February / 19 / 2016


Groundbreaking New Initiative Takes Aim At COPD

The MaineHealth ACO and the MaineHealth Chronic Disease Team are excited to announce a joint venture to improve COPD care across the MaineHealth Community.  In January 2016, the MaineHealth ACO Value Oversight Committee (VOC) endorsed this initiative. Click  here to read more. 

In This Issue
WHAT'S HOT: Important Updates

Introduction to PCMH: Foundational Concepts of the Medical Home 
April 7-8, 2016

Don't miss this two-day learning opportunity presented by NCQA staff
that will  assist your practice with becoming a recognized Patient Centered Medical Home!  
For more information click here .

Avoid the 2017 Meaningful Use Penalty- Submit a Hardship Exception by March 15th

All eligible professionals (EPs) subject to the 2017 Medicare Meaningful Use penalty are encouraged to apply for a hardship exception to avoid the penalty. The Centers for Medicare & Medicaid Services (CMS) recently stated that it will broadly accept hardship exceptions due to the delayed publication of program regulations and will require no supporting documentation if the application is submitted by March 15, 2016. In addition, CMS is now permitting group practices to submit one application for all of its EPs. As a reminder, applying for the hardship exception will not prevent an EP from earning an incentive, and EPs attesting that they have met the requirements for the 2015 Meaningful Use reporting period should still apply for the hardship exception.

For more information, access the CMS hardship exception  instructions  and  application form .

Position Available - Senior Medical Director Primary Care - MaineHealth Clinical Integration 
Given the strategic importance of creating a strong primary care network, MaineHealth is seeking a practicing primary care physician who is interested in providing the clinical leadership for Advanced Primary Care strategies and programming across MaineHealth and in partnership with the MaineHealth Accountable Care Organization.  This is an exciting way to become involved in developing, implementing and advancing Primary Care while building on the principles of the Patient Centered Medical Home and other related efforts.  MaineHealth is looking for a part time (.5 FTE) physician who has extensive experience and in depth knowledge of primary care including an understanding of practice operations, quality, financing and innovation. If you are interested in learning more, please click  here.

Helpful Resources and Links to Keep You Informed

Practice-Based Care Management Training
The Care Management Training Program TM is in its third year and is going strong. During
this training, practice-based staff members receive 30 hours of training delivered by content experts from the MaineHealth system. Continuing medical education (CME) credits are offered for this training. The following training sessions have been scheduled for 2016:
  • February 3, 10, 18 and 26 at 110 Free Street, Portland
  • April 26, May 3, 10 and 17 in Rockland
  • October 4, 11, 18 and 25 in Franklin County
To learn more about the curriculum, click here. Please contact Beth Wilcox at  or 207-671-3248 if you have questions or would like to attend the training.

Advance Care Planning Facilitator Trainings

Over the past month, Jessica Begley and Mary Bitterauf of the MaineHealth Learning Resource Center have held Respecting Choices® Advance Care Planning facilitator trainings for MaineHealth ACO Care Managers and Care Transition Coaches. The trainings teach care providers how to have conversations with patients about selecting a Healthcare Agent and documenting their future healthcare wishes. Click to read more about the training.

If you would like to meet with a facilitator to start your Advance Directive or are interested in becoming a facilitator yourself, please contact Mallory Pitt at
Community-based Care Transitions Program Update 

Please be advised that following four important and successful years working under CMS' Community-based Care Transitions Program delivering the Care Transitions Intervention (CTI)┬« to Medicare fee-for-service patients at high risk for readmission, we will end our contract as of Feb 29, 2016. Although this will result in staffing changes, we believe this will provide an opportunity to make important adjustments to the program, and we have already begun the process of restructuring the program and refining the strong foundation already established.
Read more about proposed changes and individuals who have helped to make this program 
a success.
If you have any questions, please contact Cindy Tack at

February is Heart Month 
Help for Hypertension Control: Getting Down for Life - New Toolkit Available!

Order the new Hypertension Control toolkit for your practice staff to help patients get high blood pressure under control. Included in the toolkit are operational resources, clinical support tools, patient education materials and a list of training available for staff. We can assist your staff in helping patients control Hypertension and reduce further risks of chronic disease. The toolkit is free and can be ordered by contacting Marin Johnson, Cardiovascular Health Program Coordinator, at .  
Get yours today!

Kidney Health 5K Walk

Come out to enjoy a fantastic event for an even more fantastic cause!  Maine Nephrology Associates and American Kidney Fund are partnering for their  Inaugural Maine Nephrology Associates' 5K Walk/Run for Kidney Health.   Please sign up (see attached flyer) and support Maine Nephrology and our Care Management team, Stacey Power and Trish Macomber!   Click here to learn more.

Open Questions for the MaineHealth ACO Leadership

What's On Your Mind? Open Questions for MaineHealth ACO Leadership.
Do you have a burning question for our leadership team? Each month, we'll post a question from you with a response from our leadership team. This month, Betsy Johnson (CEO), Jeff Aalberg (CMO) and Jen Moore (COO) address a question that's surfaced with several of our participating members.

Question: What is the Value that the ACO brings to participating members?
Answer: Nationwide, ACOs are sharply focused on achieving the Triple Aim: providing better quality of care for patients, lowering the overall cost of care, and improving health outcomes for the population. The resulting benefit of this work is in helping physicians and their care teams provide well-coordinated, high quality, patient-centered care for their patients, while experiencing shared savings through value-based care.

Here at the MaineHealth ACO, we have teams that coordinate work and services for you in 4 key areas that are focused on supporting you to reach the goals of the Triple Aim:
  • Contracting and Network Management/Provider Relations.
    Serves as a liaison with payers to assure smooth interactions, issue resolutions and competitive reimbursements for participating practices and providers.
  • Care Coordination/Clinical Initiatives. 
  • Works with participants to facilitate complex care coordination and implements standard practices that reduce redundancies and provide resources and initiatives that focus on improving care for patients with chronic diseases and/or complex illnesses.
  • Quality and Performance Improvement. 
  • Uses patient registry data, provides participants with reports on performance, utilization and patient satisfaction and assists in the development of strategies and action plans for improvement.
  • Data Operations and Analysis. 
  • Provides patient registry data, cost/utilization reports and comprehensive data on quality metrics, population reports and gaps in care.
There are many opportunities for participants to become involved in the activities and direction of the MaineHealth Accountable Care Organization through involvement in Board committees, workgroups, and/or regional committees such as quality, value oversight, and patient experience.
If you have a question about the MaineHealth ACO that you'd like to ask -- we really want to hear it! Email us today at  and check out next month's newsletter to see what's on the minds of our participants.