Resource Library

In 2020, MICMT will be launching new course curriculum to include: Introduction to Team Based Care, Patient Engagement, MAT Orientation, Palliative Care, and Specialty Care. The presentation reviews the new framework, training opportunities, and training reimbursements. 

2019 Best Practice Awards Submission for SDoH

A plan was developed as a healthcare system which guaranteed that patients with or without a network primary care provider were seen for follow-up with seven days of discharge. This was accomplished by: 1) maintaining designated appointments on PCP schedules every day; 2) scheduling patients with the hospital based clinic provider for hospital follow-up if their PCP could not accommodate the appointment or the patient did not have a PCP; and 3) developing a transition plan to a network PCP for patients who did not have one prior to accessing hospital services.

2019 Best Practice Awards Submission for SDoH

There was an identified need to screen all patients for SDoH, as previously only screening patients who were receiving care management services. The PRAPARE questionnaire was designed on the iPad for patients to complete during check-in process to minimize impact on time in exam rooms. Patients with issues identified through the screening met with either a care manager or community health worker through a warm handoff, and were provided support or connected to community resources as needed.

2019 Best Practice Awards Submission for SDoH

TPA's mission includes improving the health and reducing cost for the patient population. Best practice workflow for SDoH screening was defined and implemented. 88% of patients were screening, but only 42.7% received a referral when they had a positive screening. The ease of identifying and referring patients was determined as a barrier to referrals. An SDoH health database vendor was selected (NowPow, community resource database) and implementation has begun.