OHPI Newsletter

Vol. 2, Issue 3 – Stakeholder Profile

Congratulations to Martha Madero, Community Health Worker (CHW) for Family Medicine Residency of Idaho (FMRI). Martha was nominated as a Health Center Hero by the National Association of Community Health Centers. She was selected as one of ten nominees from among hundreds around the country.

Martha began her career as a medical assistant and now is a CHW working mostly with Latino seasonal farmworkers.

“Martha is incredibly effective at her job as a CHW due to her perseverance, her motivational interviewing skills, and her deep understanding of the culture in which her patients live,” writes Penny Beach, MD, Chief Medical Officer FMRI.

She understands her patients because she has lived their lives. Her parents immigrated to the United States from Mexico, working as seasonal farmworkers. Martha was born in the U.S. and started working in the fields with her family at the age of nine. Her formal education ended after tenth grade when she went to work in the fields full time. In her early 20s, while caring for her two small children, she went back to school and finished her GED and her medical assistant certification.

As a medical assistant, Martha’s language skills and cultural competence were a huge asset. She picked up quickly on medical concepts and translated them into a language understood by her Latino clientele. Soon she was doing much of the Spanish-speaking patient education for the physicians for whom she worked.

When FMRI began its CHW program in 2014, Martha was the natural choice to hire as their first CHW. When Martha started, FMRI cared for 10 migrant farmworkers. Thanks to the outreach efforts of Martha and her colleagues, FMRI now has more than 400 migrant farmworker patients.

Martha has worked with illiterate, non-compliant patients who have complex health care needs by helping them understand how to take their medications and wrangling up family support. She has kept elderly patients out of the hospital by showing them how to take their medications correctly, removing fall hazards from their homes, and connecting them with health education, dental care and housing resources.

“Martha Madero…has saved hundreds of thousands of health care dollars in her work with complex medical patients. In the process, she has helped reduce health care disparities. And most of all, she improves the quality of life for all the patients she touches,” writes Beach.

Vol. 2, Issue 3 – Virtual PCMH

Community EMT – a “call to action”

In partnership with the Bureau of Emergency Medical Services and Preparedness (BEMSP), SHIP, and the Bureau of Rural Health and Primary Care (BRHPC) is excited to announce the first Idaho CEMT training. This training, offered through Idaho State University (ISU), will be delivered live online beginning in August 2018 and will be taught by experienced Community Paramedics. Individuals who successfully complete the CEMT training will be at an advantage to better understand their patients in a more holistic manner, and be a part of successful, collaborative-driven healthcare teams.

A Community Emergency Medical Technician (CEMT) works by filling gaps in the local healthcare team, by providing primary care, post-discharge follow-up care, integration with local public health agencies, and/or providing education and health promotion programs. The knowledge, trust and respect developed as a first responder positions the CEMT as a unique part of the healthcare team. CEMT’s help individuals and communities overcome barriers that prevent them from accessing and benefiting from healthcare services by increasing access to care and keeping patients local.

For more information regarding CEMT opportunities and trainings, please contact SHIP project manager, Madeline Russell at Madeline.Russell@dhw.idahol.gov. Or the Bureau of EMS and Preparedness at CHEMS@dhw.idaho.gov or (208)334-4000.

Vol. 2, Issue 3 – HIT

Changes to SHIP Data Analytics

The SHIP data analytics project is undergoing a ‘pivot’ – a change that will substitute previously agreed upon clinical quality measures (CQM) reporting with new CQM reporting.

This change came about because we found that the data completeness and quality issues were far more complex than we anticipated. It thus became evident that we would not be able to provide the actionable CQM reports for providers and regional collaboratives as intended through the SHIP analytics solution within the SHIP timeframe.

Before making this change, the SHIP operations team conducted an analysis to determine the value and feasibility of possible options for data analytics. Several key constraints and findings identified through this analysis included:

  • The SHIP data analytics solution is not funded beyond the grant period, which ends January 31, 2019.
  • Major health systems and payers have their own analytic solutions and do not have a need for a statewide reporting solution.
  • One of the possible options was to build additional data feeds to clinics. However, the Idaho Health Data Exchange (IHDE) does not have the capacity to build new data feeds beyond what has already been planned. The enhancements required to address the data issues and provide valuable SHIP CQM reporting could not be completed in the remaining grant timeframe.
  • Medicaid has developed a quality measurement/analytics solution for its Shared Savings program and is launching a provider portal in September 2018.
  • The SHIP grant requires a CQM reporting effort and the CQMs list must include tobacco and obesity related measures.

After much discussion of decision factors, constraints, and options available to us, we arrived at a new data analytic solution that will enable us to continue to meet the grant criteria. The Idaho Healthcare Coalition agreed to these changes during its August meeting. The following outlines the new solution for SHIP CQM reporting:

  • Leverage Medicaid’s quality reporting capabilities on the 11 measures Medicaid selected for its Shared Savings program. All but one of the SHIP clinics treat Medicaid patients and these measures will be based on the claims data from those Medicaid patients. Clinics will have access to the Medicaid provider portal in September 2018.
  • Leverage statewide Cigarette Smoking; Smokeless Tobacco Use and Obesity measures reported in the Idaho Behavioral Risk Factor Surveillance System (BRFSS) survey results.
  • Continue to report the Childhood Immunization Status measure through data from Idaho’s Immunization Reminder Information System (IRIS) and the Access to Care measure through the patient interviews conducted by the SHIP State Evaluation Team.

A crosswalk between the old measures and new measures can be found HERE.

It is important to note that the IHDE will continue to establish clinic EHR connections with its database. These CQM reporting changes do not impact the connection building efforts.

Vol. 2, Issue 3 – PCMH

Save the Date | Change Management Leadership Workshops Coming this October!

Change is an ongoing process, not a single event. We understand that continually improving your clinical practice is a long-term process. Whether you’re updating payment structures, implementing a new Electronic Health Record (EHR) system, or transforming into a Patient Centered Medical Home (PCMH), we all know it will not take place over night. These changes will involve planning and dedication by all staff members to achieve the clinic’s goals and to meet leadership and PCMH expectations.

The IDHW is excited to invite SHIP Cohort Clinics to attend a Change Management Leadership workshop near you, free of charge and put on by our partner in Change Management, Briljent, to better understand what is needed to successfully move your practice through the transformation process. Learn about: Organizational Change Management (OCM) activities to help during transformation efforts, how to engage your staff during the changes, and how to create your own OCM plan for continuous improvement and success.

Every change initiative should have a Change Champion who spearheads and believes in the changes, and pushes changes forward. We encourage clinics to send someone who is leading or will lead the change and transformation efforts of your clinic to attend a workshop at four locations throughout Idaho; with the opportunity to attend a virtual conference at one location for those who aren’t able to attend in person.

During and after the workshop, you will have access to Change Management professionals with whom to share your ideas and strategy.

Watch your inboxes in September for an October ‘Save the Date’ and location information! Sign up early so you can take advantage of this great opportunity!

Any questions? Please email the PCMHID.Team@briljent.com mailbox.

Vol. 2, Issue 3 – Administrator’s Update

As I make the transition from Operations Manager to Program Administrator of the Office of Healthcare Policy Initiatives (OHPI), I can’t help but think about how far we’ve come with Idaho’s healthcare transition. From its planning stages in 2015 to 163 participating primary care practices today, 80 clinics bi-directionally connected to IHDE, and payment transformation continuing to support the work we’ve done, we’re definitely changing the Idaho healthcare landscape.

Sustainability is a key concept to any grant initiative and there are several required plans OHPI is submitting to CMMI: part one of the plan, discussing SHIP’s progress and the impact it has achieved, was sent May 30; part two, which will provide a more detailed plan of post-SHIP activities to support Idaho’s healthcare transformation, was due August 30.

As part of our sustainability activities, a survey was sent to members of the Idaho Healthcare Coalition (IHC) to determine what they thought were the most important elements of Idaho’s healthcare transformation sustainability. The top five responses were: Health Information Exchange (HIE) development to support data exchange and analytics, payment reform, alignment of common CQMs across payers, PCMH training and TA, and telehealth. Respondents also felt that support of OHPI would be needed in the future to keep engagement, focus, and support of transformation activities.

It’s important to note that Idaho’s efforts to transform the healthcare system started long before we received the CMMI grant and will continue after the fact. To that end, planning the framework for this next chapter of Idaho’s transformation is being accomplished by the IHC Transformation Sustainability Workgroup which has been established to determine how we strategically drive transformation in Idaho and how we overcome identified barriers and gaps. The workgroup will submit a draft of its charter to the IHC in September and with the support of the IHC will begin drafting the business case. The Office of Healthcare Policy Initiatives and the Department of Health and Welfare continue to support these ongoing transformation efforts.

Vol. 2 Issue 2 HIT

IHDE on the Street

Since the start of February, the Idaho Health Data Exchange (IHDE) has conducted more than 35 clinic site visits to ensure the providers are receiving the highest value from their connection to IHDE. The site visits typically include the following:

  • Reviewing the connection build process with the clinics to learn what went well and what didn’t so IHDE can make improvements.
  • Verifying that the connections are working properly and ensuring the staff know how to access patient data from the IHDE clinical portal.
  • Providing additional training, as requested, and offering quick tips that other clinics have found beneficial to improving patient care.
  • Obtaining suggestions from clinic staff for future system functionality that would improve the IHDE services.

These visits have proven to be quite helpful for the participating SHIP clinics. Several have reported that the Frequently Asked Questions (FAQ) document that IHDE provides is beneficial. The providers appreciated the additional training and the ability to ask questions. And IHDE has taken the constructive feedback from the clinics and has been working to improve its processes. The future functionality suggestions from the clinics are also going to be used in helping IHDE prioritize future system development.

IHDE will be continuing these site visits, with the objective of visiting all SHIP clinics well before the end of the SHIP grant.

Upcoming Events

IHC Meeting – June 13

Cohort Three PCMH Learning Collaborative – June 27-28 (See above)

Alzheimer’s & Brain Awareness Month – June

Men’s Health Month – June

IHC Meeting – July 11

Idaho Community Health Worker (CHW) Learning Collaborative – July 25, 2018

National Immunization Awareness Month – August

IHC Meeting – August 8

SHIPworthy News

Receive up to a $2,500 reimbursement to help offset costs associated with your virtual PCMH program! The Virtual PCMH Application is now available for Cohorts One, Two, and Three Statewide Healthcare Innovation Plan (SHIP) clinics. The application closes Monday, July 9, 2018. Additional details are provided in the application.

The goal of the SHIP virtual Patient-Centered Medical Home (PCMH) is to improve access to primary care services in rural and underserved areas through Community Health Emergency Medical Services (CHEMS), Community Health Workers (CHW), and telehealth programs. SHIP cohort clinics with at least one of these programs may apply for designation as a virtual PCMH. Designated clinics will receive up to a $2,500 reimbursement to help offset program costs.

Questions? Please email RuralHealth@dhw.idaho.gov or call the Bureau of Rural Health & Primary Care at (208)-334-0669.

Vol.2 Issue 2 Virtual PCMH

A Virtual High-Five

It’s often hard to gain perspective of what has truly been accomplished until we take two steps back and look at the big picture. There are so many moving pieces SHIP has placed into workforce development in Idaho that we can’t fully appreciate the work that’s been done at the local level. From training Community Health Workers (CHWs) to creating telehealth workflow processes in Primary Care Clinics (PCPs), a multitude of Idahoans have worked to move the Virtual PCMH model forward and keep it on track.

To date, over 75 CHWs have been trained through the Idaho State University (ISU) course. And with expertise from community organizations, 12 health specific modules have been developed to further individualized training. Throughout the state, 10 Emergency Medical Service (EMS) agencies have begun implementation of their CHEMS initiatives with guidance and partnership from the state and local levels. Despite a constantly changing healthcare landscape in Idaho, primary care SHIP clinics have established 11 telehealth pilot projects in seven clinics, a huge accomplishment in itself. One special CHEMS agency has even begun a telehealth pilot project, the first in Idaho.

With the many people who have contributed their time and efforts, we at “SHIP Central” wanted to say THANK YOU! For those involved in the Virtual PCMH initiative, we particularly want to give you a Virtual High-Five for making healthcare transformation a fun and successful process.

Vol. 2 Issue 2 PCMH

The SHIP PCMH Transformation Team has updated and enhanced the SHIP PCMH transformation portal to inform SHIP cohort clinics and to provide tools for tracking goals and activities to achieve PCMH recognition:

Three new virtual and online toolkits are now available: Clinics New to PCMH Transformation, Onboarding Employees New to PCMH Transformation, and Mentoring for Success. These toolkits are easy to access for clinics, employees, mentors, and mentees, and are designed to offer tools and resources for their PCMH transformation journey. The toolkits can be used for ongoing professional development and in curriculums for staff new to PCMH.

New features on the portal include: the Getting Started section – with Portal User Guides and quick “how to” videos on using the portal; Celebrate Success – a way for clinics to share PCMH success stories; Alert Notifications – to keep up with changes on the portal; a new Calendar feature – for clinics to list events and milestones to keep others informed and organized; and the new Discussion Forum – a collaboration site for clinics in the SHIP PCMH transformation initiative. SHIP makes available many tools and supports for helping SHIP Cohort Clinics make their PCMH transformation a journey of success! For information on the SHIP PCMH transformation portal, please contact pcmhid.team@briljent.com.


Don’t forget to register for the Cohort Three PCMH Learning Collaborative being held Wednesday, June 27 and Thursday, June 28 in Boise.

We’re expecting 160 attendees for this interactive event including SHIP Cohort Three clinic teams, Briljent and HMA, PHD and SHIP staff, and several invited guests.

Day One topics include: “PCMH Success Stories from the Field,” collecting data & patient engagement strategies from the State Evaluator Team, an IHDE presentation on the value of data & PCMH transformation, and an affinity group session on best practices of utilization of specific EHRs.

Day Two topics include: a sponsored breakfast by Blue Cross of Idaho Foundation for Health, a multi-payer panel discussion, and break-out groups aligning with PCMH principles.

Registration is through the PCMH portal until the day of the learning collaborative. Information on the venue, hotel, and parking can all be found on the portal as well.

We look forward to seeing you there!