Viewpoint Volume 3 Issue 4 Winter Solstice 2017 by VerdenGroup

CONTENTS Volume 3, Issue 4 - WINTER SOLSTICE EDITION 2017

Welcome

Industry News

Big Impacts

It's All About Disaster This Issue

Disaster Impacts on Industry

Disaster-Proofing Your EMR

Pummeled by hurricanes and with winter dead ahead, we had to focus this issue on all things disastrous! Planning is the key to minimizing damage.

We tend to think of how disasters affect people and practices, but industry takes a big hit too. Susanne takes a look at the impacts on big business and politics.

Think you've got it covered? Maybe not. David Magbee examines the processes behind EMR back ups and explores options for making your EMR disaster-proof.

ProTips

Finance Matters

Practice Matters

Surviving A Disaster

Upcoming Primary Care CPT Code Changes

How To Effectively Prepare for Disaster

Do you know how to get through a disaster? Tiffany shares tips on how to plan - and how to survive - any disaster that comes your way.

Coding expert Jenna Mirchin takes us through some primary care CPT code updates for 2018.

Are you ready for the next big storm? Preparation is the key to surviving and recovering from disasters that may hit your practice. Heidi tells us how.

HR Matters

Spotlight

Connect

Do Your Employees Know What To Do In A Disaster?

Giving Back To The Community

How To Best Use Social Media in a Disaster

Tiffany Lauria walks us through disaster planning and employee policies, and provides some resources to get you started on your plan.

Lighthouse Pediatrics set up a Swap Shop for its patients and local community, whereby folks can leave or take clothes and supplies as they need them. We spoke with Dr. Dudley to learn more.

30 Frontlines: Podcast How One Practice Weathered The Storm Susanne spoke with Dr.'s Sogol and Silen Pahlavan of ABC Pediatric Clinic in Houston, Texas, to learn about how they handled Hurricane Harvey and what they learned from the experience. 2

Social Media expert Noreen offers guidance on how best to use social media platforms during a disaster to communicate with patients, staff & family.

SPECI AL SUPPLEMENT: PATIENT CENTERED MEDICAL HOME The team at The Verden Group's PATIENT CENTERED SOLUTIONS has been so busy over the last quarter that we decided to make the PCMH section it's own special supplement this quarter. The team reports from NCQA's Quality Talks and the PCMH Congress, and discusses the new Advanced Performance Program that we've created to address NCQA's PCMH 2017 Annual Reporting requirements, plus the latest roll call for Clients receiving recognition under the program. More at www.ncqasolutions.com

Highlights from NCQA's PCMH Congress 2017

PCS' Advanced Performance Program

Notes from NCQA's Quality Talks

Sound Bites from the PCPCC

Roll Call: Clients Achieving PCMH Recognition

TEAM & CONTRIBUTORS

Susanne Madden

Tiffany Lauria

Heidi Hallett

David Magbee

Scott Hodgson

Editor

Contributor

Production

Web Master

Cover Design

Amanda Ciadella

Jenna Mirchin

Julie Wood

Noreen Quadir

Contributor

ViewPoint is a digital publication that looks at perspectives on the business of healthcare and is produced by The Verden Group. ViewPoint is available by free subscription and is distributed seasonally. Print copies are available by request. Please contact us for pricing. The Verden Group delivers expert services and advice to meet needs across your practice. We work with individuals and groups of any size, from start-ups to super groups. From contract negotiations and management, to social media set-up and administration and PCMH transition ? we are your Partner In Practice. To learn more about our services visit www.theverdengroup.com . Read past issues of the magazine and additional content at: verdenviewpoint.com 3

? WELCOME ? The end of the year once again. Time to reflect on the days just behind and begin planning for a brighter year ahead. And what a ride 2017 has been! As we go into 2018, we are dealing with a Congress that has failed to re-authorize funding for CHIP (the children's Medicaid program) and that has passed a tax bill that allows for a significant transfer of wealth to the richest amongst us and that guts the Affordable Care Act in a sly move that Mr. Donald Trump thinks is worthy of bragging. Our morals undermined, our society threatened by white supremacist neo-nazi thugs, and all in a year where facts became optional truths, our main branches of government are being run by unqualified, inexperienced hacks, and the freedom of the Internet has been sold out by the very organization sworn to protect it. Add to that pile of burning trash denial of climate change, threatening UN members on how they vote, and provoking a lunatic who possesses nuclear weapons., and it's is easy to say that if Mother Nature is in any way reflective of our psyche, it is not surprising that we've seen hurricanes so intense as to be off the historical charts, and flooding, fires, and heat waves from hell. All I can say is that 2018 must be better. WE must be bet t er. We must continue to fight against the lies, hatred and foolishness that holds our government in its grip. Whether you are Democrat, Republican, Independent or just damn disgusted, right is right and fair is fair and it's not hard to stick to the moral compass upon which this republic was founded. May we find common ground to come together and fight for what's right and may our collective voices be heard. It is no accident that this quarter's issue is focused on DISASTER. We bring you tales from the front from a practice in Houston, Texas, that exemplifies how to make the best out of a bad situation. We offer advice on disaster planning, employee policies, personal survival tips and how to secure your data. We hope that you'll use this issue as a guide for how to plan and implement measures that will keep you safe when the next storm rolls in. It's not all doom and gloom. We bring you the story of the Swap Shop out of Lighthouse Pediatrics in Florida, an inspirational initiative that we hope others will adopt. There are some CPT code changes you'll need to know about from a new voice to the publication, coding specialist Jenna Mirchin. Lastly, we've given Patient Centered Solutions its own section this quarter, given that the team has spent most of the season attending various PCMH conferences, presenting and exhibiting, and working with NCQA to improve its Oncology PCSP program as well as several other initiatives designed to improve communication and comprehension of these programs. May you find this issue useful and timely and wishing you all a peaceful and reflective new year; then roll up your sleeves please. We've got work to do!

SUSANNE MADDEN | EDITOR-IN-CHIEF 4

? INDUSTRY NEWS ? SUSANNE MADDEN, MBA, CCE CEO / CoFounder / Editor

DI SASTER I MPACTS ON THE HEALTHCARE I NDUSTRY From Hurricane Harvey striking Texas on August 17 to the forest fires burning in Northern California?s wine country in October, parts of the US have been walloped by natural disasters in 2017. While a huge toll was exacted on the affected populations, a different kind of toll was exacted on the healthcare industry itself.

Ot her Texas Insurer St rat egies t o Adapt t o Post -Hurricane Needs Insurers know that the best thing they can do in response to a disaster is to ensure their members have access to the benefits of their plan quickly and easily. In a statement from America?s Health Insurance Plans, they outlined their commitment,?

We take a look at the impacts in a variety of areas and what organizations are doing in response to such repercussions.

When a community is impacted by a tragic, disastrous event like we?re seeing unfold with this storm, plans connect immediately with state and local officials to offer support and ensure those impacted have swift access to the healthcare, resources and medical services they need.?

Heal t h Insurers?Assist wit h Rel ief Ef f ort s Despit e Losses In the aftermath of the Texas hurricane, Aetna and Humana went the extra mile and offered additional ?employee-assistance plan-type services, including resource allocation services, to all members of the affected communities?. At a time when plan members may have been affected by evacuation orders or loss of property, and may not even have had their personal belongings or identification, those extra measures could have meant all the difference to a patient needed medications or emergency care.

On August 23, Texas Gov. Greg Abbott issued a disaster proclamation which, in turn, resulted in the Texas Department of Insurance (TDI) issuing several bulletins outlining what health plans would do: -

Despite steep insurance stock losses resulting from the hurricane?s damage, insurance companies joined other corporate giants in making large donations to help with relief efforts. The Aetna Foundation pledged $100,000 each to the Red Cross and Community Foundation of Greater Houston and $50,000 to nonprofit Team Rubicon, while Humana donated $250,000 to hurricane relief efforts in Texas and Florida.

Authorize payment for necessary medical equipment, supplies, and services, regardless of the date on which the service, equipment, or supplies were most recently provided (Bulletin # B-0010-17); Waive penalties and restrictions so members affected by the disaster can get health and dental services out-of-network, and extend any claim-filing deadlines as needed (Bulletin # B-0012-17); Authorize payment for up to a 90-day supply of covered prescriptions (Bulletin # B-0014-17).

Whether it was the push from TDI or pleas from the Governor, Texas?insurers generally relaxed rules so 5

that their enrollees could access what they needed when it was needed.Members were able to utilize out-of-network providers, replace lost/ damaged insurance cards and make use of much-needed extended claims-filing deadlines. Blue Cross Blue Shield of Texas, the biggest insurer in the state, pledged $1 million in hurricane relief funds and went a step beyond the standard approach of assigning a team to answer incoming calls by also making outbound calls to some of their 1.5 million affected members offering help with emergency services.

Empl oyee Loss / Unempl oyment in t he Texas Insurance Workf orce A November 17 newsletter from The Greater Houston Partnership reported that the Texas Workforce Commission documented a loss of 16,000 jobs in Houston in September attributable to Hurricane Harvey, and also that the finance/ insurance industry (as well as healthcare industry) were represented as payroll categories reflecting job losses ? albeit not as severely as the retail/ restaurant industries. The major economic implication of these job loss statistics in terms of the Texas healthcare system is that adults who have lost their income are more likely to fail to pay required monthly premiums and medical co-pays? thereby creating more financial stress on both providers and insurers.

Research St udies on Heal t hcare Indust ry Impact of Disast ers According to a Millimanwhite paper in October 2017, there are both short-term and long-term impacts on the healthcare industry from such disasters.Long-term impacts described in this white paper were categorized as follows: -

Membership changes (potential demographic changes resulting from re-settlement to non-affected geographic regions). Health outcomes (increased infection rate widely recognized as a public health risk linked to natural disasters). Operational changes (care management disruption leading to worse health outcomes, with a resulting reduction in governmental quality-based payments to providers and insurers). Claims projections (need for adjustment to incorporate anticipated disaster effects).

The five short-term impacts were noted as: 1. More Emergency Department patient visits (due to inability of patients to see own physicians and/ or patient displacement [e.g.,temporary relocation]). 2. More necessary inpatient services (due to injuries or illnesses consequent to the natural disaster). 3. Extended inpatient stays (due to the inability of patients to safely return to home environments following the natural disaster). 4. Prescription medication effects (due to lost medications, prescriptions, and/ or duplicated prescriptions). 5. Healthcare delivery system disruption (e.g.,temporarily damaged healthcare facilities, and need to relocate patients).

Across the entire healthcare systems in disaster-affected regions, a major impact is clearly the need for both provider organizations and health insurance companies to adjust their probability calculations in terms of expenditures/ revenues for the following year. Of course in a post-natural disaster situation this usually results in increased insurance deductibles and premiums.

Flooding, power outages, and property damage from Hurricane Harvey caused the temporary closure of at least 75 dialysis clinics in Texas, leaving patients with diabetes at extreme risk. In an attempt to mitigate a potential crisis, some clinics in the area started having emergency preparedness meetings weeks in advance of the hurricane, made efforts to dialyze patients in advance, and provided patients with emergency packets.

Disast er-Rel at ed Disorders Requiring Immediat e At t ent ion

Of major concern after any storm that produces flood waters is the toxic exposure to contaminants. After Hurricane Irma, parts of Florida were covered in sewage water, while Hurricane Harvey ?dumped a year?s worth of cancer-causing pollutants into the air? from chemical plants and oil refineries. The problem with such flood-water chemical exposures is that cancers associated with such exposures often do not show up for decades. Whether or not cancers that show up years from now can be linked back to a specific storm is doubtful but the fact remains that government, private insurers and healthcare providers will bear the brunt of associated costs of these health outcomes.

A recent review of health problems following flood and storm disasters addresses the need to shed light on the importance of collecting more data to inform the medical response. The review points to a significant increase in wounds, poisonings, and skin/ gastrointestinal infections following storms that produced floods. A recent NY Times article took a look at the long term health consequences after Hurricane Harvey, noting that individuals with chronic respiratory and cardiac disorders are especially prone to long-term decreased health status following any natural disaster. After a natural disaster, complications arise when patients don?t have the necessary medications to treat chronic conditions, which results in increased hospital visits for medicines. The need for disaster preparedness becomes glaringly evident when we take a closer look at specific chronic conditions such as diabetes.

The Ment al Heal t h Impact of Nat ural Disast ers With disasters on the scale of these recent hurricanes, feelings of anxiety, fear and stress are commonplace. Often these symptoms don?t decrease on their own with time and can, in fact, lead to much more serious, long-lasting mental health conditions such as depression and PTSD. As we experience more and more natural disasters, it has become increasingly apparent that the system of care needs to go beyond disaster groups - such as FEMA and the Red Cross - to include organizations dedicated to mental health. In response to this, the Disaster and Community Crisis Center at University of Missouri prepared a factsheet to address the ?profound mental health consequences can be expected as a result of major disasters of all types.? The factsheet examines the effects of disasters on mental health and also provides insights on how the healthcare industry should respond. 7

While the focus of the factsheet is on establishing principles in disaster related mental health issues and outlining general guidelines for clinicians, the picture it paints is that the effects on mental health are substantial and the impact on healthcare is both costly and long-term.

While President Trump tweeted in October about the success ofFEMA?s relief efforts in Puerto Rico, the island remains largely without any running water or electricity? with no improvement predicted for at least a year due to the wind destruction on September 20th of all of Puerto Rico?s electrical generators. Similar to the impoverished people in sub-Saharan Africa, Puerto Ricans are currently vulnerable to succumbing from diseases associated with a lack of clean drinking water and what should be easily-treated infections.

Down-Sizing It is not only insurance companies and healthcare provider businesses that have been affected. Health IT is also reeling, with an article in the Boston Business Journal on October 19, 2017, detailing that Athenahealth planned to cut 9% of its national workforce due to the impact of these disasters.

Trump?s proposed FEMA budget for 2018 shows an utter disconnect between the monetary cost of disaster recovery efforts and federal dollars budgeted for the efforts. Trump and his Administration?s lack of recognition of the impact of warmer ocean water on increased hurricane strength (combined with a roll-back of greenhouse gas emission standards) reveals total ignorance of the relationship of extreme weather events to a hotter earth?s atmosphere from carbon dioxide emissions and does not bode well for recovering from these 2017 events, let alone how we will manage next year?s impending crises.

While not disaster-related, with only three insurers serving the Houston area expect to return to the federal exchange marketplace in 2018, and with requested huge increases in their premium rates for 2018, and eight insurers no longer offering insurance at all in Texas?individual exchange marketplace, fewer options for individuals seeking to purchase insurance in theACA-mandated marketplace will be available there. So where will disaster-related laid-off employees obtain health insurance, if insurers either exit the federal exchanges or raise their premiums to an unaffordable level?

Disast er Rel ief and Proposed Tax Overhaul The Trump Administration?s tax overhaul ? now signed into law as of December 22, 2017 reduces federal revenues spent on programs such as disaster relief. Never has it been more apparent that disaster relief funds must be bolstered, yet Trump?s plan reduces funding. Where are the funds to cover future disaster relief? The Trump Administration and Republican-led Congress do not have the answer to this critical question, except to show a mind-boggling lack of empathy for Americans who were the victims of these natural (but not inevitable) disasters through their continued attempts to de-fund ?safety-net? programs benefiting disaster survivors.

The health insurance industry?s reaction to President Trump?s refusal to provide the insurance subsidies mandated by the Affordable Care Act is to proactively "reign in" expenses. That makes financial sense for insurers in these uncertain times, but it is not good for our healthcare delivery system in the long run. Instead, it shifts a greater share of the cost-burden onto providers, and will thereby increase the number of people in the US unable to access healthcare at a time when many need it more than ever.

The Trump Administ rat ion?s 'Bl ind Eye' t oward Post -Disast er Suf f ering Even before Hurricane Maria slammed into the Virgin Islands and Puerto Rico,Moody?s Analytics had already estimated damage due to Hurricanes Harvey (Texas) and Irma (Florida) at a minimum of $15 billion.

As we head into 2018, we can only hope that more sensible politicians will be elected in the mid-terms and make the health of its People the priority once again. 8

? BIG IMPACTS ? DAVI D MAGBEE Consultant & Intrapreneur

DI SASTER-PROOFI NG YOUR ELECTRONI C MEDI CAL RECORDS Making Sur e Your Recor ds Ar e Secur e

The term ?life-threatening? takes on new meaning during a natural disaster, when critical information systems may be down and patients are in need of uninterrupted care. Healthcare IT professionals underscore the importance of backup, recovery, and operational access of this vital information for good reason ? in times of disaster, accessing information is essential to providing ongoing care and avoiding business interruption.

These are key to ensuring continued, operational success. Off-site backups can be easily scheduled through an EHR/ EMR provider and can occur without requiring physical backups. It?s important to check with your software provider to ensure your off-site backup system is HIPAA-compliant and performs backup protocols at regular intervals. To determine intervals, consider the work necessary to re-acquire any information not properly backed up; costs associated with acquiring said information; and the frequency of visits to your practice.

One Backup is not a True Backup In today?s era of using phones that function like computers, the concept of backing up digital information is a familiar one. But implementing a backup plan for a healthcare institution can be much more complicated than plugging a phone into a computer at night.

On-site backups can be much more complicated. They require more physical hardware, manpower, and time to implement. The same basic time interval principles should be considered when developing an on-site backup plan to ensure there is minimal data loss ? as what has not been logged, will be lost.

Many EHR/ EMR providers offer a cloud-based backup system in conjunction with their software. These data backup systems are great when the internet is functioning, there?s no weather-related physical damage to a system, and staff are readily able to properly implement that data recovery. But what if a computer?s infrastructure fails? Off-site cloud storage may suffer. Worse still: the data could become corrupted.

The general rule of thumb is that unless there is more than one backup (or at least three if you?re a techie), it?s not really backed up. Industry professionals suggest a three-dimensional plan to ensure data is safely stored. These three dimensions are time, space, and method; and refer to the time frequency in which backups are made, the space they keep, and the method in which they are stored.

Cloud-based backup systems are a necessary part of any backup plan. But nothing can replace physical, on- and off-site backup components. 9

Here?s a nerdy diagram to illustrate what we are talking about here:

Also keep a multi-person accountability program in place to verify that backup protocols are being met and performed appropriately.

A plan implementing frequent physical information backups will minimize instances of lost information. Consider the following: If an off-site cloud based backup occurs during non-operational hours at 2am, but there is a power outage at 11pm that evening, and your uninterrupted power supply (UPS) only maintains power to your system for 2 hours, your system will be disconnected from the cloud for backup at 1 am. Your backup is now an entire day behind.

Regular testing of on- and off-site backup options is imperative to ensure that information can function in times of need.

Recovery Data recovery is an oft-feared scenario. When critical patient information is at risk, it is no less frightening. It is essential that you always ensure data recovery is possible. Your ability to utilize recovered information is a crucial step to developing a true disaster preparedness plan.

Additionally, applications are rarely backed up? only the data. But the data is useless without the appropriate applications to access it. For this reason, always be sure to include application backups in your on-site implemented backup plan.

Many professionals in the industry would suggest a 10

Software as a Service (SaaS) option for achieving these objectives. Software as a service is a subscription-based distribution model for licensing where the software is centrally hosted. This is a great option if you can guarantee you will have power, internet access, and the staff to implement the recovery of your systems ? Hurricanes Maria, Irma, and Harvey are in recent enough memory to be a testament to the fact that this not always the case.

Operat ional Access Up to this point we?ve covered a variety of backup and recovery plans that all lead to this final act: operational access. None of it truly means anything unless you can be operational again, providing the best possible care for you patients as you originally set out to do. The key component to operational access is truly being prepared for anything. If the power goes out, do you have an uninterrupted power supply to keep your systems running so that you and your staff can access the information to provide proper care? Do you have a protocol in place for a multi-person team to implement data recovery when the systems go down in a natural disaster? Are there trusted individuals or entities who can produce a copy of the HIPAA compliant off-site saved data for use when the systems are down?

In extreme scenarios where the internet may be down, you can utilize a 3G signal to tether a computer to cloud-based EHR/ EMR systems.

All of the planning in the world for a disaster means nothing unless it can be effectively put into action when it truly counts. This can only be done through a combined plan of on- and off-site secure data storage methods, an explicit plan for execution when a disaster strikes, and true testing to ensure that all of these systems work when they are most needed.

It may seem like a ridiculous plan option, but including it in your plan, and testing its efficacy is imperative to your ability to providing the best possible care in a disaster scenario.

Given the recent slew of natural disasters, it?s hard not to acknowledge the importance of preparing for what may come.

Furthermore, it is not out of the question to make sure you have alternative options to keep the doors open, and the level of re-work down to a minimum. Paper-based systems may seem heavily antiquated in our modern era of microsized computers, augmented realities, and self-driving cars; but paper doesn?t require power to be read. Be sure to include a low-tech level of preparedness with paper forms to aid in the recovery of patient data to truly cover all of your bases.

Proper EHR/ EMR backup and recovery procedures are not only a crucial component of providing proper healthcare, they are a necessity for quality and value in the provider-patient relationship. So make sure to discuss all of your options with your EMR vendor, and if the back up and recovery plan is lacking, seeking additional coverage in the form of other HIT professionals that specialize in this kind of protection.

? PRO TIPS? TI FFANY LAURI A Consultant

SURVI VAL TI PS: HOW TO GET THROUGH A DI SASTER In a 20 year period alone, from 1995 to 2015, 606,000 lives have been lost and 4.1 billion people have been injured, left homeless or in need of emergency assistance as a result of weather-related disasters. In addition to natural disasters, we may suddenly come face to face with a number of other sudden life-changing events: terrorist attacks, active shooters, arson, and pandemic or biological events. While it is impossible to prepare for every conceivable situation, you can and should think ahead in order to take steps to prepare for situations that may occur in any disaster. The time to prepare for a disaster is before it occurs, so here?s what you can do to be prepared. -

To-Do Ahead of Time: -

Know your area: Do you live in a flood zone or where hurricanes or tornados commonly occur? Are you in a large city or rural area? Understanding the type of emergencies that may occur in your area will allow you to think ahead about preparation. Prepare your home: Make it a point to keep up on home repairs and ensure your home meets all local building standards. Broken windows or staircases, loose plaster, and any objects that could become flying projectiles are just a few examples of items to note during your preparation. Learn al t ernat ive rout es and how t o read a map: Common routes may be closed or congested, and navigation devices may or may not pick up the necessary signal and/ or may not be chargeable. Keep a paper map of the region in your trunk ? if satellites or cell towers go down, you may need it. Est abl ish your f amil y pl an and PRACTICE it : Make sure all family members know what to do in an emergencyBefore a disaster strikes, know if there are designated shelters in your area.

Choose one, or determine a building such as a library or school as a meeting location in your neighborhood. Designate a meeting place outside your home so that everyone knows where to go if you are separated. - Practice walking to the designated location with your children. - Write out contact information and your family communication plan. - If cell service goes down, remember that a text or data message may go through when a call does not. Remind your family to limit non-emergency calls to preserve phone battery life. Consider purchasing solar chargers (they are relatively inexpensive and could be a life saver) - Determine who will take responsibility for any household pets. Prepare your suppl ies: Have a Go-Bag prepared for each member of your family, and supplies in the home in the event the local authorities order you to ?shelter-in-place?(see the tips below for recommended supplies).

Recommended Suppl ies Here are just a few of the recommend supplies that might assist in surviving a disaster or emergency. Keep in mind the adjustments that must be made for your family and your location. It ems t o Keep in t he Home and in a Port abl e Go-Bag: -

Several days?supply of non-perishable food and water. Most authorities recommend at least a three-day supply. Remember to keep a manual can opener and forks, plates, and cups available if needed. A portable radio that can be battery operated and / or hand-powered by a wind-up lever, and spare batteries. Many of these radios are equipped with cell phone charger ports, so be sure to include a regular and a solar charger in your kit. A battery-powered and hand-powered flashlight and/ or electric lantern and spare batteries. Matches in a waterproof container. A large survival candle that can convert into a small stove for heating food and providing warmth. Small non-electric tools such as a pocket knife, and screwdriver. Multipurpose tools like a Swiss Army knife are ideal. Blankets and if possible a sleeping bag. Small foil emergency blankets that assist in retaining body heat are inexpensive and take up little room. A local map. A change of clothes, undergarments, sturdy shoes and a jacket/ coat. Toiletries such as toothbrushes and toothpaste, feminine products and soap. A first aid kit. Prescription medications. Consider stocking a bottle of an over-the counter pain and fever reducer. Cash in small bills. Copies of important documents- passport, insurance documents, car titles, etc., and a copy of your car and house keys. Copies of contact information for family members and the local police and fire stations. Infant formula, diapers, bottles and other items for infants and toddlers, if you need them. Pet food, a water bowl and a leash. A deck of cards or other items for distraction.

RESOURCES Ready.gov: Contains information on how to prepare for an emergency, how to receive emergency notifications and broadcasts, and a section for kids and educators. FEMA: Contact your local county offices and inquire about emergency notifications and citizen preparedness courses -

Family Communication Plan Emergency Supply Checklist

Cit izen Corps Programs: information on six different citizen volunteer programs Nat ional Vol unt ary Organizat ions Act ive in Disast er: volunteer to assist in a disaster struck area and how to donate. Corporat ion f or Nat ional and Communit y Service: resources on how to volunteer to assist in a disaster struck area and how to donate. 13

? FINANCE MATTERS ? JENNA MI RCHI N, CPC, CPMA, CGSC Coding Specialist

UPCOMI NG PRI MARY CARE CPT CODE CHANGES Care Coordinat ion and Behavioral Heal t h Get s a Boost The new year always brings about change, and from a coding standpoint 2018 looks to be no different! The 2018 AMA CPT Codebook will have several new CPT codes that will be beneficial to Primary Care providers. Here?s what you need to know:

VACCI NE CODE ADDI TI ONS CODE

DESCRIPTION

90750

Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection

(New code, but effective since July 2017) 90682 (New code)

90756 (New code)

Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use

PULMONARY PROCEDURES CODE

DESCRIPTION

94617

Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry

94618

Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry and oxygen titration, (etc.)

(New code, replacing deleted 94620)

EVALUATI ON AND MANAGEMENT CODES (REPLACI NG ?G CODES?) CODE

DESCRIPTION

Cognit ive Assessm ent and Car e Plan Ser vices 99483 Cognitive-Assessment Services: report 99483 in place of G0505

Assessment of and care planning for a patient (new or established) with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home (certain elements required)

General Behavioral Healt h I nt egrat ion Car e Managem ent 99484 Care Management-Focused Behavioral Health Integration (BHI): report 99484 in place of G0507

Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month (with certain required elements)

Psychiat r ic Collaborat ive Car e Managem ent Ser vices 99492 Collaborative Care Management (CoCM) services: report 99492, 99493 and 99494 in place of G0502, G0503 and G0504

Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (with certain required elements)

99493

Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities (with certain criteria)

99494

Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional

Consul t at ion codes continue to be included in the 2018 CPT Manual, but note that United Healthcare - one of the few commercial Payers that continued to pay these codes after CMS jettisoned the codes several years ago - has stopped paying for consult codes, effective Oct. 1, 2017.

? PRACTICE MATTERS ? Heidi Hallet t Communications Director

HOW TO EFFECTI VELY PREPARE YOUR PRACTI CE FOR DI SASTER Predict , Pl an and Prepare!

Predict , Pl an, Prepare

Trouble shooting emergencies is something healthcare professionals do every day. What if that emergency isn?t a medical one, but a natural disaster or weather related crisis?How you respond in a medical emergency doesn?t necessarily carry over to being prepared for other types of emergencies, such as natural disasters.

Approach your disaster planning as you would any business plan. You didn?t rush through the plans to open your practice, so why would you rush through the plans to safeguard it in an emergency? In order to be effective, you need to invest some time and thought into your plan. Hopefully, you?ll never need to implement the plan, so think of it as insurance. But without it, your practice could be in jeopardy.

It?s no surprise that meteorologists are calling the 2017 one for the record books.?Through Sept. 10, the Atlantic hurricane season has produced 12.75 major hurricane days (thanks to Harvey, Irma, and Jose). The only years with more major hurricane days to date were 1899 and 1933.?

For medical practices, there are several key areas to consider: -

According to FEMA, 40% of small businesses affected won?t recover and re-open after a natural disaster and a recent survey revealed that very few business owners take planning for environmental disasters very seriously. If this past year has taught us anything, it?s that disaster planning isn?t just smart, it?s key to survival. Even those businesses that are able to cover the large costs to re-open, over half reported that it took at least 3 months to recover. -

Those businesses that do survive after a disaster credit their success to planning. So, is your practice ready to weather the next big storm? 16

Maintaining access to patient charts, forms and other essential information; can this information be accessed remotely? Is it stored in more than one place, both physically and virtually (i.e. cloud backup)? - Lines of communication with patients and staff; do you have remote access to all contact info, including alternate means of communication (ie: home phone, cell phone, email address, social media groups such as your practice?s Facebook page) Financial planning for business interruption; how long can your practice sustain payroll if little to no income is coming in?

The f irst st ep t o ef f ect ive pl anning is gat hering your t eam. Every department needs to be involved from the get-go if your plan is to be comprehensive. Approach this stage of the planning as you do HIPAA compliance, engaging all team members in the process. Ask your team to take some time to think about all the tasks they do on an average day and what they would need if they had to do their job without access to the office, computers, files, supplies, etc. Consider the challenges and barriers to completing these tasks outside of the office and take measures to put workarounds in place. For someone in the billing department, this could mean remote access to secure financial files, for your RN it could be access to patient records and medical supplies so they can treat patients virtually or in a temporary space. Once you identify each challenge, create a written action plan and designate it to someone on the team.

Source: https://www.bdc.ca/en/documents/other/Action%20Plan%20Template%20for%20Maintaining%20Essential%20Service.pdf

Communicat ion pl an - writ e it down and share it earl y Identifying who will be responsible for troubleshooting communication problems is one of the most essential parts of your disaster plan. Not only will this person (or persons) be responsible for communicating with your team, they will be responsible for getting information out to patients. Things t o consider when buil ding an emergency communicat ion pl an: -

Is all the contact information for staff up to date? When was it last reviewed? Do you have more than one method of communicating with each person on your team on file (home phone, cell phone, email, social media accounts, family member to contact, etc.)

Is all contact information up to date for patients? Do you have alternate means of reaching them, such as those listed above for employees? Make it a practice to ask patients for alternate ways of reaching them in an emergency each time you update their contact information. Make and distribute a list of all of the ways your practice can be reached so that staff and patients before a disaster strikes and share it often. By providing several options, your providing some much needed reassurance. If your office is closed and phone lines are down, how and when will you communicate this? Use as many methods as you can: phone, text, notice on home page of website and pinned posts on social media accounts (see our article How Best To Utilize Social Media for tips). Lastly, if it is safe and you are able to do so, paper signage at and around your location is great way to let people know how to reach you. Consider teaming up with other practices in the area and agreeing to each share the other?s emergency contact information in advance of a disaster.

Another valuable service you can provide to your patients, staff and community is to post on your website items such as checklists, local emergency shelter information, evacuation maps, and contact information for various resources and aid organizations. Things t o secure in t he cl oud or of f -sit e: -

Current back ups of all essential data Copies of all insurance contracts and policies Copies of contracts, financial papers & banking documents, real estate records/ leases, and other agreements Tax papers and payroll records

Review your insurance Understanding your insurance coverage and ensuring you have the right types of coverage is absolutely essential. You?ll want to make sure that not only is your property protected but that you have extended coverage for things such as Business Interruption, and Loss of Use. You may think you?re covered for damage done to your property from a hurricane but what if you?re covered for wind damage but not covered for flooding? Make sure you have the extensive coverage you need and if you are not sure, ask your broker!

Pl an f or 'Business Int errupt ion' and 'Business Cont inuit y'

patients don?t go unanswered. During and after any crisis, call volumes will likely increase and you want to make sure your patients know they can reach you ? be sure to change your voicemail to indicate any changes to services, hours, location, and provide an estimated callback time whenever possible.

Consider filing early payroll. Remember that banks may close and ATMs may not work during or following a major disaster, so by allowing your employees early access to payroll so that they can get cash can provide critical help and peace of mind. One large employer in Houston made a very pro-active move and sent an HR professional and a payroll clerk out of town in advance of Hurricane Harvey to ensure that their essential work could continue without interruption. This kind of quick and clear thinking is an excellent example of being prepared and putting your team first.

In terms of keeping your team connected there are several ways you can do this. Consider creating a private employee portal on your website or in a private Facebook group; if you and your team have Internet access, an online hub can make things a lot easier when exchanging information. What about when the Internet is down but landlines or cell service are still working? A good old-fashioned phone tree is an efficient way to disseminate info to your team. A phone tree is simply a system for contacting a large number of people quickly in which each person called then telephones a number of other designated people. Of course, what?s old is new and these days there are also tech tools the job for you: enter the phone tree of today, phonetree.com. PhoneTree and companies like them provide software solutions for automated patient reminders that streamline your everyday admin but could also be extremely helpful during an emergency.

Have a clear policy on attendance, paid time off, use of flex-time, sick days/ vacation days, etc. Make sure employees know what is expected of them during a temporary practice closure and how it may affect their pay. It?s not only important to make sure employees know what they are entitled to but also what their responsibilities are. Be clear about expectations but be mindful of what your team may be dealing with outside of work. If employees are needing to meet with insurance adjustors, landlords, or contractors to deal with the aftereffects of a storm on their homes, allowing them some additional time off could alleviate a great deal of stress. Check the Fair Labor Standards Act to see if time of with or without pay is appropriate and in keeping with the Act.

At a time of crisis, it can be nerve-wracking when you can?t reach members of your team. It?s natural to be concerned for our coworkers and you want to know how everyone is faring. Having a conference line phone number and designated call times each day can be a relatively easy way for everyone to check-in. If possible, you may want to set up your conference through a service like GoToMeeting that can receive calls via phone or Internet as different members of your team may not have access to the same services.

Working remot el y If you can?t access your practice due to damage to the building or surrounding area, do you have plans for a temporary clinic set-up, or plans for a virtual office? While being able to re-open in an alternate location is ideal, it is nit usually an option, so what then? At the very least, you?ll need a plan for members of your team to be able to work remotely ensuring that calls and online messages from

Once you?ve determined how and when your team can connect, you?ll need to consider what can be 19

done off-site, and what can?t. If you?re working remotely or even fortunate enough to have access to a temporary location, it?s unlikely that you?ll be able to offer your full list of services. Make a list of key services, whether or not they can be delivered, and how to fill any gaps. Ask yourself, ?Who can offer services that I can?t?? and consider teaming up with another practice to share care in emergency. You may never need to fall back on that plan, but you?ll build a great relationship in the meantime, and know that you have each other?s backs should disaster strike.

with this option built in but it is rarely free. To find the settings on your phone, check out the handy guide in this article. You can also invest in an external piece of hardware called goTenna. According to its website, goTenna has developed?next-generation off-grid communication technologies,?ideal for use during a disaster. Here?s how it works:you send a message via Bluetooth which then goes to goTenna, your message is then converted to an analog version that is sent over radio signals ? of course, in order for someone to receive your message, they must also be using goTenna. At just over $300 for a pack of 4 GoTenna devices, that?s not much to pay to really know you can stay connected.

St aying connect ed when t he Int ernet f ail s We?ve covered a number of ways to stay connected, but many of them require Internet access. If you live and work in an area where storms are likely to occur, giving your key team members rocket sticks or other portable connectivity devices, battery packs for phone charging, and pre-approval for extra data usage costs is money well spent.

Get t ing back t o t he of f ice You?ve weathered the storm, but is it safe to return to your practice? Before you can welcome staff and patients back to the practice you need to make sure it is clean and safe to do so. Health and safety is very important during clean up. The list of possible health hazards includes (but is not limited to) concerns with air quality, mold, cuts and abrasions, and overexertion. The Occupational Health and Safety Administration (OSHA) provides a detailed list of health tips, precautions, personal protection, electrical and fire hazards on their website. Print two copies of that page now and include one in your planning kit, and post the other where cleaning supplies are stored. Make sure to take adequate precautions when evaluating your space and recruit or hire hazmat teams or those companies best equipped to evaluate the damage.

No one likes to think about it in this day and age but the fact remains that the possibility of both phones and Internet being knocked out by extreme weather events is a very real possibility. When the Internet is down you can still get online through ?tethering?or a personal ?hotspot?via your smartphone which will use cellular service instead. Tethering is when you use your smartphone or other mobile device as a modem to connect another device such as a laptop or tablet. You can tether your phone via Bluetooth or USB cable. Purchasing a USB cable is recommended as it will give you the most reliable connection and online capability when wifi is not available, and it will save on battery life. How you tether and what it will cost varies greatly from both cellphone carrier and phone models so make sure you do your research and find your best options before disaster strikes.

Addressing the critical areas of your practice and putting in place an effective plan for tackling disasters is the key to ensuring that you can ?weather the storm?.

Using your phone as a personal hotspot is another common solution when your wifi network isn?t working. Like tethering, a personal hotspot turns your phone into a wireless router to connect other devices to the Internet. Most phones today come 20

? HR MATTERS ? TIFFANY LAURIA Practice Consultant | THE VERDEN GROUP

EMPLOYEE POLI CI ES: Do Your Em ployees Know What To Do I n An Em ergency? When disaster strikes, the ensuing difficulties can be overwhelming, and sometimes result in barely controlled chaos. As the owner or manager, your employees and patients will look to you to direct the response to the situation. While it is impossible to anticipate all scenarios and the variables that may impact your practice or facility during an emergency situation, you can look ahead and plan to have a procedurally sound plan in place for the most likely of occurrences. A 2016 Medical Group Management Association (MGMA) survey revealed that 49.94% of those surveyed had an emergency preparedness plan in place, but only 28.12% of them had practiced it. Perhaps more concerning, 4.08% were not even sure if they had a plan. Not only are these practices unprepared, they lack the communication structure needed to remain organized and efficient in these situations. It goes without saying that the time for emergency planning is now, before a disaster or emergency situation is upon you.Even if you have a plan on paper, the above survey illustrates that taking action on that plan and doing practice drills often gets pushed back and never get practiced.

What t o Incl ude in Your Pol icies The goal of any emergency policy is to ensure that when confronted with a crisis, everyone knows what they need to do to help minimize damage to the people involved and the business, as well as how to aid in recovery from the event. To achieve this, here are some must-haves that a good policy should contain: -

Hierarchy of leadership and decision-making: Each staff member should know whom they report to for any assigned task and whom they will receive the most up-to-date instructions and information from. This information tree should not be limited to the lower staff levels but should include partners, providers, and managers, detailing which decisions and tasks for which each of them is responsible. Laying it out ahead of time minimizes the chance that something will be missed or that time will be wasted by multiple people working on the same thing. Communication plan and methods: Have the necessary phone numbers documented in the plan including local emergency first responders (police, fire, ambulance), hospitals, the practice answering service, any covering providers, supervisors and managers. Determine ahead of time which additional methods of communication will be used and communicate that clearly to the staff 21

AND to the patients. For example, many practices use their social media accounts and practice website to alert patients to office closings.

Which Pol icies Are Needed? The types of emergencies or disasters that you may encounter will depend on the location of your facility. Many of the procedures that are required for one situation will also work for another, as in the case of different natural disasters.

Keep a secure list of all log-ins and passwords that may be needed by delegated staff. This document need not be accessible to everyone or part of the widely circulated policy, but it is essential that the staff members assigned to these tasks always have access to the most up-to-date information so that changes to voicemail and the website can be made quickly during a crisis. -

Practices will often combine their emergency policies into one Employee Preparedness Booklet, or create an addendum to the Employee Handbook or Policy Manual. The most commonly addressed situations include:

List of tasks/ things to do: This list will vary depending on the type of emergency, but may include such items as: Backing up the EHR and storing in a secure off-site location Transporting immunizations and refrigerated medicines while maintaining a consistent cold-chain to preserve product integrity Securing confidential documents (employee files, patient charts, provider identifier numbers) Locking the facility securely

Natural Disasters and Inclement Weather: Hurricanes, tornados, floods, thunder/ lightning storms, snowstorms and blizzards

Power Outages: Prolonged and short-term

Fire: Localized or facility wide

Wide-Spread Illness or Epidemics/Pandemics: Among the staff or regionally

Active Shooter and Workplace Violence: Employee, disgruntled patient/ customer, or terrorist

Bomb Threat: Including a script to be used for keeping a potential bomber talking and

Your emergency or disaster policies should be reviewed for relevance and updated at least annually for relevance. Most importantly, PRACTICE, PRACTICE, PRACTICE!

volunteering information about location of bomb and timing -

Lockdown (Shelter-in-Place) and Mandatory Evacuations

Make sure all new employees are trained upon hire, and run drills at least once a year to familiarize and encourage staff to become comfortable and familiar with the routine.

Employee Employment Policies in Emergency Situations: Extended absences, lay-offs, reduction of hours, and medical leave

As complicated as it can be just managing the day to day operations of today?s medical practice, the trying times we are in demand that we focus our attention on situations that we may or may not ever encounter in our practices. To the extent possible, preparing your employees and the practice for potential disasters will instill confidence in them that you are in control of the situation, they can be useful in the situation, and it will minimize as much damage or loss of life and injury as possible.

Hel pf ul Resources t o Get You St art ed Many practices find that using a template or sample policy that is customizable works best for their needs. In addition to reaching out to your Compliance or Human Resource Partner, if you have one, a number of organizations make sample policies available for download for a small fee or subscription. Some of these are: -

www.BLR.com, www.SHRM.org, and www.MGMA.com.

If drafting your own policies, the MGMA suggests a reverse planning model that may help you clearly identify the steps needed:

https:/ / www.mgma.com/ emergency-planning 23

CREATING A DISASTER PLAN

? SPOTLIGHT ? HEI DI HALLETT Communications Director

GI VI NG BACK TO THE COMMUNI TY The "Swap Shop" at Light house Pediat rics We first heard about Dr. Dulce Dudley's idea for a "swap shop" earlier this year and she promised that she would tell us more once the room was up and running. We checked back in with her and her team at Lighthouse Pediatrics in Naples, FL, for this issue and found that they had created a great way to support their patients and families in the community. Heidi Hal l et t : Tell us about this special room in your practice ... what is it for? Dr. Dul ce Dudl ey: It's a dedicated room in our practice called "The Swap Shop" and it's a place where our patients and their families can come and take things they need like clothing and household items. Heidi Hal l et t : What was your motivation in creating this community initiative? Dr. Dul ce Dudl ey: It came about in an indirect way. Dr Shepard and I have a pretty diverse practice with some families in our community having a lot and some not having very much. Whenever I would get ready for a mission trip, we'd get offers of donated items. We decided to open up a room where people could donate their gently used or new items and others could go ?shopping? for much needed items without having to spend any money. Heidi Hal l et t : What has the response been from your patients and others in the community? Dr. Dul ce Dudl ey: The Swap Shop has been a huge success! We have been able to help not only some of our patients and foster families, but we have also helped others in the community during cases of emergency too.

Heidi Hal l et t : Is there a story that you can share shining a light on how something simple like this can have a big impact? For example, how someone got something they really needed or wanted and how that effected them? Dr. Dul ce Dudl ey: We heard about a family (not affiliated to the practice) who lost everything in a fire. As soon as we heard the news, I put a request on Facebook asking for donations to help this family. People immediately responded by dropping off cribs, beds, clothes, towels, food, etc. On another occasion, we found out that one of our families was not eating dinner together because they did not have a dinner table, so we set out to get them one! Heidi Hal l et t : It's inspirational to see how one practice can take such a simple but dignified and effective idea and make such a difference. Thanks for sharing, perhaps others may be inspired to similar action too!

Dr. Dudl ey & Dr. Shepard in t he Swap Room

"The Swap Room has also inspired local organizations and given them the opportunity to donate to our room. For example, one of the Girl Scout Troops used the money they raised from the cookie sales to buy diapers for our room!" - Dr. Dulce Dudley

? CONNECT ?

NOREEN QUADI R Social Media Manager

HOW TO BEST UTI LI ZE SOCI AL MEDI A DURI NG DI SASTERS As you probably already know, social media is a powerful tool for communicating and connecting with your patients and community. When a disastrous event occurs, people feel distressed and worried. Before, during and after a disaster, you will want to make sure you engage online this is an opportunity to be a voice of support and guidance in your community.

your hopes that people are safe is a fast and easy way to show support. It will then be posted automatically on your timeline and sent as a notification to the people on your ?Friends? list.

Onl ine Resources Websites such as ready.gov offers updates on various types of emergencies including severe weather, earthquakes, fires, bioterrorism, explosions, floods and more. You can sign up for free wireless emergency alerts, which are sent to your phone when emergencies arise. There are also tips for planning ahead and resources that you can share on social media, such as emergency plans for parents and children. Families will want information on what they can to do to protect their loved ones and themselves, and where they can go to for help. Sharing helpful resources from trusted sources is a great way to offer support and guidance. For example, pediatric practices can find many guides for specific types of disasters on Healthy Children, such as this article on getting your family prepared for a disaster, an earthquake disaster fact sheet, and a terrorism disaster fact sheet.

Facebook?s ?Saf et y Check? Feat ure People turn to social media during a time of a disaster, crisis or a dangerous attack to check for news updates and the safety of their family and friends. They also use it to mark themselves ?safe? utilizing the ?safety check? feature on Facebook, so that their family and friends can have peace of mind. It is very simple feature to use. Facebook automatically creates a ?safety check? page when it is notified of a disaster or a dangerous incident within your community and/ or when a number of users create posts about it. You can either mark yourself as safe or request help. Facebook sends automatic notifications to users in the location of the incident (but you must have your location listed on your profile to receive the ?safety check? notification). When you click on that, you will be taken to the ?safety check? page where you can mark yourself safe along with the option to post a message. A message expressing

What and How t o Communicat e on Social Media During Disast ers At the time of a crisis, the first step to take is to postpone any scheduled posts that are not related 27

to the disaster. Your posts during a disaster should be focused on your concern for the wellbeing of your patients and community. Relevant and appropriate posts include real-time updates about on what?s going on with your practice - if your office needs to be closed or has a power outage, it is important that patients know that your practice is unavailable. Take it a step further by mentioning alternative options such as local hospitals or clinics in the area. Be sure to post regular updates so your patients don?t have to search for this information. If your office is open and functioning, let patients know what your hours are, and any changes or limitations as a result of the disaster. Your posts should include information about how to book appointments or get in touch with the practice (particularly if regular lines of communication are down). Reassure your patients that they can reach you through your social media channels or any other alternate means of communication that you may be using.

their children. Whenever something tragic or a violent incident happens, many children feel traumatized, confused, scared, anxious and upset. They may have a difficult time understanding what?s going on and parents may be unsure on the best ways to help their kids cope and have a conversation with them about what happened.

If you are unsure of when your office will open again, encourage your followers to keep an eye on your page for announcements. Sharing these types of updates keeps your patients informed and can help cut down on high call volumes.

There is a wealth of information online for parents on how to help their children cope with a tragic event or disaster. Bookmark this article from Healthy Children about ways to support kids and talk to them about disasters so you have the link handy should you ever need it.

Consist ent Communicat ion is Key Make sure that you?re consistently active on social media, checking for and responding to messages promptly during a disaster. If you use Twitter, you can search for keywords and hash-tags associated with the event and participate in the online discussions. For both Facebook and Twitter, you can follow local and state emergency accounts for news and share these directly to your social pages. Be sure to only share information from trusted sources!

Disasters are always distressing events and the resulting chaos and trauma can last long after the event is over. Families and communities may be struggling with loss and the stress of getting life back to normal and may have to make long-term adjustments. As a medical practice, you can be a voice that provides tremendous support and be an area of guidance for your community to minimize the impact of disasters. Utilizing social media effectively is an essential part of your disaster plans.

Hel ping Famil ies Cope During and Fol l owing a Disast er In addition to updates on practice hours and available services, this is also a good time to share helpful tips on what families can do to brave through the event and how parents can comfort

Done right, it can literally be a lifeline for patients in need.

Social Media Checkl ist : 1. Use Facebook?s ?Safety Check? tool to mark yourself safe and voice your support for your community and families. 2. Postpone all social updates that are not tied in with the disaster. If the disaster is predicted in advance, sign up for the alerts on sites like ready.gov and begin posting resources and tips for your followers on what they can do to prepare ahead of time. 3. Inform your patients if your office needs to be closed for a period of time, or if your phone lines are down. Inform patients of any limitations on the services you can provide. Suggest alternative solutions for families to get the help they need. If your practice is available, let patients know how they can book appointments. 4. Reassure patients that you will be checking in and updating your social pages often. 5. Consistently follow and share local and state emergency accounts for news. 6. Post tips and guides on how people can cope during and after the disaster. Continue posting these following the incident, as patients will want guidance on how to cope with the aftermath. 7. Remember that your social accounts may receive a volume of inquiries and concerns. Be sure to respond to these in a timely fashion.

? FRONT LINES? CLICK ON THE MICROPHONE TO LISTEN

SUSANNE MADDEN, MBA, CCE CEO | CoFounder | Editor

SURVI VI NG HURRI CANE HARVEY! A Conver sat ion wit h Doct or s Silen and Sogol Pahlavan A full transcript of their remarkable story is laid out here or click on the microphone above to listen to the podcast. This is Susanne Madden f rom Verden ViewPoint Magazine. Today I'm speaking wit h t wo pediat ricians, Doct ors Sil en and Sogol Pahl avan of ABC Pediat ric Cl inic in Houst on, Texas. Our t heme t his issue is disast er pl anning and recovery and t hese t wo sist ers managed t o go t hrough Hurricane Harvey wit h f l ying col ors. I'm so gl ad t o have you guys on t he pod cast t oday. Thank you so much f or joining us and f or being wil l ing t o share your st ory. Sogol Pahlavan: Thank you for having us. Susanne Madden It looks like you really were severely challenged there, in Houston, when Hurricane Harvey decided to whip through. You closed your offices on Friday, August 25th, at 2:00 PM. At what point did you have this sense that the following days were going to be critical and you were dealing with this crisis. Sogol Pahlavan: On Friday, as we were watching the news ... We didn't even know if we were going to close that day until later on, around noon or one o'clock, then things got serious. So we decided to close at two o'clock, and by midnight on Friday the street had flooded. People were taking different routes and then on the following day, which was Saturday, is when the rain got worse. On Saturday actually, we still were hesitant about closing for the entire week. We didn't know the severity and we didn't know how devastating the flood was going to be. It was actually not until midnight, Saturday at midnight and early on Sunday, is when things became really serious.

Silen Pahlavan: We woke up on Sunday morning with the streets flooded. The news continuously talking about flooding, street closures. And then luckily we have access to cameras remotely from home. So I was able to log into the cameras, and we were just constantly watching the parking lot, the streets around the clinic. So that wasn't until Sunday. Sunday in the morning at 9:00 AM we saw the front of the street, that was flooded. And then by night time, by about 8:00, 9:00 PM, half the 30

parking lot was full. That was on Sunday. And then we started to panic at that point because we didn't have ... We weren't that prepared mentally and physically and financially for what was happening. Sogol Pahlavan: And our biggest worry was our generator. And so she'll talk a little bit about that. But we were fine with losing the revenue from the clinic but we were not fine with losing thousands of dollars worth of vaccine. So I think our vaccine fridge was our priority at this point. Susanne Madden: My goodness! Of course, there's just so much revenue tied up in those vaccines and you just can't rely on insurance to help cover for that. You want to have put your planning in place. So did you have any disaster preparedness plans in place at all generally? Had you ever experienced any other disasters before? What was that like? Did you have any prior preparation for this or was this completely out of the blue and you had to start from scratch? Sogol Pahlavan: No. I would say, personally, as having any experience, no. But we have a good community of physicians through one of the AAP groups [SOAPM] we rely on their experience. This new clinic that we're in, we built out in 2013 and we spent over $30,000 on a very robust generator. It's a commercial generator. Our old space that we had sub-leased had a smaller generator. And there's a lot of power outage in our area, so the older generator was run on power. So the new one that we received, it's run on natural gas. I would say that's one thing that we did, as far as preparing ahead of time. And it wasn't specifically for Harvey, it was just becausewe had taken some experiences from other physicians and prepared for it. But what had happened, there's a lot a power outages in this area, so I think three or four months passed; there was some sort of power outage and we relied on the generator to keep the vaccine safe. But what had happened is, prior to that, we had a gas leak scare at the clinic. And when they came out to investigate - the city came out to investigate the gas leak - they actually turned off the natural gas that had gone to the generator without notifying us. So a couple of months after that when we had this power loss, we came back and we realized, why didn't our $30,000 generator work? Well, it's because the people from the city turned off the gas! So that was a personal experience that we went through. So we were hyper focused on our generator. We had everything in place when we locked up on Tuesday and I think coincidentally we had the maintenance people from the generator come in two weeks prior to the hurricane just to do a maintenance check. But that was completely coincidental. We didn't predict a hurricane coming. Silen Pahlavan: And we do maintenance checks twice year, but it was just the right time that they had come so recently to check everything out. Sogol Pahlavan: And I would say, the other portion of the office that you really need to think about in these situations are your electronic health records. And with us, we still have an on-site physical server. We do backups every night and our office practice administrator actually physically carried the back-up disc with him everywhere. So two things that happened is that our EHR reached out to us about 24 hours [into the sitation]. I would say, probably, it was Friday or even Thursday night, they reached out to us and they said, "Let's get you uploaded on our cloud." So they uploaded all our data on our cloud. So we had that safety zone. And we really appreciated the fact that they reached out to us because once you're in the middle of preparing for all those things, if you don't have a very good checklist things get missed. And then the other thing we did is we backed up our servers. We usually would [do that] on a back-up disc 31

and we carried that in a backpack with us the entire time. Literally, if my house would have flooded, I would have probably picked up the backpack versus the kids! Susanne Madden: Your patients can rest assured that no matter what, their medical records are safe with you then! There were a couple of really great points there that you pointed out there. One, obviously, is luck. That the maintenance had been done on the generator and that you had actually identified that the generator wasn't working due to another power outage that had happened. Now it's one thing when there's a power outage and then your generator kicks in using that natural gas. It's another thing when there's a flood. So I have to ask, did the generator perform? Did the generator actually work? Sogol Pahlavan: So what happened was, the Sunday, we had full access to remote videos until Monday 3:00 PM. We were still monitoring. We were looking at the videos. Great, everything is good. We have power. 3:00 PM on Monday, it all went down 'cause the power went out, the cameras went out, and we were literally sitting in the dark from Monday 3:00 PM to Wednesday 8:00 AM. So a good 48 hours. And our nurses, the staff that lives around here, weren't able to come to the clinic because the streets were flooded. But luckily we have a neighbor that's right behind the clinic, and we were able to reach him and he would come out, literally every hour and check on the clinic. So he would give us a update on the status of how far the water is, close to the clinic, and then the generator. Do you hear the generator running every hour? We would call him, "How's it going? Do you still hear it?" And thank God, it was working. It kicked in and it started to last until we opened up. So get to know your neighbors. Susanne Madden: So, good neighbors! Couple of take-aways here. Definitely, you want to build good relationships with your neighbors. You never know when you might need them in a disaster for sure. But it sounds like, obviously then, your vaccine survived just fine. And I really like this idea that your EMR vendor actually reached out to you. Being very proactive, very supportive, really offering that partnership. For the record, who is your EMR vendor? Sogol Pahlavan: We use Office Practicum. Susanne Madden: Terrific! So Office Practicum were able to help with that preparedness; make sure that you were okay; get you backed up. Even though you have an on-site server, you have a physical record of your records. Just in case anything would happen to those they were able to upload all of your records into their cloud as well. I do think that's terrific, to have partners in a disaster is so very fundamentally important too. A piece of this around this whole disaster thing is, your staff couldn't get in, you guys were kept away from it. How did you all communicate? How did you communicate with your staff and with your patients throughout this whole disaster situation? Sogol Pahlavan: So as far as our staff, we're a mid-sized clinic. So our mission here is, "ABC Pediatric Clinic Treating You Like Family." And we have each and every single one of our staff's cell numbers, emails on our personal cellphone. We divided up the clinic. I took the physician, Dr. Silen took the nurses, and then our front-desk supervisor took the MAs - the front-desk employees. And we were in constant communication with them via text and phone. If one couldn't be reached, then one staff member reached out to the other staff member, which is something ... The silver lining in all this is that our clinic is much more solid and much

more collaborative. And there was a sense of compassion and empathy and collaboration that came through this disaster. If I were to go back and say, "Would you ever do it again?" I would say the only thing that really came out through this is that we are now a stronger team for what we have gone through. Susanne Madden: What a wonderful silver lining. That is absolutely right just to galvanize the team; everybody comes together. And then obviously you had an opportunity to show how much you care about your employees too. Silen Pahlavan: And as far as keeping the patients updated, we have a strong presence on social media. So we have a Facebook page for our clinic. We have Instagram for the clinic. So constantly we were updating our Facebook page regarding the status of the clinic; when we were going to be open; numbers patients could call for assistance; FEMA numbers. And we also posted our on-call nurse contact number. The patients already are familiar with the nurse help-line. Every patient that walks in gets a magnet with our on-call nurse helpline number on it. So they have that but we just, again, put it on the Facebook so they knew that that nurse line was available. And luckily they're out of Dallas, so they had no problems taking the calls. Susanne Madden: Of course, if they had been located in Houston and going through the same thing then that absolutely would've put you in some situation there where you probably would have been fielding patient calls on your cellphones or some such thing. I think that's remarkable too. Just the use of social media to really be able to connect with people and that people really know to go there. To be able to say, "In a disaster, if I can't get to the office or reach these people in another way, I know there's going to be communication coming out through Facebook." So it's almost as if social media has really become part and parcel of disaster [management] for the future. Including their feature to report yourself safe and do those sorts of things. I think that that's very powerful. So in terms of resources that you could fall back on and rely on, obviously social media was one of them and a really big component of it. Your nurse line that you already had in place. So that was sort of continuity of something that patients would already be familiar with. What other resources were you able to fall back on, if any? Was FEMA around? Were there local services? Did the AAP help in some way? What did that look like for you guys? Who were you able to turn to for a little bit of extra help? Sogol Pahlavan: So FEMA was definitely around, but as you can imagine, they were overwhelmed. So with any natural disaster, having the support to be able to ... And this was a historical flood. So if it was just a regular flood then I think the manpower from FEMA would have been able to handle. But it was beyond that and I don't think that the federal government or the State had any insight into the severity of this natural disaster. I think overall if you looked back FEMA did a good enough job, as much as they could, with the resources that they had. Did they reach out every single family? No. Did they reach out to every family in a timely manner? No. But I don't think, in a situation like this, they could have. It's not practical. In reality, they could not have reached out to every single family. We opened up the office Wednesday afternoon. Most offices around our area, if you drove down Wednesday morning when we came to our clinic, if you drove

down Wallisville [Road], which is like a two-mile street, I would say, I think we were the only medical clinic that was open. 50% of the dental clinics, there's about four or five on the span of that road, were all flooded. And half of those still have not opened. We really wanted to do something to really give back, but within our own capabilities, to give back to the community. We did two things. There were four staff members that were affected by Harvey; our staff members specifically. One of them totally lost her apartment and she had a two-month-old infant at home. Another one had significant damage to her trailer home. One was displaced for an entire week, and you can just imagine the salary that she lost for that week. And then the other lost her car. So what we did for our staff members, we ... Again, via social media, we created a GoFundMe page for them. The amount of support and love and compassion that we received from people that we don't even know. It was friends of a friend, or physicians that other physicians in other states was ... Incredible. Silen Pahlavan: And it was immediate. It was like right away, "I wanna help you. What can I do? Here it is." Sogol Pahlavan: So we raised $13,000 through our GoFundMe page and we divided that money according to employees' needs. So the one that lost her home got a significant amount out of that fund. And then the one that was displaced basically got the funds that would cover her salary for that week. And besides that, we also reached out to our community through Facebook. We're in a underserved Hispanic community. So we personally reached out to the upper class communities in the more affluent areas of Houston to be able to give donations and clothing to our patients and also the two employees that had lost clothing in the flood. Silen Pahlavan: Four days after the hurricane hit we were able to start collecting the items. It was clothes, it was backpacks, it was books and diapers and toiletries; anything that we could get. After four days our entire kitchen was full of items that were donated. And what we did for the next three weeks, as the patients were coming through, we would give them a survey, a questionnaire, and they would mark their needs. Do you need diapers? Do you need toiletries? Do you need clothes? What size do you need? And they would fill out the questionnaire and we would come to the back. We had one nurse that was in charge. She would come in the back and kinda shop for these items for them from our donation center. And they really appreciated that. Susanne Madden: So you really turned what was a disaster for everybody into you guys really becoming the resource for your community and for your staff. That is an incredibly powerful story. We will be providing links on the website and in this story to your Facebook page so that people get some of these videos and read some of the responses from the community. But I have to say, in terms of hearing a disaster story, the sort of recovery where you become the resource for your community themself, is really, truly remarkable. I have to give it to you. You took something that could have been potentially devastating and really turned it into such a positive way to foster closeness in the community and reach people in need and be able to deliver those services. You sorta became your own FEMA for your patients. To heck with FEMA! ABC Pediatric Clinic is the place to go to in a disaster! 34

Sogol Pahlavan: We were incredibly blessed that we had minimal damage. We had just, prior to the storm, built out the back of our clinic, which is an additional 2000 square feet literally four weeks before the storm. And the only damage we had was minimal water damage that seeped in through foundation. But in my, and Dr. Silen's office, which is way in the back of the building ... And we rarely use the office. It's not a functional part of our workflow that affects the patients. So we felt like with that we really need to do something to really give back. Susanne Madden: And you accomplished it. Well done. In terms of any quick tips, if you had a top two or three pointers that you wanted to give to other pediatric practices that may experience something in the future - because it certainly seems like that's where we're headed for, more and more with these historic storms - are there any two or three quick-hit points that you would want to identify for other practices? Silen Pahlavan: So I would say anything is possible. We never thought we would have this historical natural disaster in Houston. We've had other storms before. So preparation is really key. The reason that we got out some of it was by luck, but looking back, if we didn't have that luck, we would've had a lot more damage. One of the things that we didn't mention is to definitely get business interruption insurance. I did not know that existed prior to this storm. Some of the insurances have a deductible of 72 [hours]. It was 48 to 72 hours of business prior to reimbursing. Because we opened up within those 72 hours we didn't meet any of their criteria to have any money reimbursed. But look into that and really look at the details like with any other insurance. And read the fine print to see what it does cover. And then, definitely, insurance for your vaccines. So cover yourself with insurance and then cover your insurance, your building generator. Cover your vaccines somehow, even physically. A lot of the smaller offices in Houston had taken their vaccines to hospitals, bigger entities. And then your EHR. I would say those are the top three things. Those are the big dollars in business that really need to be KEY TAKE AWAYS covered. Don't wait for a disaster to get to know your And then engaging with your patients and staff and treat them like family. engaging with your employees, which, it shouldn't Get Business Interruption Insurance and read take a disaster for you to be able to do that. That the fine print (most policies will only cover you should be a culture in your business. And reaching after you've been closed for 48-72 hours). out, because we were really surprised by the Insure your vaccine (or medicine) supply. significant effect that social media had and using If possible, install a generator and keep it that medium to communicate with our patients. maintained. Check it regularly to make sure it And it worked. is functioning. Utilize social media now in order to connect Susanne Madden: Terrific. Thank you both so very with patients online, it may be your best way much for sharing your story with us today. It really to communicate with them in the event of a is truly a remarkable tale. And I just love that disaster. there're so many positive things that have come If you can, be a resource for your staff and your out of this for you, including galvanizing your staff, community. Many need help and your practice really building better relations and really may be a 'go to' resource that many may need becoming this resource for the community. Well Prepare a disaster plan now. Don't wait until done. you are in the middle of an event to figure out And again, thank you so much for your time today what to do. in sharing your story with us. We very much Make friends with your neighbors! You may appreciate it! need their help one day.

Win t er Solst ice 2017 | Volu m e 3, Issu e 4

SPECIAL SUPPLEM ENT: PATIENT CENTERED M ED ICAL HOM E

w w w.NCQASolu t ion s.com

AMANDA CI ADELLA Senior Consultant, PCS

HI GHLI GHTS FROM NCQA'S PCMH CONGRESS 2017 Since 2015, the National Committee for Quality Assurance (NCQA) has hosted their annual Patient Centered Medical Home (PCMH) Congress to bring together healthcare professionals to brainstorm, educate and learn PCMH best practices from one another. With the release of the PCMH redesign program in April, there was excitement in the air participants were engaged and eager to begin sessions at this year?s Congress, especially as NCQA released its 2017 PCMH Standards and overhauled its program this year. The speakers didn?t disappoint, and provided the knowledge, real-world examples and reassurance for professionals to take their ideas from concept to reality. It?s always nice to be surrounded by individuals within your industry that are energized and willing to provide guidance and this year was no exception. We?ve compiled some highlights to share some of what we learned at the Congress. Perhaps we?ll see you there next year?

That the software improvement from ISS survey tool to QPASS was a good and appreciated change, That the redesigned program has more flexibility for practices to pick areas that mattered to them, And the added involvement from NCQA with the virtual reviews helped practices demonstrate criteria they might not have been able to meet with the old documentation requirements.

PCMH Al igns wit h QPP, MIPS Several breakout sessions focused on the changes occurring within healthcare policy and payment reform. It?s widely known that payers are moving away from fee-for-service (FFS) payments to value-based models that incentivize providers based on quality and efficiency. Matt Gannon and Jameson King, both PCMH CCEs, from the New York City Department of Health and Mental Hygiene, discussed how the PCMH program aligns with the Quality Payment Program (QPP) Merit-based incentive program (MIPS), one of CMS?new payment models to shift providers to value-based payment arrangements.

Redesigned PCMH Program Wel l Received In the opening remarks, guest panelists that have had experience with the PCMH 2017 redesign program shared their lessons learned. The overall impression was: 37

Val ue-Based = Viabil it y f or al l Pract ices Eligible MIPS providers can earn 70+ points (percent) on their MIPS composite score by strategically incorporating and aligning their PCMH and MIPS efforts. Even if your practice doesn?t qualify for participation in the QPP, such as in pediatrics, there is still a push to embed value-based strategies within your practice to remain viable with commercial payers and Medicaid plans. Goal s Shoul d Inf orm Your PCMH Recognit ion Approach Shannon Nielson, MHA PCMH CCE, of Centerprise, pushed participants to dig deeper when pursuing their PCMH recognition. Her advice is to avoid completing the program in a ?check-the-box manner?, but rather, first determine the goal you hope to accomplish by getting your PCMH recognition. Such as, improving access for your complex patients to keep them from using the ED for services you can provide in-house, or restructuring office staff and processes to become more efficient. By identifying the goal early in the project you?ll be completing the core criteria in a goal-oriented manner and picking elective criteria that will complement and support your overall goal versus picking elective criteria that are easy to complete. Focus on total transformation, not just pursuing recognition status. Physical and Behavioral Heal t h Under One Roof NCQA is pushing the integration of behavioral health into primary care with the redesigned program. While the need for accessible behavioral healthcare is evident, many practices struggle with the concept and initial integration. PanCare of Florida, Inc., gave a presentation onIntegrative Health, a patient-centered collaborative effort combining both physical and behavioral health services under one roof for a common goal. Their approach included: -

Implementing standardized tools (PHQ-9) to evaluate patients, Having a warm hand-off between the primary care provider and the behavioral health specialist, Coinciding primary care and behavioral health appointments to make the best use of the patient?s time and all services being under one roof.

Large Scal e Communit y Programs I presented at the Congress on the topic of PCMH for Communities, alongside Susanne Madden, Cofounder of PCS. We discussed two specific projects: the Florida Chapter of the American Academy of Pediatrics and Cincinnati Children?s PCMH Learning Collaborative Program, both of which were large scale community programs that allowed the larger organizations to assist smaller practices with transitioning to medical home models.

Amanda Ciadella speaking at the 2017 Congress on 'Creating PCMH Programs for Large Communities' 38

We developed different concepts to help meet the needs of those communities, deploying project management principles and technology platforms to deliver education and support to practices. Consider At t ending! There was a great sense of camaraderie at the 2017 PCMH Congress and individuals that may have arrived unsure left with an education on PCMH concepts and new tools to help move their practices forward. Alignment was a recurring theme, whether it was between PCMH and MIPS, in aligning your practice goals to match your approach to getting there, or physically aligning complementary physical and behavioral services under the same roof. Susanne Madden speaking at the 2017 Congress on 'Creating PCMH Programs for Large Communities'

From improved software to increased flexibility for practices, it?s clear that NCQA is working to make it less complicated for practices to navigate the recognition process and the Congress is a great way to take in many talks and case studies across a plethora of areas, including Oncology Patient Centered Specialty Practice. We?ll be back again next year; you might want to join us there too. The 2018 Congress will be held in San Diego, CA, September 14-16. For more details on NCQA's Congress, you can access details here: ht t ps:/ / www.pcmhcongress.com/

Go h er e t o view if video doesn't play: h t t ps:/ / vim eo.com / 234501370

AMANDA CI ADELLA Senior Consultant, PCS

KAREN DUDA PCMH Consultant, PCS

JULI E WOOD Co-founder, PCS

PCS' ADVANCED PERFORMANCE PROGRAM We spoke to the team at Patient Centered Solutions to get their take on why they created the Advanced Performance Program and how this initiative can help their Clients.

However, we wanted to go further and assist our clients with meeting any Payer performance goals too. Keeping on top of quality improvement (QI) initiatives is important, but many clients also need to perform to designated metrics put out by insurance companies, such as meeting HEDIS measures and pay-for-performance requirements under certain contracts.

Tel l us about t he new program you?ve l aunched t hat wil l hel p pract ices t o st ay on t rack year-t o-year wit h PCMH: Our new program was born from the need to help practices stay on top of the requirements that they will need to meet year-to-year with NCQA. We consider our ?Advanced Performance Program?- or APP -a low impact, yet highly effective, initiative that focuses on the core PCMH concepts that cultivates quality improvement. We use the term ?low impact?to help convey that unlike the demands of working through an initial PCMH program, APP is designed to be a series of brief monthly check-ins for support and advice and consistent monitoring of practice information by our team. Soour program gives providers the tools, education, and support to meet the requirements of NCQA?s mandatory annual reporting program.

Is t here a part icul ar t ime t o enrol l or t ype of pract ice t hat woul d best benef it f rom t he program? Any practice interested in improving quality will benefit from this! The best time to enroll is as soon as you?ve realized there is a need for quality improvement or as soon as you have received your Recognition. We can help you identify the right type of QI activities and align them to all your goals so that there are no duplicative efforts occurring between PCMH 40

and other quality initiatives. Why do things twice when we can help set up a plan that optimizes efficiency for our clients?

PCMH 2014 Level 3 practices will have to attest, upon their transition into PCMH 2017 Annual Reporting Program, that they have been doing QI activities since their 2014 recognition. If a practice enrolls in APP right after receiving their 2014 recognition or well in advance of their entrance into PCMH 2017, then they will be well prepared for a seamless transition.

Start early to allow for ample time to work full cycles of quality improvement. By allowing enough time, if something isn?t working we can change it and try again. Also, don?t be afraid to make changes. We can help educate staff and make patient materials to explain the changes to ease the transition, you must welcome change to get where you want to be - a truly transformed practice.

Does t he APP al ign onl y wit h NCQA?s PCMH program?

If a Cl ient is al ready doing a great job wit h QI, is t here a need f or t his Program?

No, if you have not yet completed the NCQA PCMH Recognition Program, but are interested in developing a quality improvement program in your practice, APP is a great way to get started. We can align the program to Federal, State and Payer initiatives, in addition to NCQA?s medical home programs.

We have learned over time that clients that get ?too good? on their quality metrics ? say, once they hit a 90% threshold on a certain measure ? would simply stop monitoring their metrics over time. When we?d start a renewal with them, there would be a harsh realization that those high performing quality metrics had significantly dropped over time. What doesn?t get measured, doesn?t get improved, but by the same token, if not consistently measured then there is the risk of slippage.

Can you describe what a t ypical Cl ient experience wit h APP may l ook l ike? -

arise. The PCS team provides regular process and workflow guidance to help you streamline and maximize your quality improvement activities.

A monthly meeting with a PCS Consultant helps to keep Clients on track with clinical measures, care coordination activities, and patient satisfaction surveys. Resources, tips, and best practices are offered throughout the year to help Clients run an efficient and healthy practice. Training resources are provided to educate Client staff about Quality Improvement work and to help build a strong medical home team. The PCS team reviews and analyzes data on a monthly basis (or as needed) to identify and help remedy any missed targets or compliance issues that may

So the Advanced Performance Program allows for that continuous monitoring of measures to ensure long-term success. The practice can then put their time into focusing on more challenging QI projects. Practices organically evolve into high-performing, efficient medical offices that have improved patient clinical outcomes and patient and staff satisfaction, provided that is managed well and consistently monitored. "That is the goal of APP ? to free up the practice staff from on-going monitoring and allow them to focus efforts ahead" - Amanda Ciadella 41

use improves patient care, many of the speakers focused their comments on the patients themselves.

JULI E WOOD Co-Founder, PCS

Surgeon and Johns Hopkins professor of health policy, Dr. Martin Makary, emphasized the fact that what matters to the patient is not usually what matters to the physician.

NCQA'S 'QUALI TY TALKS' 2017

In his talk Measure What Matters: Asking the Tough Questions, Dr. Makary stated that patients are hungry for honesty in healthcare, and that a recent study found that 21% of procedures may be unnecessary. Patients want to know if they actually need the procedure or medication being prescribed, and that a good doctor is not defined by the outcome measures, but in part by their honesty - being able to tell a patient ?I don?t know,? and by giving consideration to the making appropriateness of certain types of care in healthcare a focus for the benefit of each individual patient benefit.

The National Committee for Quality Assurance (NCQA) began hosting its annual Qual it y Tal ks event in 2015 in order to highlight innovation in the healthcare industry that has the potential to improve quality care and change the status quo going forward. This year?s talks were no exception, from discussions on what?s in the technology pipeline to a movement to make sure that innovation does not drown out personalization for patients. Here are some of the highlights and you can access video of the talk via the links on the talk titles throughout this summary. In the introductory talk by NCQA founder and President, Margaret O?Kane, she discussed the goal to align measures across each of the different platforms, and additionally for these measures to be reported directly in a system to system format. Quality reporting is rapidly enabling the gathering of needed data, specifically with HEDIS measures gaining momentum: 57% of the population is now represented in the data, which equals 184 million lives. Despite the obvious use of data and technology, and the evidence on how its

One of the speakers to highlight making a push towards a more human connection was Lynn Baneszak, executive director of the Disruptive Health Technology Institute (DHTI) at Carnegie Mellon University (CMU). For an institute with the title ?disruptive?, Ms. Baneszak?s comments during her talk Building Health Care?s Future: A Prognosis were refreshingly down to earth, or should we say, at the patient level. With a call to action to remember the human connection in 42

healthcare, Ms. Baneszak stressed that 87% of patients feel that kindness is an important consideration in choosing a provider, and three quarters of study respondents said they would pay more for a provider who emphasized kindness in care. She encouraged this aspect of care by highlighting how providers must apply the technologies that are coming next, while finding a way to make and maintain the personal connection in the era of checking boxes next to pre-determined questions.

more quickly, and decrease the resulting blurriness when the camera is moving back and forth. Not limiting itself to technology, CMU has also spearheaded the research and use of bioactive raspberry extract to reduce permeability in the GI tract - leading to an inexpensive therapy that lacks the side effects of conventional medicine. Also heavy on technology innovation is IBM Watson Health. Dr. Kyu Rhee, Watson?s Chief Health Officer and President of the IBM Health Services, discussed some of the ideas they are exploring to improve quality of care, and quality and efficiency in practice.

After dropping that CMU was responsible for developing the first emoticon- the smiley face

During the discussion The Future of Health Is Cognitive: Beyond Jeopardy, IBM?s Watson Provides Health Care Answers, he discussed the potential for an automated accreditation process ? rather than have practices and facilities allot a large amount of staff time for compiling paperwork and completing recertification and accreditation applications, having the appropriate technology in place would allow for continuous and automated accreditations.

- she explained that at the institute, disruption using innovation means ?a big leap in a shorter time to get it off the bench and into the field.? With the goal of increasing affordability, accessibility and effectiveness of healthcare, DHTI is using technology such as artificial intelligence and 3D printing along with models such as behavioral economics and human computer interaction to determine what?s next and what works in healthcare. One such use of a technology not typically found in healthcare, is the use of the same algorithm that recognizes faces in a crowd. Applying this to colonoscopies has helped to find polyps

On the patient front, IBM is exploring how utilizing devices and instruments in the home can predict and prevent frailty conditions in the ever-growing aging population. IBM calls their intended use of technology 'Augmented Intelligence'. The quality piece comes from not just the stores of data now available but from a system that can support providers in identifying patterns, and complementing the people who focus on the actual relationships with patients. 43

Integrative Medicine department.

According to Dr. Rhee, the three principles of AI are to: -

Perhaps the most impactful talk of the event was focused around ensuring quality in end of life care for all patients.

Support humans, not replace them, Provide essential transparency: this is ?not a black box, it?s a glass box.? There must be transparency in how these systems are trained and the information that is used to make recommendations, and Create a new model of human plus AI to deliver outcomes.

Evidence, Et hics and Val ue Providing the right care where and when the patients need it continued to be a focus in the discussion on Toward More Complete Health & Wellbeing, by Kyle Hill, Co-Founder & CEO of Harvey, a leading telehealth provider of personalized and integrative medicine. With four out of five deaths in the US being due to lifestyle diseases, Mr. Hill explained that they decided to go for the ?lowest hanging fruit? in healthcare ? the patients who fall through the cracks of the conventional medical system and are misdiagnosed or not diagnosed at all. Using a telehealth platform, Harvey brings integrative medicine to the patients via video consults in home with a number of integrative health providers, with the intention of complementing conventional medicine and creating more of a focus on personalized prevention. Mr. Hill challenged the medical community to build more whole-body health measures into their quality metrics, and to welcome integrative health professionals into patient care. Reducing the $400 million prescriptions written annually is a main goal of preventative integrative healthcare, and the industry is starting to warm up to this care - the University of California at Irvine just received a $200 million grant to start an

Nneka Mokwunye Sederstrom, Director of Ethics for the Children?s Hospitals & Clinics of Minnesota, gave the stirring address Ethics Is Quality, Quality Is Ethics: Improving Care at the End of Life. According to Ms. Sederstrom, approximately 80% of patients want to die at home, but 60% of patients die in hospital, 20% in nursing homes, and only 20% die at home. ?We know that dying is a thing, so why don?t we work toward the goals of dying patients?? Patients desire to be free of pain and to die peacefully at home - the medical community needs to adjust and have death be embraced as a natural end of life, not a situation in which technology goes from being curative to organ substituting, with a ?no one gets out of life alive? attitude. Enhancing the quality of end of life care challenges providers and facilities to develop quality indicators that measure how they are doing with end of life care, and to create dashboards that measure successes, applying the same tools that are used to measure quality and improvement in chronic and preventative care. 44

Ms. Sederstrom ended with a challenge for participants to take a hard look at their institutions, with a list of 10 suggested questions to start: 1. How many patients received a palliative care consult in the last 6 months? 2. How many patients were offered hospice? 3. How many had advanced directives or other durable power of attorney forms? 4. How many with terminal disease were given death preference? 5. How many received end of life care counseling? 6. What are the demographics of those who received that counseling? 7. Where did your patients die? Was that where they wanted to die? 8. What are the barriers for your patients at the end of life? 9. How many had an ICU admission in the last year of life? 10.How many had an ethics consult last year of life?

Nneka Mokwunye Sederstrom, PhD, FCCP Director of Ethics, Children's Hospitals & Clinics of Minnesota

The 2017 NCQA Quality Talks provided attendees with a glimpse into how technology and other innovations are continuing to push quality in healthcare forward. While pushing at these boundaries, the talks also provided the very timely reminder that patient care should always be focused on the most important measure of quality: the patient. You can find more information here: ht t p:/ / www.qual it yt al ks.org/

SUSANNE MADDEN, MBA, CCE CEO / CoFounder / Editor

SOUND BI TES FROM THE PATI ENT CENTERED PRI MARY CARE COLLABORATI VE (ANNUAL CONFERENCE 2017) Put t ing Shared Principl es Int o Pract ice Founded in 2006, the Patient-Centered Primary Care Collaborative (PCPCC) is a not-for-profit multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. PCPCC represents a broad group of public and private organizations, with the mission ?to unify and engage diverse stakeholders in promoting policies and sharing best practices that support growth of high-performing primary care and achieve the ?Quadruple Aim?: better care, better health, lower costs, and greater joy for clinicians and staff in delivery of care?. While the team at PCS has long used the PCPCC?s resources and data to inform our own strategies and educational offerings, we became paying members this year and decided to attend the one and a half day annual conference in October. I was not disappointed!

well as insurers, employers, physicians and consulting firms like ours. Opening comments were delivered by Jill Rubin Hummel, President & General Manager, Anthem Blue Cross Blue Shield of Connecticut, Anthem, Inc., who is the Chair for the organization. I had the good fortune to work under Mrs. Hummel more than a decade ago when we both worked for United Healthcare in New York. Since then, she has remained committed to the physician community and has invested considerable time and effort in moving the concept of value-based care forward at the national level through Anthem. Her remarks focused on how much the concept of patient centered care has developed over the last decade, the value that it has delivered across stakeholders in the market, and where it is all going as we head into 2018. I, for one, am very enthusiastic about what can be accomplished through the collaborative under Jill Hummel?s leadership, and in conjunction with Karen Remley, Executive Director and CEO of the American Academy of Pediatrics as the Chair-Elect.

There were several healthcare super powers in the room - from AAP, ACOG, AAFP, ACP - as 46

The opening keynote was delivered by Sarah Krug, Chief Executive Officer, Cancer 101 on New Methods for Gleaning Patient Input (you can download her presentation by clicking on the title). Her focus was on presenting the Magic Wand Project , and extraordinary initiative that included patient ?shark tanks?to glean advice from (now) more than 5000 patients on how to improve the ?patient experience?. For clinicians or administrators looking for resources to help patients navigate through the complexity of care, go to the Magic Wand Project for tools, tips, research and data.

Medicaid Innovation; moderated by Robert A. Berenson, Institute Fellow, Urban Institute. Different care delivery and payment models were presented, including patient-centered medical homes, direct primary care, Accountable Care Organizations, bundled payments, and other payment ?reforms?along the lines of where we are seeing success and what the challenges may be. There are many! Laura Sessums, MD, discussed how payments are changing to support the medical home. Don't want to have to file claims to get paid for delivering care? Look out for Medicare?s evolving Comprehensive Primary Care Plus (CPC+) program to get that route. CPC+ is testing whether fee-for-service is the right model for primary care at all; Sessums thinks not and CMS will be testing that theory in the future to come. CAPG's Amy Nyugen-Howell thinks fee-for-service (getting paid by CPT / HCPCS code) will persist but perhaps needs some revisions, while Nextera's Clint Flanagan posited that we may all be headed toward Direct Primary Care under current administration policies.He went on to discuss that 'direct primary care' (DPC) - which is patient self-pay model where you pay your doctor a flat monthly fee and he / she does not participate with insurance plans removes cost sharing barriers, labor and costs involved in the practice collecting from insurers and so on.

Of particular interest to me was the panel discussion: Re-Inventing Primary Care via Practice Transformation and Payment Reform - What Works and What Can We Learn? That panel consisted of Clint Flanagan, Founder & CEO, Nextera Healthcare; Amy Nguyen Howell, Chief Medical Officer, CAPG; Laura Sessums, Director, Division of Advanced Primary Care, Center for Medicare and

Nextera works directly with employers too, developing the model to allow employers to pay on behalf of their employees, and the results have been to save industry substantial dollars while improving patient care too. DPC also untethers physicians from the limits of what services Payers will allow and what they

creating a new primary care model, and inviting select providers to contract with them to supply that care. Insurance still plays a key role: the insurer had to redesign benefits and payment structures for those participating providers and execute on this new plan for the employer. It has been highly successful from all angles: patient, provider, employer and insurer.

will pay for, which has resulted in Nextera utilizing 'tech tools' like telemedicine, going on site to employers facilities, and doing such things like holding patient 'happy hour' with doctors to open up education and access. I see much promise in DPC, particularly in light of ever-larger deductibles, and we have been working hard at The Verden Group to connect providers and employers under similar models.

On day two, Peter Lee, Executive Director, Covered California led the second keynote (download presentation here) on What Can and Should Purchasers Do To Promote Primary Care? He discussed how Covered California used its clout as a purchaser for 1.4 million covered lives to advance primary care through its contracted plans via benefit design, assigning a primary care provider for every enrollee, utilizing payment reform, and focusing on increasing the number of practices recognized as Patient Centered Medical Homes.

No healthcare discussion would be complete without technology and data. Guy Mansueto, Vice President, Portfolio Marketing at Watson Health / IBM, presented on Technology and Data: How Are They Transforming Primary Care Delivery, Payment and Patient / Family Engagement? It was a stimulating presentation, covering the trajectory of how data has been used historically and where it is going to: in a nutshell, Mansueto stated that ?we need to move to 'cognitive computing' to improve health?.

Frankly, that?s pretty big news as California seems to have dodged the PCMH movement that has swept across the rest of the country (with the exception of Kaiser Permanente and some healthcare systems embracing the model in recent years).

There was a fascinating presentation on Labor & Management: Strange Bedfellows With a Common Cause, discussing how partnerships between employers and unions can transform care and what is generalizable and unique about these arrangements so that others may follow suit. Kevin Kelleher of the New Jersey Education Association and Jennifer Duffy, Former Chair School Employees Health Benefit Plan Design Committee; Appointments Director, Office of Governor Chris Christie, provided details of how they redesigned benefits for NJ school employees by looking closely at care delivery and costs,

Mr. Lee also went into detail about what is working, where there are challenges and what the future holds for the program ? unfortunately they have no choice but to add on to premiums due to fiscal uncertainty under the Trump administration. To put this in context, 2018 had been on track to deliver on improved health to its population, now it looks like by 2019 California will have taken big steps back due to erosion of the Affordable Care Act under this President and the GOP. The present at ion lists out exactly how Covered California designed its program and provides plenty of data and resources to 48

illustrate the points made. Well worth reviewing. My favorite part of this one? That nut rit ion is a key f act or of heal t h!

time as practices matured into the model and more healthcare providers came on board. Unanimous passing of a bill at the state government level resulted in all Payers having to invest at least 12% of spending in primary care. This does not mean simply paying primary care providers higher fee-for-service rates, that 12% must be invested in high value care, behavioral health integration and development of medical homes. You?ll find more information here. What is particularly encouraging about this effort is that Payers were forced to be transparent ? in doing so, improvements could be made across the spectrum of Payers to improve population health and support medical home initiatives, creating a ?win / win?situation (for everyone).

Next up was Other State and National Strategies to Advance Primary Care which was

Brian Marcotte, National Business Group on Health, discussed how decisions have historically been made on cost data alone and that industry needs to be able to assess based on value instead and develop plan design from there. There is now a move away from simply focusing on demand and instead looking to involve all stakeholders to deliver better health care. A huge takeaway from this voice of the employer is the statement that "The Patient Centered Medical Home is integral to better plan design? from the employer perspective. To me, this sets the tone for innovation at the employer-as-purchaser level and bodes well for initiatives that we are working on, such as the advancement of Oncology medical home for purposes of developing collaboratives of high quality cancer care delivery focused on controlling end-to-end costs of care.

a panel discussion between Evan Saulino, MD, Clinical Advisor, Oregon?s Patient Centered Primary Care Home Program and Mark Fendrick, Executive Director, VBID Center, moderated by Brian Marcotte, President & CEO, National Business Group on Health. They discussed strategies to elevate primary care, including value-based insurance design and a focus on the part of states to leverage regulations and / or legislation to increase resources going to primary care. Evan Saulino, MD, stated that 80% of all patients in Oregon are now receiving care from medical homes. They emulated compensation in Oregon after Rhode Island's model, requiring all Payers to report primary care payments. What they observed was that investments in primary care were highly variable. A collaboration was formed to tackle this and ultimately Oregon managed to lower costs while creating quality improvements $240 million is now saved per year ($14 per person per month) and savings grew over

Mark Fendrick, MD, of the VBID Center, discussed that we need to enhance access across the continuum of the care episode. For example, once a patient is screened for breast 49

cancer, it needs to be much easier to have the biopsy and surgery resulting from that diagnosis. Certainly we have seen that fragmentation of care is a big problem, lack of coordination and patient confusion keeps costs higher than they could be. Fendrick?s position is that ?PCMHs must be better supported? in order to improve health outcomes.

leverage social movement strategies to advance primary care. His message was around creating consistency in values, making physicians' roles 'bigger' and "harnessing local power to get things done" . . . "find your power? . . . and "build communities" by capitalizing on our natural tendency toward community and "be inclusive". "Don't be afraid" that folks won't agree on your positions, the goal is to find common ground where we can. We can get away from "us vs. them" by moving our thinking to "our friends and our future friends" instead. I found his philosophies refreshing and his enthusiasm contagious.

Some novel approaches were laid out in What Will It Take to Integrate Population Health Into Primary Care? This panel included Evan Behle, City of Baltimore; Beth Tanzman, MSW, Executive Director, Vermont Access/ Blueprint for Health; and Somava Stout, MD, IHI Exec Lead for 100 Million Healthier Lives and they discussed methods for integration. The key takeaway from the discussion is that healthcare as to be taken to where the patients are - at home, at school, at work - and understand the patient reality in order to fit care around their needs.

You can follow his writing here and if you are interested in learning more about social networks for here:http:/ / connectedthebook.com/

Evan Behle illustrated this by discussing how they reduced mortality rate by connecting pregnant moms to pregnancy programs that deliver home services. By sending a nurse out to where the mom is at, care that would not otherwise be obtained (with significant impacts on mortality) is now better delivered. While the line up of speakers and topics was quite incredible, my favorite talk was What Can We Learn From Social Movements To Advance Primary Care? by Andrew Morris-Singer, President & Founder, Primary Care Progress.

The conference concluded with hopeful remarks from Karen Remley, CEO, American Academy of Pediatrics, who focused on Innovation Review and Implications for Policy. Despite challenges under the current administration (including the failure to reauthorize CHIP, the Medicaid program for children) the future looks bright for continuing to improve care in this country and develop collaboration across stakeholders to do so.

Dr. Morris-Singer started as an advocate for gay rights and brought that experience to his residency where he successfully led an effort to improve primary care programming at Harvard Medical School.

If you?d like more information on the annual conference, you can access it here: https:/ / pcpccevents.com/ or the Patient Centered Primary Care Collaborative which can be found here: https:/ / www.pcpcc.org/

He shared with us his current work to 50

AMANDA CI ADELLA Senior Consult ant

JULI E WOOD Co-Founder

- ROLL CALLAt The Verden Group's Patient Centered Solutions, we assist many practices in achieving National Committee for Quality Assurance's Patient Centered Medical Home and Specialty Practice Recognition programs.

Congratulations to our clients that have achieved NCQA PCMH Recognition this season! PRACTICE

STANDARD

LEVEL

Ballard Pediatrics, Seattle, WA

2014

Katz Pediatrics, Stuart, FL

2014

Dover Pediatrics, Dover, NH

2014

Clearwater Pediatrics, Clearwater, FL

2014

Eastern Pediatrics, Greenville, NC

2014

Heights Pediatrics, Brooklyn, NY

2014

Kidz Pediatrics, Angier, NC

2014

Pediatric Associates of Fall River, Fall River, MA

2014

Riverside Pediatrics, Georgetown, SC

2014

Palm Beach Pediatrics, West Palm Beach, FL

2014

Kevin Norowitz, MD, Brooklyn, NY

2014

Pediatric Associates of Savannah, Savannah, GA

2014

El Paso Pediatric Associates, El Paso, TX

2014

?A huge thank you to the consultant team ? it would never be more accurate to say ?We couldn?t have done it without them.?They really know all of the details, from logical to quirky, of how to do NCQA PCMH.? ? Jeff Bernstein M.D.-Pediatric and Adolescent Care of Silver Spring 51

VIEWPOINT Edit or -I n-Chief : Susanne Madden | Edit or ial and Pr oduct ion Manager : Heidi Hallet t | Cover Design: Scot t Hodgson ViewPoint is a seasonal publicat ion, dist r ibut ed digit ally Â© The Ver den Gr oup 52