August 2017
Top Story 

Reporting Base Measure Data for Advancing Care Information (ACI)

When it comes to MIPS, we're all in this together. All participants in the ACO's MSSP contract are automatically enrolled in the MIPS APM, Medicare's value-based payment program that aggregates every individual provider's performance to derive a single ACO-wide performance score. When individual providers do well, all participants in the ACO benefit by becoming eligible for reimbursement increases.

ACO In Action 

Barbara Steele
Early Dementia Detection: One Care Manager's Mission

Barbara Steele is a MaineHealth ACO nurse care manager who noticed a problem. Working at Southern Maine Health Care's family medicine and internal medicine practices in Sanford, she was receiving numerous referrals for elderly patients coming in with undiagnosed moderate and severe dementia. She met families struggling to care for grandparents who had become unsafe at home. And she knew that dementia patients were entering long term care facilities well after their disease state warranted it. In short, dementia patients were being diagnosed too late. Providers were missing opportunities to identify dementia early on, when tools for coping were available and plans could be made for managing the progression of the disease.

Measure of the Month 

Diabetes: Hemoglobin A1c 

Measure of the Month is a series of articles that explore key MaineHealth ACO quality measures and provide tips and resources to help achieve the measure goal. 

This month we take an in-depth look at the Diabetes: Hemoglobin A1c measure, one of our Top Ten Quality Goals. 

Hemoglobin A1c testing in primary care is a quick and easy point-of-care test to evaluate a patient's diabetes control.   While the HbA1c measurement should not be viewed in isolation, it provides a good starting point to determine if a treatment plan is working or if the plan needs to be adjusted.  Studies have also shown that keeping diabetes in control, as measured by staying at target HbA1c, can help reduce or delay the onset of many diabetes chronic complications.  

N eed To Know: Important Updates

Coming Soon: A New and Powerful Population Health Management System

The MaineHealth ACO is preparing to launch a new population health management system that will expand the ACO's, and participants', understanding of our patient populations. The system we've selected uses two tools - Epic's Healthy Planet and a tool called Arcadia- to mine both clinical and claims data to answer questions about cost, utilization, the health of populations and much more. This article is the first in a series that will help introduce the ACO's new population health management capabilities.

Reduce Apparent Gaps in Care with "Z" Codes

Interested in reducing gaps in care associated with breast and cervical cancer screening measures? Harness the power of "Z" codes!

You can use ICD-10-CM diagnosis Z codes to exclude patients who've had hysterectomies or mastectomies from breast or cervical cancer screening requirements. Simply bill a Z code when one of these patients has a visit, and they'll no longer be counted in the gap report for the appropriate measure. Just be sure that the Z code is billed at $0 and is accompanied by at least one other ICD-10-CM code on the claim.

To exclude a patient who has had mastectomies from the breast cancer screening measure, use these codes:

Unilateral Mastectomies:
  • Z9011    Acquired absence RT breast and nipple
  • Z9012    Acquired absence LT breast and nipple
Bilateral Mastectomy:
  • Z9013    Acquired absence BIL breasts and nipples
To exclude a patient who has had a hysterectomy from the cervical cancer screening measure, use one of these Z codes:
  • Z90710  Acquired absence both cervix uterus
  • Z90712  Acquired absence cervix remaining uterus
Questions? Please email Jenn Maurice.


Be Heard at the MaineHealth ACO Listening Dinner in Camden on  September 7th 

What part of your work is most important to you? What gets in the way of achieving your goals? What does a good day look like at your practice? We'd like to know.
ACO participants in the Camden area are invited to join us at 40Paper for our first regional Listening Dinner.
The dinner is hosted by Dr. Mike Clark, MaineHealth ACO physician liaison, and will include ACO leaders Dr. Betsy Johnson and Dr. Jeff Aalberg.
There is no cost to attend, but space is limited. Please register today. 

2017 MaineHealth ACO-Wide Quality Forum Sept. 19
Join us as we share strategies to promote sustainability and spread of both quality initiatives and efforts to decrease low value care across the MaineHealth ACO. Practice leaders, physicians, and care team members will benefit from learning new approaches, sharing their own success stories with others, and networking with colleagues from across the MaineHealth ACO network. 
When: Tues., Sept. 19, 2017, 8:30am - 3:30pm
Where: MaineHealth,110 Free Street, Portland, ME 
Keynote Speaker: Omar Hasan, MBBS, MPH, FACP - Senior VP, Chief Quality & Safety Officer MaineHealth, Maine Medical Center 
For registration information  Click Here

Cancer Genetics Management in the Primary Care Setting

On September 22, The Jackson Laboratory and Dempsey Center are holding a free workshop on using family history information to identify patients who might benefit from increased cancer screening, genetic testing, and/or referral to a genetics specialist. Click here for more details.

6th Annual Let's Go National Obesity Conference

On September 28  and 29, join Let's Go! to explore the key role of physical activity to improve your patients' health. Using the National Physical Activity Plan as a framework, we will explore how to use physical activity in the prevention, management, and treatment of obesity and related health conditions. We have an exciting line up of speakers from near and far! 

Medical Assistant Training - Free to All

2017 Training Dates and Locations
Septe mber 6th & 7th, MaineHealth, 110 Free St., Portland
October 4th & 5th, MaineHealth, 110 Free St., Portland
November 1st & 2nd, MaineHealth , 110 Free St., Portland

Click here for details and registration
Questions? Contact Claire Schreiber, Program Coordinator

Advanced Medical Assistant Training - Free to All 
2017 Training Dates and Locations
A ugust 23rd , Western Maine Health Care
September 20th,    MaineHealth , 110 Free St., Portland
October 25th , Waldo County General Hospital
November 8th , MaineHealth , 110 Free St. Portland

Click here for details and registration
Questions? Contact  Claire Schreiber , Program Coordinator

Care Management Training - Free to MaineHealth ACO Participants & $100 for non-participants

August 22nd, MaineHealth, 110 Free Street Portland
October 3rd, 10th, 17th, 24th, MaineHealth, 110 Free Street Portland
November 28th, December 5th, 12th, 19th,  MaineHealth, 110 Free Street Portland

Click here for registration
Questions? Contact  Claire Schreiber , Program Coordinator

Coding References and Tools for Common Chronic Conditions

Complete coding of chronic conditions isn't just about reimbursement, it's about ensuring that patients with complex conditions are correctly identified and receive care coordination and other services that can contribute to better clinical outcomes.
To consistently support these patients, it's important to accurately document treatment and assessment as well as the severity of conditions at each visit. The most effective coding is supported by documentation within patient records.  
Visit Anthem's website for useful references and tools for coding some of the most common diagnoses.

Excitement is Building for Launch of EndoECHO Project 

EndoECHO is a collaborative learning opportunity, whereby a hub (specialist's practice) and spokes (regional practices/providers) get together using virtual technology to create an endocrinology knowledge sharing network. The teleconferences will include a didactic and case review component. The calls are scheduled for the second Tuesday of the month, from 7:30 - 8:30 am. There will be an introductory call in September and content will launch in October.

EndoECHO is still accepting spoke sites to join the initiative . Unsure if you are interested? Check out the draft curriculum to see if the planned subjects would be of interest to you or anyone in your practice, and see our project overview for general information about EndoECHO here.  
For more information or to sign up to be a spoke site, email Joan Ingram, program manager, or call 662-1548.   

Fall Prevention

As a health care provider, you are already aware that falls are a serious threat to the health and well-being of your older patients. More than one out of four people 65 and older fall each year, and over 2.8 million are treated in emergency departments annually for fall injuries. You play an important role in caring for older adults and you can help reduce these devastating injuries (CDC, 2016). 
For clinical information on Fall Prevention and Safe Mobility resources, email Gloria Neault, MSN, RN, MaineHealth Center for Health Improvement / Healthy Aging.
Watch this video from Memorial Hospital to learn how one remarkable woman overcame repeated falls and a fractured femur to help other older Mainers improve their balance and confidence.

FAST FIVE: ACO Spotlight

Omar Hasan, MBBS, MPH, FACP
Senior Vice President, Chief Quality & Safety Officer, MaineHealth & Maine Medical Center
Keynote Speaker, 

Each month, we ask an ACO stakeholder five quick questions about their work and life.