core curriculum guidelines - suffolk care · the core curriculum guidelines for practice sites...
TRANSCRIPT
Core Curriculum Guidelines for
Practice Sites Audience: Primary Care Practice Sites Medical & Non-Medical Staff & Care Teams
V.01
PROGRAM TOOL FOR PARTICIPANTS OF THE
SUFFOLK CARE COLLABORATIVE
DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM
SUFFOLK CARE COLLABORATIVE | PROJECT MANAGEMENT OFFICE| www.suffolkcare.org | [email protected]
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Table of Contents
Welcome ............................................................................................................................................................... 2
User Guide for Core Curriculum Guidelines .......................................................................................................... 2
Purpose of this Tool .......................................................................................................................................... 2
Train the Trainer Approach ............................................................................................................................... 2
Getting Started .................................................................................................................................................. 3
Core Curricula Learning Modules .......................................................................................................... 3
Required Training Topics ....................................................................................................................... 3
Online Learning Center ..................................................................................................................................... 4
Instructions to Return ....................................................................................................................................... 4
Core Curriculum Modules ..................................................................................................................................... 5
New Models of Care and Healthcare Trends ........................................................................................................ 5
DSRIP 101 .............................................................................................................................................................. 6
Community Orientation ........................................................................................................................................ 7
Cultural Competency & Health Literacy................................................................................................................ 8
Ethics & Professional Boundaries ....................................................................................................................... 10
Patient Centered Medical Home Recognition .................................................................................................... 11
Care Coordination Methodology, Protocol & Treatment Plans.......................................................................... 12
Chronic Disease & Co-morbidities ...................................................................................................................... 13
Primary Care & Behavioral Health Integrated Care Program ............................................................................. 14
Cardiovascular Health & Diabetes Wellness & Self-Management Programs ..................................................... 17
Interventions for Tobacco Cessation .................................................................................................................. 18
Promoting Asthma Self-Management Program ................................................................................................. 19
Performance Reporting & Improvement ............................................................................................................ 20
Health Information Technology, Connectivity & Documentation ...................................................................... 22
Regional Health Information Organization (RHIO) ............................................................................................. 23
HIPAA and Compliance Program ......................................................................................................................... 24
Practice Site Training Attestation Form .............................................................................................................. 25
Practice Site Training/Meeting Sign-in Sheet Template ..................................................................................... 26
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Welcome The Suffolk Care Collaborative (SCC) welcomes you as a participating practice site. You play a key role as we
pursue our commitment to improve the health and well-being of the community we serve through the New York
State’s Delivery System Reform Incentive Payment (DSRIP) Program.
User Guide for Core Curriculum Guidelines
Purpose of this Tool The Core Curriculum Guidelines for Practice Sites include training requirements for participating practice sites in
the Suffolk Care Collaborative (SCC). Most of the curricula was designed based on national literature reviews of
training provided around the country and vetted through appropriate key internal stakeholders. Core Curriculum
Learning Modules described should be considered as a starting point for practice site training, are customizable
and will evolve and grow overtime, some Learning Modules are optional while others are required under
participation in the DSRIP program.
The Core Curriculum Learning Modules represent recommended topics for practice site trainings and will position
your organization for successful participation in the DSRIP program. It will serve as a training foundation to harvest
a consistent base of knowledge on the system transformation, clinical improvement, population-wide programs,
patient education, care coordination, and many more. We believe the completion of this tool will enhance the
effectiveness of the services provided by your practice site.
Train the Trainer Approach Each participating practice site will identify a Practice Champion, as described in more detail in the SCC’s
Implementation Guide for Practice Sites. The SCC will train each Practice Champion on the contents of this tool
through a blended learning approach. Every Practice Champion will coordinate the completion of all required
training requirements by job family as described here.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Getting Started Once you are comfortable with the Core Curriculum Guidelines described in this tool, you will begin coordinating
practice site trainings with your staff. Some trainings may be in-person and/or facilitated by the SCC, via WebEx or
via the SCC’s online Learning Center. You may engage your staff multiple times in various forums that may work
best for your practice. Each time you host a training, we ask that you document the training on the Practice Site
Training/Meeting Sign-in Sheet Template appended to this tool.
Core Curricula Learning Modules We’ve provided a list of the Core Curriculum Learning Modules below. Each module includes recommended topics,
as well as learning objectives describing key competencies gained from each topic. Lastly, there will be links to all
core curricula to be used to facilitate training in each module.
1. New Models of Care & Healthcare Trends 2. DSRIP 101 3. Community Orientation 4. Cultural Competency & Health Literacy 5. Ethics & Professional Boundaries 6. Patient Centered Medical Home Recognition 7. Care Coordination Methodology, Protocol & Treatment Plans 8. Chronic Disease & Co-morbidities 9. Primary & Behavioral Health Integrated Care Program 10. Cardiovascular Health & Diabetes Wellness & Self-Management Program 11. Interventions for Tobacco Cessation 12. Promoting Asthma Self-Management Program 13. Performance Reporting & Improvement 14. Health Information Technology, Connectivity & Documentation 15. Regional Health Information Organizations (RHIO) 16. HIPAA and Compliance Program
The current list of Core Curriculum Learning Modules may change from time to time, these changes and/or
updates will be communicated to you via email and published in future versions of this tool.
Required Training Topics The training topics outlined in the table below should be completed to
meet DSRIP training requirements. The audience and mode are
provided. The audience is specified by job title or grouped by clinical
or non-clinical staff.
Required Training Modules/Topics Audience Mode
DSRIP 101 Clinical and Non-clinical Online Learning Center
Community Orientation
Clinical and Non-clinical Online Learning Center
Cultural Competency Health Literacy 101
Clinical and Non-clinical Online Learning Center
Understanding the Basic Principles and Core Elements of Care Coordination
Care Manager/Coordinator, Social Workers, Community and Health Worker
Online Learning Center
Understanding the Purpose and Benefits of Successful Patient Hand-offs
Care Manager/Coordinator, Social Workers, Community and Health Worker
Online Learning Center
When navigating through this tool, you will find required training topics marked with this symbol:
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Cardiovascular Health & Diabetes Wellness & Self-Management Program (full Module)
Primary Care for adult patient population
Online Learning Center
Interventions for Tobacco Cessation - 5 A’s of Tobacco Cessation Control and Referring to the NYS Quitline
Primary Care for adult patient population
Online Learning Center
Asthma Home Environmental Trigger Assessment Services Overview
Clinical and non-clinical Coming Soon
The SCC Performance Reporting & Improvement Program
Administration, Health Information Technology, Physicians, PA, NP
Online Learning Center
Clinical Data Sharing & Interoperability Administration, Health Information Technology, Physicians, PA, NP
Will be facilitated by IT Team
RHIO Connectivity Overview
Administration, Health Information Technology, Physicians, PA, NP
Will be facilitated by RHIO Representatives
Use of DIRECT Secure Messaging & Alerts
Administration, Health Information Technology, Physicians, PA, NP
Will be facilitated by RHIO Representatives
HIPAA Privacy, HIPAA Security and Compliance
1 Representative per Practice Site to be completed during on-boarding
Online Learning Center & Self-Directed Learning
Online Learning Center The SCC Online Learning Center can be accessed at https://suffolkcare.org/forpartners/learning-center, where you
can access online health education at your convenience. Many of the Core Curricula Learning Module referenced
in this tool are available online, as indicated on the Required Training Topics table. You may choose to use the
web-based system tool to roll-out all training requirements. Each module is about 15-30 minutes in length,
participants will be required to complete a brief registration form and post-evaluation and test.
Instructions to Return When your practice has fulfilled all training requirements, you will complete the Practice Site Training Attestation
Form and return it to your designated Provider Relations Manager. To accompany this attestation, please provide
all sign-in sheets completed by your staff.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Core Curriculum Modules
New Models of Care and Healthcare Trends
Module Overview: This module provides an overview of the country’s health care delivery system and the goals of
health reform, both Federal and State levels. It focuses on new models of care, an introduction to care
coordination, and the changes in the way that health care is being paid for and delivered. Participants will gain an
understanding of the Triple Aim and how the system is being transformed in order to reach this goal.
Topic Learning Objectives Core Curriculum
Overview of US Healthcare System and Payment System
Describe the private, governmental, professional, and economic contributions to the development, maintenance, alteration, and operation of the U.S. health care system.
Describe the types and interrelationships among health care facilities, services, and personnel.
Understanding the basics of Medicare and Medicaid and private insurance as well as the basics of payment structures including capitation, value-based payments and their purpose in health care reform.
Understanding how health care reform will impact the delivery of health care services.
Describe the values and assumptions that underline the changing priorities in health planning resource allocation.
1199SEIU TEF and PCDC Care Coordination Fundamentals Module 1 - 2 1
New Models of Care
Understand the basics of the Triple Aim.
Describe new models of care (Health Homes, Patient-Centered Medical Home, ACOs, Clinically Integrated Networks, and DSRIP) and understand similarities and differences.
Understand the basics of PCMH standards as it related to care coordination.
Understand the difference between home care and health homes.
Understand how a value-based purchasing/pay for performance payment model differs from transitional fee-for service.
Understanding the differences between Individual vs. Population Health.
1 1199 SEIU Training and Employment Funds and Primary Care Development Corporation. Care Coordination
Fundamentals Teaching Guide, 2014.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
DSRIP 101 New York Delivery System Reform Incentive Program
Module Overview: This module provides an overview of the New York State’s Delivery System Reform Incentive
Payment Program (DSRIP). It focuses on the overall goals of the program, provides an overview of the SCC
structure and discusses the SCC Quality Improvement Agenda.
Topic Learning Objectives Core Curriculum
New York Delivery System Reform Incentive Program (DSRIP 101)
Required
Discuss the goals of DSRIP
Identify what a Performing Provider System is and its purpose
Describe the Suffolk Care Collaborative’s Structure
Recognize the 11 SCC DSRIP Projects
Discuss the Suffolk Care Collaborative’s Quality Improvement Agenda and Sustainability Plan
https://suffolkcare.org/forpartners/learning-center
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Community Orientation
Module Overview: This module provides an overview of the Suffolk County Community, its needs and Suffolk
Care Collaborative (SCC) initiatives. It explores how the SCC aims to focus multiple initiatives and strategies for the
high priority needs in Suffolk County to prevent chronic disease, promote mental health and prevent substance
abuse. Participants will gain a better understanding of the population characteristics and demographics,
understand and learn about strategies to address areas of need, and also how the Suffolk Care Collaborative is
connecting target populations and families to health and wellness services within the community.
Topic Learning Objectives Core Curriculum
Community Orientation
Required
Understand the population characteristics and demographics of Suffolk County
Identify and understand the priority areas/needs in Suffolk County community and the relationship to the chosen clinical projects through our Community Needs Assessment.
Identify areas of need in order to better target the intended recipients
Identify the individuals and communities where avoidable utilization of high-cost health care resources currently exist.
Learn about the SCC and HITE partnership
https://suffolkcare.org/forpartners/learning-center HITE REFERENCE INFORMATION: http://files.constantcontact.com/b450ac0d401/ba317dd2-08c7-401b-acff-0cd56de6de7c.pdf?ver=1485200358000
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Cultural Competency & Health Literacy
Module Overview: This module establishes an overview of concepts used to enhance both patients’ and providers’
understanding of the health care system. It emphasizes the terms cultural competency and health literacy. These
terms enable the differing cultural needs of patients to be recognized while not overlooking a patients’ true
understanding of their overall health and well-being. The social determinants of health will also be analyzed in
order to further patients’ knowledge of their unavoidable risks with in the health care system.
Topic Learning Objectives Core Curriculum
Cultural Competency Health Literacy 101
Required
Define health literacy and cultural competency
Discuss the scope and the challenges of health literacy and cultural competency and why it is important.
Understand how culture, health literacy and language access influence patient-centered care.
Suffolk Care Collaborative: Learning Center: CCHL 101 Module
Cultural Competency
Recognizing patients’ families’ cultural needs/factors that may affect their choices or engagement
Define cultural competency, cultural respect, and cultural diversity.
Learn the factors that influence culture
Identify patients and communities in need including populations facing health disparities
U.S. Department of Health and Human Services National Institutes of Health Agency for Healthcare Research and Quality U.S. Department of Health and Human Services - Office of Minority Health
Communicating with patients and families in a culturally competent manner
Understand the impact of cultural backgrounds on patient decision making in healthcare
Educate partners about culturally appropriate methods to providing services to patients and their families
National Institute for Cultural Competence - Providers U.S. Department of Health and Human Services - Health Resources and Services Administration
Health Literacy
Create understanding for patients and their families in order for them to better understand health information
Define health literacy and the different factors that influence it
Identify and understand the 3 different types of health literacy and how to communicate effectively
Identify ways to educate patients and improve health literacy
Educate partners in linguistically appropriate methods in order to more easily communicate, process, and understand each patients needs
Centers for Disease Control and Prevention U.S. Department of Health and Human Services Health Literacy Partners
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Topic Learning Objectives Core Curriculum
Allowing patients and their families to understand the factors that influence a person’s overall health and wellness
Identify the five key social determinants of health
Identify new interventions and resources to address social determinants of health
Define Health Equity and the relationship to social determinants of health
Healthy People 2020 Centers for Disease Control and Prevention World Health Organization
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Ethics & Professional Boundaries
Module Overview: This module reviews general ethics for healthcare workers. It focuses on making sure that
trainees understand ethical decision-making.
Topic Learning Objectives Core Curriculum
Ethical and Responsible Decision-Making
Identify a framework for ethical decision making.
Be familiar with and know the purpose of the patient’s bill of rights.
https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf Modules 2, 23, 24 2
Professional Boundaries
Understand personal and professional boundaries and why they are important.
Describe the role personal and professional boundaries have in creating positive relationships with partners and teammates.
Understand appropriate boundaries with social media while working with patients.
Describe ways to maintain healthy boundaries.
Understand risky behaviors that lead to boundary violations.
Understand the relationship between professional boundaries and burn out.
https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf Modules 23, 24 3 https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf https://www.ncsbn.org/NCSBN_SocialMedia.pdf
2 1199 SEIU Training and Employment Funds and Primary Care Development Corporation. Care Coordination
Fundamentals Teaching Guide, 2014. 3 Ibid.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Patient Centered Medical Home Recognition
Module Overview: This module provides an overview of the National Committee of Quality Assurance (NCQA)
Patient Centered Medical Home Recognition. It focuses on the recognition process; an introduction to the PCMH
model of care; and the national Standards for practices for PCMH recognition. Participants will gain a better
understanding of the PCMH requirements and the roadmap to recognition submission. For the advanced
participant, a comprehensive look at the new 2014 Standards and Guidelines has been included in the curriculum.
Topic Learning Objectives Core Curriculum
NCQA PCMH Recognition Process: Start to Finish
Participants will gain an understanding of the PCMH recognition the process from start, “Is your practice eligible for PCMH recognition?” to finish, “Maintaining your NCQA recognition status.”
https://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh
Introduction to PCMH and Eligibility
Participants should be able to identity aspects of PCMH recognition including contents, scoring and eligibility as well as the documentation requirements.
https://www.youtube.com/watch?v=YQHHt-cEu4s&feature=youtu.be
Overview of the NCQA PCMH: Understanding the Six Standards
Participants should be able to identify and describe the six PCMH Standards. In addition, they should gain knowledge about the Elements and Factors that support the Standards and their documentation requirements.
Standard 1: Patient - Centered Access
Standard 2: Team-Based Care
Standard 3: Population Health Management
Standard 4: Care Management and Support
Standard 5: Care Coordination & Care Transitions
Standard 6: Performance Measures & Quality Improvement
https://www.youtube.com/watch?v=YQHHt-cEu4s&feature=youtu.be https://www.youtube.com/watch?v=qRSEy1NZruM https://www.youtube.com/watch?v=vI9RrGh0xjk https://www.youtube.com/watch?v=oB-632xbKsU&feature=youtu.be https://www.youtube.com/watch?v=9Sd_eof7q8w&feature=youtu.be https://www.youtube.com/watch?v=wuCitK1-SOk https://www.youtube.com/watch?v=fUPohydorRk https://www.youtube.com/watch?v=I_DwadhQ_T4
NCQA PCMH 2014 Standards and Guidelines
Participants should be able to discuss in detail the six PCMH Standards, their Elements and Factors. This tool will guide the user on documentation requirements to meet PCMH recognition.
http://files.constantcontact.com/b450ac0d401/929d2e83-a8a5-4fa8-82b1-c79659abc903.pdf?ver=1485200937000
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Care Coordination Methodology, Protocol & Treatment Plans
Module Overview: This module provides an overview of Care Coordination and its place in the health care delivery
system. Emphasis is placed on the importance of coordinated care throughout the continuum and how social
determinants of health can impact a patient’s health outcomes. Participants will gain an understanding of who can
coordinate care, how this is accomplished through transitions of care, and the importance of providing patients
with effective, efficient, patient centered care.
Topic Learning Objectives Core Curriculum
Understanding the Basic Principles and Core Elements of Care Coordination
Required
Understand and define what it means to coordinate care
Describe those members of the care team that coordinate care and how they work as in interdisciplinary team
Understand the importance of coordinating care throughout the care continuum
Describe basic barriers to reaching optimal health outcomes and explain ways in which these barriers can be overcome
Understand the difference between care coordination and care management
https://suffolkcare.org/forpartners/learning-center
Understanding the Purpose & Benefits of Successful Patient Handoffs
Required
Understanding a warm hand-off & benefits of warm hand-offs, referrals and transfers
Understand effective and ineffective transitions in care
Describe the root causes of ineffective transitions
Describe various models of transitions of care
https://suffolkcare.org/forpartners/learning-center
Integrated Delivery System (IDS) 101
Understanding the concepts of IDS, Clinical Integration, Clinical Interoperability and Population Health Management.
Understand the definition and meaning of an Integrated Delivery System
Understanding the SCC Clinical Integration Strategy
Describe the various levels of care coordination occurring throughout the care continuum
Understand how the DSRIP projects enhance the ability for care to be coordinated
Identify and differentiate between care coordination and more specialized, complex care management occurring at various levels of the integrated delivery system
https://suffolkcare.org/forpartners/learning-center
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Chronic Disease & Co-morbidities Module Overview: This module reviews the major chronic diseases, co-morbidities and the implications of poor
chronic disease management on patients and the health care delivery system. It teaches students tools and
strategies to help patients thrive by reviewing both chronic disease care and the social determinants that affect
health outcomes. It includes a basic overview of the major chronic conditions. Programs should explore in greater
detail conditions relevant to the students’ occupations, work settings, and rural versus urban settings.
Topic Learning Objectives Core Curriculum
Chronic Disease & Co-morbidities (Part 1)
Understand what a chronic disease is, the prevalence of it in the U.S., and how it relates to our healthcare system.
Understand the basics of diabetes, hypertension, high cholesterol, asthma, heart disease, stroke, Hepatitis, HIV, behavioral health, and substance abuse.
Understand stigmas often associated with these chronic conditions.
1199SEIU TEF and PCDC Care Coordination 4 https://www.1199seiubenefits.org/wp-content/uploads/2014/07/CC-Teacher-Manual-FINAL-web.pdf
Chronic disease and co-morbidities (part 2)
Identify behaviors and risk factors related to diet, exercise and smoking that impact chronic disease.
Know the appropriate team member to report changes in behavior/condition.
American Academy on Communication in Healthcare: Behavior Change http://aachonline.org/dnn/Resources/Academic-Articles/Behavior-Change
Disease Registries: A Powerful Tool to Support Your Practice!
Understand what a disease registries is.
Understand why healthcare organizations and providers use computerized disease registries.
Understand and identify different types of registries.
Disease Registries: A Powerful Tool to Support Your Practice http://files.constantcontact.com/b450ac0d401/5e74f8aa-04af-4bd7-
a030-c6ac47629ad8.pdf?ver=
1488912825000
4 1199 SEIU Training and Employment Funds and Primary Care Development Corporation. Care Coordination
Fundamentals Teaching Guide, 2014.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Primary Care & Behavioral Health Integrated Care Program
Module Overview: This module provides a comprehensive look at the process of primary and behavioral health
integration. The modules progress though understanding the core concepts related to integrating services, and the
prevailing models on integration and their relation to population health, to preparing for integration, and finally to
full implementation and documentation. Participants will gain a full understanding of the potential of this type of
integration to improve the health outcomes of patients, and what the steps will be to work towards this
integration.
To access the trainings, please contact your project manager or email us at [email protected]
Topic Description Learning Objectives Core
Curriculum
Basics of Integrated Care
This module prepares the audience to understand the core concepts related to integrating behavioral health services into a primary care setting
Describe the population based goals of integrated care
Describe the continuum of integrated care
Name the core competencies for providers in an integrated care approach
https://suffolkcare.org/forpartners/learning-center
Basics of Bidirectional Integrated Care
This module prepares the audience to understand the core concepts related to integrating primary care services into a behavioral health setting
Describe the basic parameters of bidirectional programs
Identify the common goals of bidirectional interventions
Identify the core factors that make bidirectional programs effective
https://suffolkcare.org/forpartners/learning-center
Primer on Evidence Based Models of Integrated Care
This module prepares the audience to understand the current prevailing models of integrated care and their relationship to constructs such as “level of integrated care” and “population penetration.”
Name and describe the three prevailing models of integrated care
Describe the meaning behind the constructs of levels of integration and population penetration
Describe the difference between models and programs
https://suffolkcare.org/forpartners/learning-center
Rating Your Level of Integrated Care Using the MeHAF
This module prepares the audience to learn how to self administer the MeHAF tool which is used to rate a site’s level of integration.
Describe the team members required for self-administering the MeHAF
Describe the core competencies of the MeHAF
Self-administer the MeHAF rating scale
https://suffolkcare.org/forpartners/learning-center
Primer on Screening for Integrated Care
This module provides an introduction to the concept of screening as it pertains to integrated care efforts including the different uses of
Identify the typical tools used in primary care
Describe the concepts of screening, assessment and tracking
https://suffolkcare.org/forpartners/learning-center
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
screening tools and key implementation concerns.
Describe implementation considerations for establishing screening pathways
Working with BHCs: The Warm Hand-Off
This module provides primary care providers with basic language and understanding of how to effectively provide a warm handoff of a patient to a behavioral health consultant.
Describe the function of a warm handoff
Describe the strategies often used to manage flow in a primary care setting
Describe a sample introduction that a primary care provider can use to introduce services to a patient
https://suffolkcare.org/forpartners/learning-center
Documentation for Primary Care
This module provides an exemplar of effective standard practices for documenting for the primary care record. Although North Carolina standards are referenced the core concepts are applicable across different state settings.
Describe the components of a primary care specific SOAP note
Describe elements that do not belong in a primary care record
Describe regulatory parameters that may influence the content of a SOAP note
https://suffolkcare.org/forpartners/learning-center
Primer on the Primary Care Consult
This module provides behavioral health consultants with a framework for how to structure consults with patients in primary care in a 15 to 30 minute modality.
Describe the core components of a typical consult
Describe the content of an effective introduction
Describe the content of an effective functional analysis
https://suffolkcare.org/forpartners/learning-center
Primer on the PCBH Model
This module provides an overview of one of the three prevailing models of integrated care, the primary care behavioral health model.
Describe the core attributes of the PCBH model
Describe the goals and core metrics of a PCBH service
Describe the core competencies of a BHC in this model
https://suffolkcare.org/forpartners/learning-center
Registry Basics This module provides the audience an overview of the use of and rationale for registries in managing patient populations.
Describe the difference between a spreadsheet and a database
Describe the way in which registries are used to manage care
Describe considerations for implementing a registry based care pathway
https://suffolkcare.org/forpartners/learning-center
Improving Screening and Identification in Pediatric Practices
This module provides the audience with a strategy for identifying pediatric patients who are at risk of behavioral health issues.
Name the percentage of children who have identifiable behavioral health conditions
Describe the components of the AAP Mental Health Toolkit
https://suffolkcare.org/forpartners/learning-center
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Describe the elements to consider when implementing screening
Primer on Pediatric Consults for Primary Care
This module provides the audience with basic strategies for structuring a pediatric primary care behavioral health consult.
Describe the areas where primary care consultation can be effective
Describe the strategies for engaging pediatric patients
Describe the core competencies of a pediatric behavioral health consultant
https://suffolkcare.org/forpartners/learning-center
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Cardiovascular Health & Diabetes Wellness & Self-Management Programs
Module Overview: This module reviews the evidence-based resources and treatment strategies being
implemented to support the Cardiovascular Wellness and Self-Management Program and the Diabetes Wellness
and Self-Management Program. You will learn about the Million Hearts® campaign, tools available to identify
patients in need of follow-up care, how to successfully retrieve accurate blood pressure readings and teach self-
monitoring blood pressure techniques, and methods to reduce tobacco use in patients. You will also learn about
tools available to identify patients with diabetes or “at-risk” of developing diabetes, comprehensive diabetes
testing methods and lifestyle recommendations. Finally, you will learn about documentation of patient self-
management goals and how to refer patients to self-management education.
Topic Learning Objectives Core Curriculum
The Cardiovascular Wellness & Self-Management Program
Required
Demonstrate the elements of the DSRIP Cardiovascular Wellness & Self-Management Program
Recall major strategies, goals, and tools of the Million Hearts® campaign
Recognize how a registry is used to identify and track hypertension patients
Summarize key points from guideline recommendations
https://suffolkcare.org/forpartners/lea
rning-center
Blood Pressure Measurement (practice-based or self-monitored)
Required
Summarize proper techniques and equipment for measuring Blood Pressure
Identify implications of performing blood pressure measurements incorrectly
State the impact of self-monitored BP programs (SMBP) in reducing risk of disability or death due to uncontrolled hypertension
Identify features to consider in guiding patient in selection of SMBP equipment
Review the validation process for automatic blood pressure measurement devices
https://suffolkcare.org/forpartners/lea
rning-center
Diabetes Wellness & Self-Management Program
Required
Review the impact of diabetes
Define the elements of the Diabetes Wellness & Self-Management Program
Apply the screening and treatment recommendations for patients with diabetes
https://suffolkcare.org/forpartners/lea
rning-center
Patient Self-identified Goals and Diabetes & Chronic Disease Self-Management Education
Required
Formulate ‘smart goals’ in collaboration with patient
Illustrate Motivational Interviewing techniques to assist patients in setting health goals
Identify benefits of diabetes and chronic disease self-management education, components of self-management programs, and the various programs to which a patients can be referred
https://suffolkcare.org/forpartners/lea
rning-center
18:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Interventions for Tobacco Cessation
Module Overview: This module is intended to support trainees in understanding interventions for tobacco
cessation to support the SCC’s clinical improvement programs and population-wide wellness initiatives. You will
learn about Tobacco Cessation control methods endorsed by the Million Hearts® campaign as well as
understanding the services provided through the NYS Smokers’ Quitline.
Topic Learning Objectives Core Curriculum
5 A’s of Tobacco Cessation Control and Referring to the NYS Quitline
Required
Summarize the 5 A’s of tobacco cessation counseling
Describe the services of the NYS Smokers’ Quitline and the referral process
Illustrate how Progress Reports are obtained and the information included in the reports
Discuss the role of patient-center communication in providing effective tobacco counseling
Provide evidence-based brief interventions in counseling tobacco users
https://suffolkcare.org/forpartners/learning-center
Tobacco Dependence and Cessation Treatment in Individuals with Mental and/or Behavioral Disorders
Identify strategies that individuals with mental and/or behavioral health disorders may use to support their efforts to quit using tobacco products
Define the 5A’s for treating tobacco dependence as outlined in the US PHS Guidelines Treating Tobacco Use and Dependence
Identify the FDA approved medications used to treat tobacco dependence for patients who use tobacco products and increase the rate of successful quit attempts
Evaluate various resources available to assist patients to quit
Summarize the 5R’s to enhance motivation to quit using tobacco products
https://suffolkcare.org/forpartners/learning-center
19:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Promoting Asthma Self-Management Program
Module Overview: This module reviews the evidence-based resources and treatment strategies being
implemented to support the Promoting Asthma Self-Management Program. You will learn about tools available to
assess and monitor patients with asthma, comprehensive education about asthma self-management, the
importance of controlling environmental exposures that affect asthma patients, medication to treat asthma.
Topic Learning Objectives Core Curriculum
Asthma Home Environmental Trigger Assessment Services Overview
Asthma Home Environmental Trigger Assessment Services Overview.
Values of promoting asthma self-management and learn about the tools and patient education resources available.
https://suffolkcare.org/forpartners/learnin
g-center
The American Lung Association’s Asthma Basics Course
Recognize and manage triggers.
Understand the value of an asthma action plan.
Recognize and respond to breathing emergency.
View the What is Asthma? Animation that shows the three primary changes in the airways during an asthma episode.
Learn about comprehensive resources, including asthma medication devices and demonstration video downloads for patients.
Asthma Basics in English
Asthma Basics in
Spanish
20:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Performance Reporting & Improvement
Module Overview: This module provides an overview of the SCC Performance Reporting and Improvement
Program. It focuses on an introduction to the SCC Performance Reporting and Improvement Program and
describes the Domain 1 Patient Engagement Reporting Requirements. Participants will gain a better
understanding of how to deploy PDSA cycles to conduct tests of change and utilize control charts to understand
data variation.
Topic Learning Objectives Core Curriculum
The SCC Performance Reporting & Improvement Program
Required
Describe the purpose of the SCC Performance Reporting and Improvement Plan
Define the SCC approach to Rapid Cycle Improvement
Discuss the performance reporting organizational structure and stakeholder roles and responsibilities
Identify the 11 DSRIP projects the SCC is implementing across Suffolk County
Explain the performance reporting requirements for Domain 1 Patient Engagement, Domain 1 Project Engagement and Domain II & III Performance Outcomes
Discuss the Pay-for-Performance (P4R) and Pay-for-Performance (P4P) model and associated timeline
Explain the Gap-to-Goal improvement standards
Describe the SCC approach to data aggregation and analysis including the decision support tools used to support the performance reporting program
Explain the SCC action planning process
Describe the SCC recommended model for performance improvement (IHI Improvement Model)
https://suffolkcare.org/forpartners/learning-center
IHI – An Introduction to the Model for Improvement
Describe the Model for Improvement
Discuss how to use the Plan-Do-Study-Act (PDSA) cycle to conduct rapid tests of change
Explain the three questions that can help drive quality improvement work
https://suffolkcare.org/forpartners/learning-center
IHI – Building Skills in Data Collection and Understanding Variation
Describe how to evaluate data variation
Explain common and special causes of variation
Identify data collection strategies
https://suffolkcare.org/forpartners/learning-center
IHI – Using Run and Control Charts to Understand Variation
Describe the history of how statistical process control (SPC) methods evolved over time
Identify three key questions to construct and use a control chart
Explain how to select the appropriate control chart based on the types of data
https://suffolkcare.org/forpartners/learning-center
SCC Domain 1 Patient Engagement
Describe the DSRIP Domain 1 Patient Engagement Reporting Requirements and commitments made to the Department of Health
Identify the SCC data request timeline and DOH reporting
https://suffolkcare.org/forpartners/datarequest
21:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
schedule
Explain the patient engagement data specs needed by DSRIP project
Discuss the temporary strategy for transmitting Protected Health Information (PHI) to the Suffolk Care Collaborative to meet each Patient Engagement Quarterly Reporting Requirements
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Health Information Technology, Connectivity & Documentation
Module Overview: This module provides an overview on the SCC’s Clinical Data Sharing & Interoperability plan
and the essential steps defined as “technical on-boarding” which our Information Technology Team will be
engaging with your practice to complete. Upon successful completion of “technical on-boarding” your practice will
have access and interoperability with the SCC’s Population Health Management platform and applications.
Topic Learning Objectives Core Curriculum
Clinical Data Sharing & Interoperability
Required
1. Introductions to the SCC Information Technology Team 2. Introduction to the DSRIP & SCC values and roles 3. Provide a program overview of the SCC’s Building an
Integrated Delivery System, benefits and how “big data” is an essential element in integrated care delivery.
4. Describe the SCC’s Population Health Platform and six applications used in the platform.
5. Understand the 4 steps in the technical on-boarding process, timeline and deliverables at each stage in the process.
6. Preview step 2 of the technical on-boarding process the “technical deep dive”
Please note training will be provided by the
SCC IT Team Representatives
directly. Technical On-boarding
Process Training
Basic Technology documentation requirements in the electronic health record
1. Learn what the SCC’s expectations are for clinical documentation and/or modifications in the electronic medical record
2. Understand the basic technology documentation specifications in the electronic health record.
3. Understand the forms that will need to be returned to the SCC to demonstrate successful completion of documentation requirements.
An Orientation to the Suffolk Care Collaborative: DSRIP Clinical Programs Presentation Slides: 20, 24, 28, 32 http://files.constantcontact.com/b450ac0d401/7fb7e6a6-b88f-4cdb-aa66-54ac6f23cd46.pdf?ver=1485200360000
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Regional Health Information Organization (RHIO)
Module Overview: This module provides an overview of Regional Health Information Organization (RHIO)
Connectivity, the ways in which RHIO connectivity can improve and streamline using and accessing patient specific
data, the use of DIRECT secure messaging and receiving alerts. This module will also provide information for
physicians on explaining and obtaining patient consent. At the end of this module, you will be have increased
knowledge on RHIO, the benefit as a provider to accessing the RHIO and knowledge on how best to discuss RHIO
consent with your patient.
Topic Learning Objectives Core Curriculum
RHIO Connectivity Overview
Required
1. Learn the value of a Regional Health Information Exchange
2. Understand why RHIO connectivity is an essential element to improve the quality and efficiency of healthcare for Medicaid eligible patients
3. Understand how RHIO connectivity allows a bi-directional connectivity/communication line between the provider and a Qualified Entity
Please note training will be provided by RHIO
Representatives directly.
Use of DIRECT Secure Messaging & Alerts
Required
DIRECT Secure Messaging: 1. An exchange that occurs through the Qualified Entity
Health Information Service Provider (HISP) and the provider
2. Secured access thru webmail to exchange care summary and other clinical information between providers in the community
3. DIRECT secure messaging supports patient referrals and transitions of care
Alerts: 1. Physician practices, health home providers and health
systems can receive a notification whenever their patients are admitted or discharged from any partner hospital or emergency department.
2. Patient RHIO consent is required to use this feature
Please note training will be provided by RHIO
Representatives directly.
24:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
HIPAA and Compliance Program
Module Overview: This module presents essential information about the SCC’s HIPAA and Compliance Program
including information privacy and security, ethics, Code of Conduct, confidential reporting, the legal framework for
compliance, and how to get more information when you need it. Attention is also given to the relationship
between Coalition Partners and the SCC in the implementation of the Compliance Program.
Topic Learning Objectives Core Curriculum
HIPAA Privacy
Required
Describe the Health Insurance Portability and Accountability (HIPAA) Privacy Rule
Describe Individually Identifiable Health Information (PHI)
Describe Protected Health Information (PHI)
Understand the basic responsibilities of Business Associates (BAs)
Understand Patient Rights under HIPAA
http://files.constantcontact.com/b450ac0d401/f9d8c75c-1e84-42e3-999b-5109e66ee5ec.pdf?ver=1485200421000
HIPAA Security
Required
Understand the Health Insurance Portability and Accountability (“HIPAA”) Security Rule and e-PHI
Describe the Health Information Technology for Economic and Clinical Health Act (“HITECH”)
Understand the basic responsibility of Business Associates (BAs)
Understand Administrator Requirements of the HIPAA Security Rule
Describe a Breach Notification/Assessment/Impact
Understand the basic responsibilities of Subcontractors
Understand investigations and consequences of HIPAA violations
Describe HIPAA case studies
http://files.constantcontact.com/b450ac0d401/6f11f159-1058-4e7f-9e03-4a5c974a6196.pdf?ver=1485200421000
Compliance
Required
Understand the scope and requirements of the SCC Compliance Program and how to get information when you need it
Read and acknowledge the SCC Code of Conduct
Understand the duty to report compliance concerns and how to do so confidentially
Know that retaliation against good faith reporters is prohibited
For SCC personnel only: complete a Conflict of Interest disclosure form
SCC Compliance Training Video
25:
CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Practice Site Training Attestation Form Practice Information
[Practice Name ] [Address Location]
[Practice Site Primary Contact Name & Title]
[Practice Site Primary Contact Phone Number] [Practice Site Primary Contact Email Address]
Attestation of Training Completion The purpose of this Practice Site Training Attestation Form is to document completion of the training which occurs at practice sites. Please print this page, complete and sign this attestation when your staff has been trained on all required DSRIP training requirements as outlined in the Core Curriculum Guidelines for Practice Sites. It is recommended that you keep a copy of this completed form for your reference as it will be submitted to the New York State Department of Health as documentation your staff has been trained.
I attest the office of _____________________________________________________ has successfully completed all required DSRIP Training requirements.
[Practice Site Primary Contact/Administrator (Print)]
[Practice Site Primary Contact/Administrator Title]
[Practice Site Primary Contact/Administrator Signature]
Instructions to Return Once all training requirements are complete, please attach the corresponding Practice Site Training Sign-In Sheets. Please use the SCC Practice Site Training Sign-In Sheet Template, provided on the next page. You may have multiple sign-in sheets. If your staff utilized the SCC Online Learning Center to complete any of the DSRIP required training modules, you do not need to attach sign-in sheets, as participation is automatically captured. Please return all materials to demonstrate the completion of all required DSRIP training requirements to your designated Provider Relations Manager at the Suffolk Care Collaborative.
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CORE CURRICULUM GUIDELINES | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788
Practice Site Training/Meeting Sign-in Sheet Template
Instructions to return: Please print when completing this template, once complete please return to your designated Provider Relations Manager at the Suffolk Care Collaborative.
[Practice Site Name ]
[Address Location]
[Training Module and Training Topic Name]
[Training Facilitator Name & Title (if applicable)]
[Format/Mode of Training]
[Date]
[Time]
Frist Name Last Name Suffix Title Email Initial