1. Assessing the Client - Part 2 [Site Name] Health Home Staff Training Service Model Developed Primary Care Development Corp

2. Objectives Upon completion of the training, staff will… Understand the purpose of and value of case conferencing Improve skills related to obtaining quality and accurate information from the case conferencing process. Have increased understanding of the providers’ perspective Become familiar with best practice techniques for conducting case conferences.

3. Agenda 9:30am Feedback & Review 9:45am Purpose of the case conference 10:30am Review of workflows and tools 11:00am Role Plays 11:10am Teach Backs 11:20am Summary & Take-A-Ways 11:30am Close

4. Feedback & Review Feedback Does everyone know where the tools are?

5. Recall - Assessment Domains Domains – Medical – Mental Health – Substance Abuse – Housing – Social/Legal – Vocational/Educational

6. Why do we case conference with providers? Assessment specific Critical medical/mental health event Significant change in client status To accurately and completely document that appropriate Health Home services were provided

7. Why do we case conference with providers? Assessment (Comprehensive Care Management) – Gather information – Gain fuller understanding of client – Set goals and plan follow-up steps Coordinate Care (Care Coordination and Health Promotion) – Follow-up on goal progress Client’s, Provider’s, Care Manager’s – Manage care transitions i.e. Hospitalizations or ER admissions/discharges

8. Workflow and Tools In-person Case Conference Workflow Assessment Templates – Providers

9. Patient Assessment In-Person Case Conferencing Workflow

10. In-Person Case Conferencing Workflow - Continued

12. Provider Templates Medical Mental Health Substance Abuse Housing

17. Obtaining Medical Documentation from Brooklyn PC Site 1.Send e-mail to medical case manager indicating client(s) for whom you need documentation No more than 3 requests at a time 2.Medical case manager will add your client(s) to her eCW calendar and e-mail you date & time for case conference. Will occur w/in 24 hours of your request Can be in person or via phone 3.You will confirm appoint and indicate format (in person or phone). 4.You will arrive for case conference PROMPTLY or call medical case manager to reschedule (x6032). 5.Medical case manager will provide you with documentation and requested information at this time.

18. Other Providers How do you request information from providers outside of our organization? Who do you reach out to if not the doctor?

19. Practice Specific Every practice has a different procedure – Medical Case Manager – Reception Desk Staff – Nurse – Practice Manager – Others Relationship-building is key!

20. Role Play Care Manager & Primary Care Provider Care Manager & Mental Health Provider Debrief

21. Teach-Backs/Practice Templates Groups of 2 Each group practice one template Debrief

22. Summary/Take-A-Ways Care Managers should use workflow & templates to prepare for case conferencing Templates & Workflows are available on shared drive Case Conferencing is critical in providing care coordination Building relationships with providers & their staff will help you get the information you need Think creatively and persevere!