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Care Management

The Importance of Huddles In Primary Care (taken from the Center of Excellence in Primary Care)
Huddles are short, daily meetings in which a teamlet (a Primary Care Provider and a Medical Assistant or other support staff) reviews their patient list for the day. They usually last no more than 10 minutes. Huddles enable a team to anticipate care needs and special situations, so that members of the care team can support each other through the day.
In addition to care team huddles, all-staff huddles are used at some clinics to alert everyone to staffing issues, upcoming events, or important policy updates. They are usually no more than 5 minutes/day. Sometimes, all staff huddles are followed by care team huddles.
There is not one right way to conduct a healthy huddle. Huddles can range from a few minutes to twenty minutes. They may be held daily or at the beginning of a clinic session, and the agenda varies depending on the team needs. The goal is for a huddle to be an effective and efficient tool for communicating about patients and the flow of the clinic session.
The most effective huddles involve some preparation in advance. For example, in some clinics a medical assistant “scrubs the charts” or does pre-visit prep work in advance, identifying preventative care gaps, chronic disease management needs, screening alerts, or patients with recent hospitalizations. The person who does the most visit preparation will often lead the huddle as they know what is ahead of the teamlet for the clinic session or day.
Huddles often result in great improvements for relatively small time investment. Clinics often report that staff are more likely to show up on time and communication is quickly improved.
For additional tools to implement huddles in your practice.  Please visit,events%2C%20or%20important%20policy%20updates.

Erica Ross, Clinical Services Manager
Patient Centered Medical Home

Welcome to the Blue Cross Blue Shield of Michigan Patient Centered Medical Home (BCBSM PCMH) monthly newsletter update! Each month we will bring together all relevant PCMH news and updates for our participating provider community. This month we will discuss the requirements for new capabilities 2.29 and 3.23.
Anticoagulant capability:
2.29 Registry is being used to manage all patients that are identified as taking one of these 5 oral anticoagulants (warfarin, apixaban, dabigatran, edoxaban, rivaroxaban) for such conditions as atrial fibrillation, venous thrombosis and after a myocardial infarction
PCP and Specialist Guidelines:
a. Registry may be paper or electronic
b. Practices using anticoagulation clinics are excluded from this capability
c. Collection information must include the following 3 components:
i. Name of anticoagulation
ii. Date and result of last serum creatinine – Direct Oral Anticoagulant (DOAC) patients
iii. Concurrent antiplatelet use
d. Other optional collection components:
i. Indication for anticoagulation
ii. Start date of anticoagulant
iii. Estimated anticoagulation stop date
▪ To identify patients that should be taken off anticoagulant
iv. International Normalized Ratio (INR) target range (warfarin only)
v. Dates and results of INRs (warfarin only)
vi. Dates of emergency department (ED) visits for bleeding
vii. Dates of ED visits for ischemic stroke (atrial fibrillation pts) or recurrent venous
thromboembolism (VTE) for VTE patients
viii. Date of last clinic visit assessing anticoagulation (adverse events, need for continued
anticoagulation, dose, etc.)
Anticoagulant Capability
3.23 Performance reports are generated for the population of patients taking one of these 5 oral anticoagulants (warfarin, apixaban, dabigatran, edoxaban, rivaroxaban)
PCP and Specialist Guidelines:
a. Required anticoagulants metrics:
i. % of patients on DOACs with last serum creatinine test > 1 year ago
ii. % of patients on combination anticoagulant-antiplatelet therapy without history of heart valve replacement, recent myocardial infarction, CABG, or PCI (within past year), or other clear indication for combination therapy
b. Optional anticoagulants metrics:
i. % of patients in which <50% of International Normalized Ratio (INR) were in-range over the past 6 months
ii. % patients with 2 or more ED visits for bleeds in the past 6 months
iii. % of patients with 1 or more ischemic strokes (atrial fibrillation patients) or recurrent
venous thromboembolism (VTE) for VTE patients within the past year
iv. % of patients in which last clinic visit assessing anticoagulation was > 6 months ago
 Kathryn Correll-Rice, Manager of Quality Improvement Strategy

Palliative Care Initiative

Medical Network One is now participating in the BCBSM Palliative Care Initiative designed to assist Primary Care practices implement a Palliative Care model in their practice.  Five physician organizations, including MNO, have been selected to develop the Palliative Care initiative, the first time physician organizations have been given this opportunity by BCBSM.

Many practices offer Provider Delivered Care Management (PDCM) to their patients; Palliative Care is an advanced PDCM model for a patient population defined by the provider.  Many of the processes that are in place to deliver PDCM will allow the practice to expand care delivery to this patient population.  For practices that are engaged in this initiative, the first steps include a practice assessment to determine the practices readiness for Palliative Care , training of providers and staff that will lay the foundation for palliative care in the practice, and workflow assessment.  Upon completion of these activities, additional items include incorporating patient assessment tools into the workflow (e.g. functional assessment, pain assessment), expanding upon referral processes for specialists and community resources, providing caregiver support, and determining other aspects of palliative care that a practice will need to provide. 
Practices will be have the opportunity to engage in the Palliative Care Initiative during 2022.  If you are interested in participating in this initiative, please contact Medical Network One.

Teresa Choate, Compliance

Quality Improvement

Welcome to the quality improvement portion of the newsletter. We will be going over important updates to quality measures and changes that may occur throughout the year.
This month we will be going over end of the year gap closure and what some of the key deadlines are. With the new year here, it is important to recognize and capture all data for those patients who still had gaps-in-care, but whose gaps were met prior to the end of 2021. For gaps-in-care to be closed for the 2021 measurement year, the service must be completed prior to January 1st, 2022. On top of this, there are opportunities to enter supplemental data into payer portals, in order to ensure the highest quality scores possible. If you have specific questions about submitting supplemental data on top of entering data into payer portals, please reach out to Andrew or Kathryn. Some of the key deadlines for supplemental data submission or for entering data into payer portals are: Health e-Blue – January 22nd, 2022; Priority – January 31st, 2022;

Andrew Kurecka, Director of Innovation, Research and Improvement

Human Resources

“Bleisure,” the trend of business travelers adding leisure days to their work-related trips, took on a different meaning around the recent holiday season as workers extended their holiday travel to include working days while visiting family or vacationing. It was an opportunity that wasn’t as easily accepted by managers before the pandemic and wasn’t really an option in 2020, when travel was considered unsafe.

Moving forward into 2022—with an eye on future travel-friendly holidays like Memorial Day weekend and the Fourth of July—managers face a unique challenge when overseeing extended holiday travel.

The start of the holiday season is traditionally Thanksgiving, and in 2021, an estimated 53.4 million people were expected to travel over Thanksgiving weekend, according to AAA. That is close to 2019 levels and the highest single-year increase since 2005.

CLEAR, a biometric airport security kiosk company, says the median trip length of its members in 2021 was double what it was in 2019.

A Deloitte survey released before the recent holiday season found that working vacationers planned to take twice as many trips—and to stay longer—than those who planned to unplug during the holidays. Three in four workers said they would add at least one day to their holiday trips, and 38 percent said they would add three to six days. Many also planned to increase their vacation travel budgets because of their companies’ work-from-home policies.

The pandemic has blurred the lines between work and life more than ever before. Employees are taking advantage of increased workplace flexibility to extend their holiday travels. Gone are the days of workers being stuck in the office until the day before a big holiday. The freedom for employees to add a couple of days to their travel with remote work is truly a gift that managers can give their teams” during holiday seasons.

Some managers may worry about lost productivity or time zone coordination when employees remain in their holiday spots and continue to work remotely. But as long as the lines of communication are open with employees and they’re getting the work done, there should be little difference from traditional ‘work from home’ situations. Not only do workers avoid some of the headaches of traveling on the busiest days, but it allows for a healthy work-life balance, which can keep employees happy long term.

As the pandemic continues and future holidays approach, workers and managers need to recognize that there’s always a chance that traveling for holidays may wind up being extended longer than planned—such as with the massive delays that travelers saw as hundreds of flights were canceled in late December when airlines were short-staffed, or if travelers find it difficult to comply with COVID-19 testing requirements before they can return.
During this period everyone should expect the unexpected.

Robert Pejas, HR