PDCM Training

The Introduction to Team-Based Care course helps the learner better understand how to work in a multidisciplinary care team and in collaboration with the patient. Open to all members of the practice to gain foundational knowledge in Team-Based Care. Introduction to Team-Based Care will include:

• Why, What, Who and How: Team-Based Care
• Care Management Process
• Outcomes and Triple AIM
• Billing Applications

Open to all members of the physician organization or practice staff interested in gaining additional knowledge of PDCM codes and foundational care management billing.

This training will create a foundation for introducing palliative care into the primary care setting earlier in the course of a serious illness.  Multiple training sessions have been created and are available to any physician or care team member who would like to attend. Additionally, several on-demand learning opportunities are available that can be viewed at any time.  

The goal of this course is for all Care Team Members to learn engagement tools/skills in order to have productive conversations with patients about their health including basic motivational interviewing skills.The Care Team Member will build upon this foundation in order to apply their skills in different situations, such as Medication Assisted Treatment, (MAT) and Palliative Care. The objectives of this course are:

• Describe the patient-centered approach of MI.
• Explain the conversation style that is the Spirit of MI.
• Demonstrate basic MI skills. Discuss how to use patient language cues (change talk and resistance) in the application of MI skills.
• Explain how to engage the patient in the four processes in MI necessary for health behavior change.
• Identify barriers to patient engagement and behavior change.
• Identify how to make cultural adaptations to MI

The Specialist Team-Based Care course is designed to provide care team members with an understanding of the Blue Cross Blue Shield of Michigan Specialist Team-Based Care Program and how teams work to support success in this program. Learn about processes and communication between Primary Care and Specialist offices to improve care coordination and patient outcomes.

The goal for this education is to provide primary and specialist care teams a better understanding about the significant role of medications and diet in individuals with chronic kidney disease. Some medications may require dose adjustment or avoidance in the later stages of CKD due to nephrotoxic effects. Diet is also important throughout all stages of CKD and recommendations should be individualized to help improve patient understanding and compliance.