from the Primary Care Development Corporation share a national outlook on transforming health centers from fee for service to value-based payments and discuss helpful models being implemented across the nation. Elena Thomas from John Snow, Inc. (JSI) talks about a NACHC readiness assessment tool that highlights important factors and competencies to be successful in service delivery redesign and payment reform initiatives.
Webinar RecordingWebinar SlidesNACHC Payment Reform Readiness Assessment Tool

Regional Care Collaborative Webinar Session
“Switching EHRs: What to Consider & Lessons Learned”

Tired of hearing complaints about your EHR? Not sure if you team needs more training or needs a new system? In this one hour webinar, Kelly Maggiore and Jack Millaway from Louisiana Public Health Institute (LPHI) take you through common decision factors for switching EHRs, what to consider when transitioning, and best practices for vendor selection. Coastal Family Health Center, a Primary Care Capacity Project participant, also shared their EHR replacement process and lessons learned.

Webinar RecordingWebinar Slides

Regional Care Collaborative: Sustaining Patient-Centered Care
March 25-26, 2015
InterContinental Hotel New Orleans, LA

Final Agenda:

Wednesday Presentations:

Thursday Presentations:

Regional Care Collaborative Webinar Session
“Disaster Preparedness and Response”

As we know, Gulf Coast communities, residents, and businesses face natural and human-created disasters throughout the year, not just during Hurricane Season.

In this presentation, Chandra Smiley, MSW, Executive Director of Escambia Community Clinics, Inc. (ECC) will discuss a recent flooding disaster that caused severe damage to ECC's facilities and equipment. As she describes the impact of the event, Ms. Smiley will discuss both planning and real action steps needed to assure a CHC has the support in place to successfully respond during and recover after emergencies.

You can find the slides and a recording of this presentation below:

Emergency Preparedness and Response Webinar

Regional Care Collaborative Webinar Session
“Building Care Teams”

Webinar Recording: <Please note there is a four minute delay before Dr. Rollow>

Please join us on September 5th for a webinar titled, “Building Care Teams”. We will discuss the role of care teams in the care planning process as a part of a Patient Centered Medical Home, and explore traditional and non-traditional care team models, and options for how to best train members of these teams.

Date: September 5th, 2014
Time: 12- 1 PM CST
Mode: GoToWebinar
Speakers: Dr. Bill Rollow and Judy Mitchell
Bill Rollow, MD MPH – Medical Director, Primary Care Development Corporation (PCDC)
Dr. Rollow is Assistant Professor in Family & Community Medicine and Director of Clinical Services at the Center for Integrative Medicine at the University of Maryland. Board-certified in family medicine and with a master’s degree in public health, he has an extensive background in primary care practice transformation, quality improvement, healthcare technology, medical management, managed care, federal government programs, and administration, having developed and led the EmblemHealth Medical Home High Value Network Project, directed the CMS group with responsibility for the Medicare Quality Improvement Organization and End Stage Renal Disease Networks programs, provided technology-based strategic and analytic consulting services at IBM, and held senior medical director positions at BlueCross BlueShield of Illinois and at Anchor HMO.Dr. Rollow seeks to promote improvement in health care outcomes and cost through organizational and delivery system redesign, and to provide and promote learning about clinical and preventive services that are integrated across conventional and other modalities and inpatient, ambulatory, and community settings.

Judy Mitchell – Director of Healthcare Quality, Franklin Community Health Center in Alabama
Judy Mitchell has served in several capacities as a professional nurse for over 30 years, including 11 years at Franklin Primary Health Center. In addition to training as a nurse she is certified by professional boards in the following areas; Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM), Professional Academy of Health Care Management (PAHM) and Certified Professional Coder-A in 2014. Judy has 20 years of experience working with the underserved, uninsured and underinsured populations.
She has worked on an 1115 Medicaid demonstration waiver and assisted with incorporating 41,000 Medicaid recipients in the Mobile area, including the Aged Blind and Disabled, into a managed care environment including formation and implementation of Primary Care Provider homes. Judy has worked extensively with implementation and management of several projects at Franklin including: The Southern Community Cohort study (SCCS) projects at Franklin Primary Health Center serving as the Center Project Director for SCCS recruitment and cancer patient navigation activities, Joint Commission Primary Care Medical home implementation and certification and Clinical lead for implementation of the NextGen electronic health record.

The intended audience includes, quality managers, health center leadership, providers, care team members, clinical staff, and anyone who is interested in learning more about care teams.

To register, follow the link below:

Regional Care Collaborative Webinar Session
“Building Care Teams”

Regional Care Collaborative: Advancing Patient-Centered Care

June 17th, 2014 8:00 AM - 6:00 PM

Battle House Renaissance Marriott Hotel, Mobile, AL

Thank you to everyone who was able to attend the Regional Care Collaborative: Advancing Patient-Centered Care event! We hope that you were able to gain valuable information and connections with other organizations at the event to expand your Health Centers’ efforts to improve health and provide high-quality care across the Gulf Region. As promised, here are the slides from the presentations that you saw on June 17th. Presentations are listed in the order that they were presented at the RCC.

Behavioral Health Integration in Federally Qualified Health Centers:

Strategies for Making It Work

Kathy Reynolds, MSW, ACSW

Vice President, Integrated Health and Wellness, National Council for Behavioral Health

For FQHCs moving to PCMH, behavioral health will become more important. This presentation will identify strategies for successfully providing behavioral health services in the primary care setting.

Care Teams in PCMH and Beyond

Maia Bhirud and Julie Peskoe, Primary Care Development Corporation (PCDC)

Judy Mitchell, Franklin Primary Health Center

What are the elements components of effective care teams and what are the barriers to effective teams? This presentation covers the characteristics of effective teams and the development of those teams. Franklin Health Center will share their perspective on the resources and challenges of creating strong, high functioning care teams.

Sustaining Patient Center Medical Homes

Alan Mitchell, PCDC

This presentation describes how to sustain your Patient Centered Medical Home operations despite competing priorities, limited resources, and other challenges. We’ll discuss building sustainability plans before, during, or after your initial implementation, calculating costs associated with PCMH activities, and approaches to developing cost benefit analyses.

Strengthening Integrated Health with the FQHCs

Dr. Jennifer Langhinrichsen-Rohling, University of South Alabama

Michelle Brazeal, University of Southern Mississippi

In this session, the presenters will explore different work flow models for integrating behavioral health within an FQHC.

Patient Centered Medical Home and Meaningful Use: Two Birds, One Stone

Alan Mitchell, PCDC

Stacey Curry, Coastal Family Health Center, Inc.

This presentation describes methods for efficiently achieving Patient Centered Medical Home and Meaningful Use standards simultaneously. We’ll discuss overlaps between the two standards, areas where they diverge, and approaches to tackling the work each entails.

Quality Improvement and Performance Monitoring in a PCMH

Maia Bhirud, PCDC

Beth Edwards, Mostellar Medical Center

This presentation describes how to approach complex quality improvement initiatives from their inception through their completion. Through the lens of a robust referral tracking initiative, we'll frame one method for embracing quality improvement challenges and finding effective solutions.

Chronic Care Management in a PCMH

Julie Peskoe, PCDC

Dr. Shondra Williams, Jefferson Community Health Centers, Inc.

This breakout session is an introduction to the chronic care model and the role of the care manager and care team in addressing the needs of chronically ill patients. Learn how Jefferson Community Health Center transformed to address the needs of their patients with cardiovascular and diabetic disease.

Facilitated Conversation with State Primary Care Associations


Tom Knox, Director of Preparedness & Education Programs, Florida Association of Community Health Centers


Sharon Parker, Chief Quality Officer, Alabama Primary Health Care Association


Robert Pugh, Executive Director, Mississippi Primary Health Care Association

Angel Greer, CEO, Coastal Family Health Center, Inc.


Jasmyne Watts, Emergency Preparedness Coordinator, Louisiana Primary Care Association

Rolling Up Your Sleeves on ICD-10 Webinar Session

Speaker: Adele Allison, National Director of Government Affairs with Greenway

The transition from ICD-9 to ICD-10 is set to take place on October 1, 2014.

All areas of the healthcare delivery system will be impacted// by this changeover and the enormity of the many considerations associated with the changeover process can be daunting. Are you ready?

Join Adele Allison as she speaks about the task at hand and the interdependency of disparate systems such as claims, interfaces and other technologies. Adele will review the core components of ICD-10 and how it differs from the current ICD-9 system, as well as the impact to the healthcare infrastructure. Designed for those seeking to be fully prepared, Adele will shed light on the benefits and challenges associated with adoption of ICD-10 nationwide and the steps you need to be taking now to position for success later.

Target Audience: Hospital Administrator, Clinical Director/Manager, Executive Director, Fiscal Officer, Health Educator, Information Systems/Tech, Medical Director, Nurse, Physician, Physician Assistant, Clinical Operations

By the end of the presentation, attendees will:

1. Understand how to analyze and improve clinical processes to ease the ICD-10 transition.

2. Be able to explain the impact of third parties on ICD-10 preparedness.

3. Discuss the importance of implementing a Clinical Documentation Improvement (CDI) program.

4. Learn to identify opportunities created by ICD-10 and emerging analytic technologies.

Recorded Session:

Presentation Slides:

December 10th RCC Webinar Learning Session: Clinical Transformation

Presentation Slides: