Meeting Highlights and Resources
11/2025 – End of Year Focus, Patient Experience, Site Visit Learnings, Education, and Preparing for 2026
1. Welcome, Announcements and Agenda Information
2. Suggested Process. End of Year Gap Closures
3a. Post Discharge phone script- Adult (Added. Affording mediciation question)
3b. Post Discharge phone script – Pediatrics (Added. affording medications question)
4. Finish the year strong. Start the new year with a plan!
5. Standard Work Sending Messages in Registry
6. Standard Work patient names and SOGI
8/2025 – Janus, MHM, NorthStar Palliative Care
6/2025 – Financial Hardship/Write offs with Deb Schepperly, PDCM Practice % Report and Discussion, Capability Opportunities.
Welcome, Agenda, and Announcements
Ask Our Lawyer – Waiving Copays
Legal Alert_Financial Hardship Policy
Practice Care Management Billing Report 2023
Practice Care Management Billing Report 2025
D 11 Education self Management, Chronic Management, Team based Self Management
D11 Education PP Motivational Interviewing
D11 Education PP NPO_SMS__2019_Teach Back
D11 Health Literacy and Health Literacy Barriers
3/2025 – ACP Decisions, Documentation Learnings, Updates to Post Discharge Phone Scripts, G9007 Billing Updates
Welcome, Agenda and Announcements
HEDIS and Documentation Reminders
G9007 per practice and provider 2.2025
BCBSM Retinal Eye Exam Job Aid
Supplemental Audit Presentation-Final (05.2024)
Practice Care Management Billing Report Fall 2023
Post Discharge phone script- Adult
Post Discharge phone script – Pediatrics
Tips Medication Reconciliation, Transitional Care Management
Tips Timely Follow-up ACO Reach Measure
Medication Chart Adult Pneumonia
Medication Chart Pediatric Asthma Treatments
Medication Chart Pediatric Respiratory Conditions
When TO and when NOT TO Bill PDCM Phone Codes
1/2025 – PCMH Interpretive Guidelines Update, Best Practices 2025
Welcome, Agenda, and Announcements.
PCMH IG Updates 2024-2025 with NPO Comments
BCBSM PCMH and PCMH-N Interpretive Guidelines 2024-2025 Redline Final
BCBSM PCMH and PCMH-N Interpretive Guidelines 2024-2025 Final
Best Practices to Kick off 2025
12/2024 THE COLLABORATIVE CARE MODEL – Integrating Behavioral Health and Primary Care for Improved Outcomes
9/25/2024 – Medicaid Changes Update, Health Focus, TOC and ADT, HCC Recapture, Health Focus Reports, Care Management
9.25.24 Agenda, Announcements, End of Year Focus
9.25.24 Health Focus End of Year Focus Presentation
8/14/2024 PCMH User Group – Lori Boctor Presentation
5/22/2024 PCMH User Group – Updates, Supplemental Audit Presentation
Supplemental Audit Presentation-Final (05.2024)
BCBSM Retinal Eye Exam Job Aid
2/20/2024 PCMH User Group – 211 Presentation, Midwest Health Monitoring, NPO Palliative Care Resources
Welcome, Agenda, Announcements, Palliative Care Resource’s Presentation
Midwest Health Monitoring and Northern Homecare Presentation Handouts
Serious Illness Communication Reference Guide Brochure
Palliative Care Handout Packet
1/30/2024 PCMH User Group – Best Practices Kickoff, 2024 Interpretive Guideline Updates
BCBSM PCMH and PCMH-N Interpretive Guidelines 2023-2024 Final
BCBSM PCMH and PCMH-N Interpretive Guidelines 2023-2024 Redline Final
PCMH – IG Updates 2023-2024 with NPO Comments
Medication Chart Adult Pneumonia
Medication Chart Pediatric Asthma Treatments
Medication Chart Pediatric Respiratory Conditions
Best Practices to Kick off 2024
CKD and Inhaler Demo Presentation
Four Week Follow-up Phone Script
11/15/2023 PCMH User Group – PDCM Billing Report and Opportunities, ED/TCM/Timely Follow-up Scripts, Practice Communication Survey Results and Plans for 2024
Welcome, Agenda, and Announcements
Practice Care Management Billing Report,
S0257 Charting Information for AWV. Medicare Annual Wellness
S0257 Reimbursement Information
Anxiety Care Plan For Care Management
Depression Care Plan For Care Management
Generic Care Plan (for any disease) for Care Management
HTN Care Plan for Care Management
Initial Contact Care Management Workflow
Master Anxiety Resource Handout Workbook
Post Discharge phone script- Adult
Post Discharge phone script – Pediatrics
ACO REACH End-of-Life Care Report
BCBSM MA-BCNA Persistency (2023-10)
NPO-CIN BCBSM Blueprint 2022 Distribution
NSPC-Referral-Card-Most up to date
Palliative Care-Fax-form-Hospice of Michigan (002)
Priority Health Quality Scorecard (2023-11)
The Impact of Palliative Care on Hospice Utilization
"We all have different gifts and see the world a little differently. Because of this, we are able to problem-solve and make plans to help shape a bright future for our physician members and the patients of the NPO regions."
Peter Sneed, MD, Chair NPO Board of Directors, Oculoplastic and Reconstructive Surgery
Novello Physicians Organization
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