Meeting Highlights and Resources

5/22/2024 PCMH User Group – Updates, Supplemental Audit Presentation

May 2022 Updates

Supplemental Audit Presentation-Final (05.2024)

Cancelling the Order in eCW

BCBSM Retinal Eye Exam Job Aid

Eye Exam Reporting Form

2/20/2024 PCMH User Group – 211 Presentation, Midwest Health Monitoring, NPO Palliative Care Resources

Welcome, Agenda, Announcements, Palliative Care Resource’s Presentation

2.1.1 Presentation Handouts

Midwest Health Monitoring and Northern Homecare Presentation Handouts

Serious Illness Communication Reference Guide Brochure

Advanced Directive Handout

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

PCMH Primer 01.2024

Medication Chart Adult Pneumonia

Medication Chart Diabetes

Medication Chart Hypertension

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

Post Discharge. Counseling Points for Diuretics, ACE-Inhibitors, ARBS, Calcium Channel Blockers, and Beta Blockers

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

9/21/2023 PCMH User Group – Direct SNF Admissions, Self Monitoring Blood Pressure, Ideas for impacting Blood Pressure readings for year end

Admissions from Home Power point Handouts

AdmitFromHome check list



Self Monitoring Blood Pressure PowerPoint Handouts

Patient (and Care Manager) Blood Pressure Packet

HTN Care Plan for Care Management

End of Year Blood Pressure Process for Optimal Readings Fall 2023


5/25/2023 – Lori Boctor from BCBSM presentation


5/12/2023 – PCMH-Neighborhood Webinar

NPO Primary Care Specialist Agreement

Specialist Test Tracking flowchart

Specialist Referral Flow chart

Specialist Phone Triage Flowchart

4/6/2023 – Supplemental Audit Learnings Meeting


2/22/2023 – Disease process and helping patients, Health Focus PCMH Specialist, PH Clinical Edits, PaMPM Payments, PDCM Guideline Updates

1/19/2023 Quality Measure Guide, Colon Cancer Screening, ACP Videos, New VBR opportunity


11/1/2022 – Incentive Program Overview, Health Focus

9/20/2022 – Jill M. Young, Young Medical Consulting, CPC, CEDC, CIMC – CCM and PCM billing


6/23/2022 – Perinatal Support Alliance, Self-Care, PDCM, Health Focus

4/13/2022 – PGIP Quarterly Updates, Health Focus, Reminders

2/17/2022 – BCBSM Interpretive Guidelines, Takeaways from 2021 and Opportunities for 2022, Health Focus

11/2020 – In lieu of a PCMH User Group meeting, please find below the following resources: Health Focus Tips video (only 16 minutes long!!!) from Michelle Anderson of NPO and the 2021 Site Visit take-aways from Rachael Smart of NPO.

2021 Site Visit Key Takeaways


Stacey Hettiger, MSMS Senior Director, Medical and Regulatory Policy, presented to NPO PCP practices at a PCMH User Group meeting 10/21.  Her presentation is titled “COVID-19 Vaccination Policies for Health Care Employees”.

COVID-19 Vaccination Policies for Health Care Employees_102121

MSMS Legal Alert LA_Mandatory Vac



Shira Gabry-Kalikow, LMSW, MPH, Partner Success Manager, ACP Decisions will discuss the ACP Decision videos (content, workflow, best practices) which NPO offers at no cost to practices for patient use.  There are many videos available on this platform regarding diseases, advance care planning,  caregiver support, etc.  including some for pediatric patients.

NPO shares HealthFocus features/best practices.

6/24/2021 Practices discuss:
Chronic Care Management Services Vendor
Behavioral Health Collaborative Care Model  PCP Role Handout
Care Management program for patients newly diagnosed to Diabetes.

4/20/21 NPO was very pleased to present its new HealthFocus population health management system including a document prepared by NPO for your practice’s use, attached as HealthFocus Overview, which helps explain how some specific HealthFocus features can help support your practice’s PCMH and operational processes.

HealthFocus Overview – Final (2021-04)

2/24/21 The good work done over the past ten years by NPO practices leading to the next step in fee for value – Direct Contracting –  was discussed.

Highlights 2.24.21

2021.2.24PCMH User Group Meeting (presentation)

CMS Direct Contracting Model Primary Care Codes

1/21/21 The updated BCBSM PCMH capabilities were  discussed and Best Practices for many processes were shared.

Highlights 1.21.2021

NPO Commented Interpretive Guideline Updates 2020-2021

Interpretive Guideline Updates 2020-2021 (1)

Best Practices to Kick off 2021

Care Management. Remember Motivational Interviewing Flyer







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