Application for GAFP/Collaborative Health Systems PCMH University Class of Deadline Friday, September 12, 2014

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1 The Georgia Chapter is providing information on an opportunity for your practice to participate in a Patient Centered Medical Home University. This opportunity is in collaboration with the GA Academy of Family Practice and Universal American ACO. To participate, your practice must be a member of Universal American ACO. There is no fee to participate in this PCMH University opportunity but the deadline is Sept 12 to submit your application for participation/funding. Attached is the information if you are interested in participating in the next session to transform your practice as a Patient Centered Medical Home.

2 Northlake Commons 3760 Lavista Road ~ Suite 100 ~ Tucker, GA Phone: Fax: TollFr Application for GAFP/Collaborative Health Systems PCMH University Class of Deadline Friday, September 12, 2014 Name of Practice Street Address City Zip Code Practice website address GAFP members practicing at this address Number of clinical providers (physicians and mid-levels) at this site (in full time equivalents [FTE]): Specialties of clinical provider(s) Check all that apply Family Medicine General Internal Medicine Pediatrics Other specify: Number of clinical and administrative staff at site (in full time equivalents [FTE]) Physicians Nurses (RNs, LPNs) Physician Assistants Administrative staff members Nurse Practitioners Medical Assistants Other, please describe: Is this practice site part of a larger medical group or health system, apart from the Collaborative Health Systems ACO? Yes No If yes, please name the larger medical group or health system below If needed, please put name and contact information of person at the parent organization that needs to approve your practice s participation in the PCMH University. Required for PCMH U: At least 36-hour-per-week operation Hours your practice is open: Monday to

3 Tuesday to Wednesday to Thursday to Friday to Saturday to Sunday to Required for PCMH U: Use of electronic health record (EHR) for at least one year Your electronic health record name and version: Date the practice started using the EHR: Do all staff use the same EHR system? Yes, No. If no, please explain: Dates of attestation or submission of data to CMS for Meaningful Use (either already accomplished or planned): Stage 1: - Stage 2: Required for PCMH U: Transformation Team Your practice will need a Transformation Team with representation from each part of the organization (physician, mid-level, nursing, practice manager, front office), and led by a physician champion. Name of your PCMH Champion, who will lead the transformation team: Other members of the Transformation Team, and their titles (use as many lines as needed): Required for PCMH U: Screening interview by telephone and/or in person. Please enter three dates and times, between August 20 and September 12 - when your Transformation Team can have screening interviews, by phone and in person, with the PCMH U Team. We will need about 30 minutes for a phone interview first, and one hour for a follow-up inperson interview Date: Time: Date: Time: Date: Time:

4 Required for PCMH U: Attendance by Transformation Team at All Learning Collaborative Events Please check whether you can have the whole transformation team in attendance for all of the following dates in addition to the on-site work of transforming: Monthly meetings* with PCMH U coach (scheduled in advance) CME Meeting Friday, October 17, 2014, 8 AM 3 PM (Atlanta) CME Meeting - Friday, March 20, 2015, 8AM 3PM (Atlanta/Macon TBD) CME Meeting - Friday, August 7, 2015, 8AM 3PM (Atlanta/Macon TBD) Atlanta *monthly working sessions with your transformation team and coaches to assist with, and check on, the transformation process (work done and next steps). The visits will be 2-3 hours in duration. Required for PCMH U: Please state your goal the change(s) you expect to bring about with the help of PCMH U: Please have all physicians and staff in your practice sign below: By signing this application, we affirm our commitment to transforming our practice to a patient-centered medical home. We acknowledge that this transformation means a change and improvement in the way we practice medicine. There will be changes to our practice, including aligning staff responsibilities differently to form functioning teams, and pro-actively reaching out to patients. We are willing to make the changes needed in the next 14 months to become a patient-centered medical home.

5 If more space needed, use another sheet. If your practice is selected, your entire team (all partners and staff) will need to sign a Letter of Agreement. Please state the approximate percentage of your patients with the following types of health coverage: % Commercial insurance % Medicare % Medicaid % Self-pay or uninsured Please list the person GAFP should contact to follow up on this application (please print or type) Name Title Phone Anticipated Costs for Your Practice to Participate Survey Tool (required for submission of NCQA application): $80 Travel: (for at least four team members) to three in-person, seven- hour meetings (Location to be held in either Atlanta or Macon). If you are selected and funded by UAM/CHS, you will receive a travel stipend of $500 per meeting. NCQA Application fee: determined by number of clinicians (physicians, PAs, NPs) in practice - $500 per clinician up to $4,000 (additional cost if greater than 50 clinicians). 6-8 hours per week of staff time, including Transformation Team members and others, for planning and implementing transformation.

6 What Your Practice will Receive 1. Free Tuition for Universal American/CHS ACO Practices!!! 2. New PCMH-related skills for the whole team through three face-to-face meetings with local and national experts (18 free CME credits pending AMA/AAFP approval) 3. Monthly working sessions in your office with transformation coach; examination of your data compared to benchmarks 4. Team building/organizational management skills 5. Guidance on PCMH Recognition from an NCQA application expert 6. Access to the PCMH Resource Delta Exchange, an online network that is dedicated to physicians, clinical staff, office staff, and primary care-focused residency programs committed to the Patient Centered Medical Home 7. Access to group rates for a complete, PCMH-related patient survey percent discount for NCQA PCMH Application fee 9. Travel stipend to attend each collaborative (up to $500 per practice). Many practices are interested in this selective opportunity. To ensure your practice is considered for the class, we encourage you to apply as soon as possible. Please contact Samantha Cochran, Georgia Academy of Family Physician s Director of Practice Enhancement, or Linda Kincaid, Project Director at Discern Health, to express your interest or ask questions: Samantha Cochran scochran@gafp.org / Linda Kincaid lkincaid@discernhealth.com You may also complete the attached application form and send it electronically to scochran@gafp.org or by fax at

7 Seize the Benefits! RSVP by September 12, 2014 to Apply for the First Patient Centered Medical Home University ACO Class. For practices in a Universal American/Collaborative Health Systems ACO, UAM/CHS Provides Scholarships to Attend PCMH University Q What is a Patient-Centered Medical Home (PCMH)? A A comprehensive primary care practice that uses principles endorsed by all of medicine's primary care organizations including the American Academy of Family Physicians and the American College of Physicians. The guiding principles include: a personal physician for each patient, quality and safety, enhanced access to care, care coordination, whole person care, active outreach to patients, and appropriate payment structures for more efficient care. Q What is PCMH University? A A program of the Georgia Academy of Family Physicians and Discern Health, sponsored by Universal American/CHS. A 14-month process (October 2014 December 2015) during which your practice transforms itself to operate in a team-based, patient-centered way. You will be able to utilize your ACO shared savings measures and achievements to jump-start your PCMH journey. Q What will occur during PCMH University? A 1. A PCMH U coach who works both onsite and remotely with your selected Transformation Team. Your coach will provide the road map, know-how, and encouragement you need and keep your practice on track. 2. Advice from experts, three whole-day learning collaboratives, and interaction with a group of other practices participating in PCMH U to bolster your experience. 3. Preparation to gain PCMH recognition from the National Committee for Quality Assurance

8 (NCQA). Q How does UAM/CHS help? A Universal American/CHS will pay the whole tuition for your practice to participate in PCMH U, if your practice is chosen. Not only this, they will reimburse a travel stipend for your practice to attend the three whole-day learning collaboratives. Q And the benefits? A This is an in-depth opportunity for your practice to: Build better clinical outcomes and patient experience Improve performance toward shared-savings rewards in the Medicare Shared Savings Program Qualify for rewards from other payers with NCQA recognition Better use patient information to meet your patients' needs Create a culture of quality improvement Build teamwork among all staff and increase staff satisfaction Strengthen the support of CHS Care Coordinators. Q What are next steps? A Many practices are interested in this selective opportunity. To ensure your practice is considered for the class, we encourage you to apply as soon as possible. Please contact Samantha Cochran, Georgia Academy of Family Physician s Director of Practice Enhancement, or Linda Kincaid, Project Director at Discern Health, to express your interest or ask questions: Samantha Cochran scochran@gafp.org / Linda Kincaid lkincaid@discernhealth.com You may also complete the attached application form and send it electronically to scochran@gafp.org Healthcare is changing rapidly. Let us help you benefit from this change and join more than 7,000 practices nationwide who have achieved NCQA Recognition as Patient-Centered Medical Homes.