Additional Resources (MAT)
File
File
Resource Type
Resource Library
Care Planning provides the learner with the necessary elements, purpose, framework and skills for care management team members to develop a high quality patient-centered plan of care. The learner will also be able to apply knowledge from the care planning lesson to a case study.
The expected time to complete this module is 60 minutes.
Lesson 1: The Patient-Centered Care Plan
Objectives:
Resource Type
Training Framework 2020 Presentation
Video file
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.
Resource Type
Wexford PHO: Access to Healthcare
File
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.
Resource Type
Upper Peninsula Health Group: Utilizing iPad Technology to Screen for and Address Social Determinants of Health
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.
Resource Type
The Physician Alliance: Social Determinants of Health Screening Workflow and Resource Database Development and Implementation
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.
Resource Type
Physician Health Care Network: Care Management Intervention for SDoH Resources
2019 Best Practice Awards Submission for SDoH
The goal of the program is to identify patients who may need extra resources that may not be referred through the Care Management referral process. The program was developed by the Care Management team with a SIM template serving as the guide to create their own screening tool. A SDoH survey is performed on all patients; and for those who report a positive response, staff will begin the process by offering community services information materials and connect to a Care Manager.
Resource Type
Northern Physician Organization: Implementation of a Social Determinants of Health Assessment Tool by Kids Creek Children's Clinic
2019 Best Practice Awards Submission for SDoH
A Social Determinants of Health Screening project was implemented at Kids Creek Children's Clinic between June 2017 and October 2017; and is still on-going and expanded. During the implementation, the Social Needs Screening Tool was completed by 1863 patients/parents and a Community Resources Guide was distributed as well. Additional referrals were made to the Care Manager for more intervention.
Resource Type
Metro Health Integrated Network: Integrating Social Determinants of Health Screening in the Primary Care Setting
2019 Best Practice Awards Submission for SDoH
The first part of the program involved establishing and implementing a standardized SDoH screening tool into the workflow. The second part of the program was using the information to identify patients with social needs and link them to appropriate community resources. Lastly, education and training was provided to the practices with the objectives of defining SDoH, explaining the five domains of SDoH, understanding the importance of screening, describing the screening and documentation process, utilizing proper tools and resources, and identifying patients in need of follow-up.
Resource Type
Jackson Health Network: Addressing Social Determinants of Health within Jackson Health Network
2019 Best Practice Awards Winner for SDoH
The implementation of the 15-question SDoH screen occurred in June 2018. The goal was to identify patient needs and link them to community resources to address their needs. Through July 2019, 50,338 SDoH screens were administered, resulting in 4,809 unique referrals to community resources. Screenings for SDoH are being completed in 23 primary care practices.
Resource Type