And so this month's, again, welcome. I'm Bill Tullick, director in our federal services center, and this month's office hours are originally scheduled for July, but then moved to August, involves value based care in PCMH. So this is a big topic in, health care as we change how we reimburse for care, from an episodic to a value based model and how the PCMH, transformation to the BCH model, but the model itself can really help you, achieve success in the value based care world. So thrilled to be able to bring this to you today. So we do have a disclaimer that we wanna start with. This is just something HRSA has asked us to include in all of our presentations for the agency, under our contract. As you can see, the contract number there, we do thank them for their support, but note that there are nonfederal resources in these slides, that are not endorsed or approved by HHS or HRSA. So just wanted to make that clear. So we're we're gonna be talking about today sort of the where value based arrangements happen, what they look like, and then the PCMH benefits. And, of course, I'll be taking your questions throughout the session. So, so let's talk a little bit about sort of the the how, PCMH really can benefit you, with the value based care arrangement. So what we saw interestingly early on when we first started doing PCMH work, and and we have to understand we're we're almost two decades into our PCMH work. I just realized that looking at the the calendar, it is twenty twenty six, and we started our first program back in two thousand eight. And in fact, I believe the precursor to that was actually two thousand and three. So it's been a while. We have been working on this journey, for a while. And when we first began, it was actually relatively easy. Perhaps it's the wrong term, but there were a lot of very clear benefits to practices for, working, into the PCMH model. That is payers, specifically, insurers, but even HRSA, were were providing a lot of direct reimbursement for recognition. That is they're providing bonuses just for the the, achievement of recognition. There were enhanced payments to providers who who were in recognized practices or to the practices themselves. Plus, there was a lot of technical support. In fact, New York State did a huge effort, basically wanting to get every single primary care practice in the state, recognized, as a PCMH. I'm not sure if they got fully to that to that goal, but a good chunk of them are. And they actually provided free TA, over the course of a three year period to every practice in New York State. Excuse me. And that, involves NCQA training a huge number of PCMH CCEs up in the up in the New York area to be able to provide, that support. Then, of course, the ongoing cost of maintaining recognition. Now HIERS, of course, continues to pay for the surveys itself, TA like this to to to keep folks informed and aware of what's going on with the model and with our program. But they did, and and they used to pay out quality bonuses on an annual basis, but they were never guaranteed. It was always sort of of a a true bonus. Right? A true, surprise benefit as it were. And over time, they have really transitioned to, believing that PCMH should be, foundational to a health care center. And so they have now, changed sort of the benefit of becoming recognized rather than getting a, qualifying for, like, a cash bonus. Now you qualify for points in the, service area competitions. So if you are recognized, you sort of get more points there. Not necessarily as huge a benefit, but certainly, still recognition. And, of course, they continue to pay for the cost of maintaining recognition. A lot of the other payers don't do that anymore. The a lot of those enhanced, those bonuses certainly. New York still has some enhanced payments for, practices, and I think there are some other states that continue or the payers that continue to do that. But the PCMH model really, again, has become this foundational idea that it it it in and of itself, it shouldn't be rewarded, but that it allows you the ability, if we are talking about value based care arrangements either that are are paying for, you know, sort of I I'm not sure if folks have been really successful in sort of creating episodes of care payment, as has been talked about a lot, sort of like paying for the whole surgery over time that includes all of care. But certainly, we have seen the rise of both, one-sided and two sided risk contracts in value based care, which basically, provide enhanced payments and potentially reduce payments depending on how you do on a whole series of quality metrics. And, of course, as we know, moving quality metrics is not an easy thing to do. And so we really think, though, that the PCMH model is the way, to have that foundation there to be able able to provide better quality care and service, which can actually move those metrics, both the the clinical metrics, but also any satisfaction metrics that may be part of, a value based care arrangement as well. So if we think about sort of the concept areas, and why they would be helpful in a value based care arrangement, well, certainly, if we think about the team based care and practice organization, you know, we talk a lot about having staff at the top of their licenses operating at the top of their license where their skill set, depending on how you how you define them and what type of provider, they are, what type of employee they are. Now that obviously promotes efficiency, and it can, really increase the capacity to treat different patients. But I think it has some other real, intangible benefits. One of them is that, obviously, there's a staff satisfaction improvement that we see in the PCMH model when folks are feel like they're being respected, that they are valued members of the team, and that they have independence in what they do. I think the anecdote I've said before I've used before, a a physician I saw many years ago talking at a lunch sort of he was the keynote speaker at lunch at a conference talking about the difference in his practice, with the PCMH model. Whereas before they transitioned this was a private, commercial practice. Before they transitioned to the model, the patients would come in. They they wait in the waiting room, then they would go into the, examining room, they'd have, you know, their a nurse or an MA or somebody would check their weight and blood pressure, very common, and then they would wait for the doctor. Doctor would come in, typically with nurse, MA, whoever the the team was, and they would go through sort of everything with the patient labs, medications, current symptoms, whatever the the the sort of chronic care management issues might be with that patient. And then the doctor would sort of fire off a series of instructions, and either the individuals in the room would go out and and and, follow those instructions or they would get other folks to do it. And it would be sort of like a scurrying of staff to go out and do everything for this patient. They'd do it, come back, sign everything, patient would go. With the PCMH model, however, because they're doing morning huddles, because there's a clear understanding of who's coming in, at least those patients who are scheduled, and what they're gonna need, then the nurses, the MAs, the the the staff, whoever they're they've got at the the practice, they know when the patient's coming in what they need to do. And so the patients are still waiting in the waiting room. They're still brought back. But rather than just having their weight and blood pressure checked, they're also you know, someone's handling, double checking their meds, making sure that we have a current list, making sure that they're, updated on prescriptions. Are there any things they're running out of? Are they having any side effects? They're they're checking all their lab orders and making sure that whatever routine care needs to be done is is handled. And and, basically, the the the physician explained, excuse me, doing a lot of webinars this week, that by the time he got into the room, most of the care was done. He was able to sit down and have a one on one discussion with the patient about how they were doing. It wasn't about sort of getting all the i's dotted and the t's crossed. And he ended up spending less time with each patient, but they were getting care for more of the time they were in the practice because all the other staff were doing what they needed to do. So that, you know, sort of independence and and that sort of system, obviously, make sure that that folks feel valued and all that, but you're also ensuring that those gaps in care are less likely to occur. Right? So you've got folks that are responsible for doing this. And so they're they're making sure those gaps in care are happening, which is gonna improve quality metrics. But the other thing that that that system does is it really does, promote this idea that also everyone on on the team is sort of speaking from the same the the the same bible as it were. That is they're all, aware of whatever the care management, goals are. They're all aware of what's going on with these patients. They can reinforce messages in different ways, and that can be really effective. I know when my, when my dad was, he passed away a couple years ago. And when he was, sort of, going back and forth with doctors, he he's was, an obese man his entire life. And I mean morbidly obese, well over four hundred pounds at one point. When he was first diagnosed with high blood pressure in his forties, the blood pressure was so high. His doctor actually wanted to admit him because he was at such a high risk for stroke. My father refused, being admitted to the hospital, and the doctor, basically compromised by making him take a double dose of the medication and then calling my mother and ratting out on him. I'm not sure under HIPAA that would be allowed these days, but he basically told her she he's gonna have a stroke if he doesn't follow these instructions. So he did follow the medication and things, but he never never, was successful losing weight, tried many different things. It just it was one of those things where where he struggled, for for many, many years. He retires. He goes, and, moves into an over fifty five community in Florida. I go down to visit him regularly. I come down one time, and he had already lost some weight just because he he wasn't, working as much, he was golfing more and exercising more and and things like that when he retired. But he had been I don't know. Since the last time I'd seen him, he'd lost about forty pounds, and this has been over a couple of months. And my immediate thought was, where's the the the girlfriend? Right? He was a widow at that point. He'd been a widow for many years, and he wasn't a girlfriend. What it was was he I'd gotten him to a medical home model, practice. And and rather than the message being, basically, you're fat, you need to lose weight, and because you're fat, you're a failure. That's sort of that's very negative messaging. Someone at the practice, I can't remember if it was a nurse or an MA or or a PA, but one of the the the the folks at the practice was sort of reinforcing the messaging that it would be good for him to lose more weight, but it was more about his symptoms that he was having with his knees and some other issues where they said, you know, if you if you were to exercise a bit more and maybe lose some of the weight, you would also relieve some of that pressure and and alleviate some of these symptoms. And it was the first time it had been promoted as a way to feel better versus a way to stop failing. And that was really the mentality that he had been, told. And and it was the the one person who finally got that message across, and they were having a a deal where he got a a discount on bikes, on the on a bicycle, and he was riding the bicycle, which is how he had started to lose all this weight. And it was just sort of interesting because he was, of Scottish, descent, and I thought, well, that that fits the the the stereotype, doesn't it, quite well. He got a deal. That's also, not not to be not to be sneezed at. But I think it's important when when those messages are reinforced in different ways, you never know what the what sort of the patient's really gonna hear and what's gonna click for them. And for him, it took a long time, and it finally did. And and he ended up at one point, he was actually, he weighed less than me. I was in better shape. I'll I'll put that. But I was sort of like, wait. That's not supposed to happen. But it was sort of interesting that that was what, helped him click. So I think that's really an intangible of the of the the PCMH model of practice in that you can reinforce those messages. Of course, we also look at knowing and managing your patients, and this is probably the most important aspect for really, achieving success under value based care because knowing who your patients are and how outreach is gonna work, to reduce miscarriage and get better chronic care management, that's gonna be what's gonna really move those metrics. Getting folks that aren't normally coming into the practice who who, who are dealing with, their their care well. So certainly, doing outreach and doing outreach in a way that really reaches people. It's been interesting to see, you know, we we do these trainings, under HIE every year about our standards. And one of the things we ask about is sort of your population outreach and what's effective. And the switch from mailed pieces, which was so common for so long, to text and electronic messaging, which I think is obviously more efficient for folks, but I think it's also, reaching folks better. You know, you get those text messages reminding you you've gotta do something, and that that's probably more effective than mail you can throw away. You know? So I think some of the the changes in how we do outreach has has been really effective. But also knowing, sort of where your patients are and and what's gonna work with them is gonna help you do better outreach and get folks in for that those chronic care and also those preventive care, management, issues. Obviously, the the medication reconciles reconciliation and management that we promote, is a great way to avoid interactions and promote efficient care, but also it's a great way to make sure that folks are on medications and understand. I recently joined my father in being diagnosed with high blood pressure. I'm almost twenty years older than him, I will point out, in in having that happen. But one of the things that I'm dealing with is the medication I'm on, which has been very effective. It makes you a little bit dizzy. And so the fact that this has been reinforced by my physician and the care team, and and with some strategies. So for instance, when I went to the the dentist and, you know, they lay you down the table for the cleaning, you know, they now know to let me get up a little bit more gradually and let me sit for a minute, because the dizziness might might that's a a real problem when I might feel it. But because it was from the beginning, they said this may happen, that even though I'm having the side effects a little bit, it's not bad at all, but it really helps me as a patient say, okay, this is normal. It's not something to be scared of. It's just something to sort of navigate as part of that. I think that also helps with, that medication management. We also hear about some really, innovative ways that health centers have used to help folks understand and stay on medication. I think one of the most interesting, and I can't remember where the where the health center was, but they had a program with newly diagnosed, patients who are newly diagnosed, with depression and are on antidepressants for the first time, where they set up automatically a series of weekly phone calls with the patients as they, began the medication knowing it's gonna take a few weeks to to titrate up. It's gonna be a little a bit of time before you start to feel the effects, but the side effects may kick in earlier. So having this this twenty minute call, fifteen minute call, whatever it was to say, are you taking the meds? How are you feeling? Are you having any side effects? And if there were issues, they were able to then get back to the provider and say, we need to adjust these meds or adjust the dosage. Something like that really helped keep them on that med long enough for them to start to feel the positive effects and say, okay. Now there's a reinforcement for staying on the med. Think those kinds of things can really, help as well. And then the other aspect that I think is so important that got overlooked for so long before the PCMH model is this idea of patients are not just their health, whether that's medical health and behavioral health, however you wanna look at it, they are their lives. And all of their life challenges are part of what, impacts their ability to manage their care and for you to hit your quality metrics. So understanding those transportation issues, which may, be solvable or may lead you to more telehealth and telemedicine because that's more convenient for the patients. Right? Understanding some of those issues with translation, with legal services, with life stresses, who's a caretaker, and and, you know, getting somebody who has a parent with, dementia problems, for instance, who they're taking care of at home, you know, connecting them with with respite care services so they can have a little bit of time to take care of themselves, whether that's dealing with medical care or just having time off from from the the stress of being a caregiver. All of that can really help folks manage their own, health care better, remove some of those obstacles to self management, and improve your improve your metrics. But, again, you need to know sort of what challenges your patients are facing before you can set them up for success with some of these community resources. So I think that's another aspect that that the community health center world also has as a real strength. Pardon me. I'm I'm one of those speakers, and I've gotta keep the the whistle wet as it were, in in being part of their communities in a way that that that commercial practices often are. I remember we were doing a training, one of the very first trainings I was on when I started working on the PCMH product, out in California where, we were talking about some of these community resources. And, one of the physicians from a community health center asked a totally reasonable question. Well, are these internal or external resources? And my colleague at the time sort of answered automatically, well, external to the practice. This is what we'd expect to see sort of these external community resources. And we got enormous amount of pushback. It's one of the few times I've been faculty in a in a in a room where I felt like they really don't like us right now. And it was because what we hadn't factored in as we were just starting our work with community health centers is that the commercial practices were using the services and benefits that the community health center was or the programs they were putting together for their patients. Well, why wouldn't we give credit for the community health centers for doing that, you know, internally rather than externally? And it really required us to go back to our our policy folks who put the standards together and say, you know, the intent of this of the standard is to is to have these resources for nonmedical needs. Why is it a bad thing if it's internal to the practice? And that changed our interpretation of the standard and led us to say no. In fact, they can be internal, external. And sort of the more rural you are, the more I expect them to be internal. Right? If you're in a large urban area, there's there's probably services out there that you can utilize. If you you know, I remember hearing about one of the health centers up in Northern California. By then, I mean, the Oregon border. So really north, well north of San Francisco and all that area in a very rural part of the state where they were the one stop shop. They were basically the community resource center for everything. It was sort of like a community hub that happened to have a health care practice thrown in the middle of it. And so there was basically no outside, resources because of of the nature of their community. So it was sort of interesting that we had to be challenged ourselves as a standard setting body to say, no. No. No. The intent is to help patients with all these nonmedical needs. If the practice is doing it because that's part of their mission as a health center, that's a good thing, and we need to recognize that. Some other, strengths that can really help you, of course, the the access and continuity. Some something we we're always looking at is how are you, providing care, when are you providing care, and does that meet the expectations and the needs of your patients? So one of the things we added when we updated our program in twenty seventeen, to this new format was, yeah, we want you to assess very specifically your patient's needs and preferences for appointments. Are are your appointments at the at the times they need them? Are they convenient? If you're gonna change your appointment times, is it something that's actually good for the patient, or or have you reached out to them? I'm I'm thinking specifically of a pediatric practice that thought it would be a great idea and thought it was a no brainer, to have Saturday appointments for well child visits. And they started doing it, reshuffled their entire schedule for all their staff so that they they weren't violating any forty hour a week rules or anything like that, and no one was taking advantage of these Saturday hours. They were sitting basically empty doing nothing. And what it turned out was they hadn't talked to the patients. They hadn't talked to the the parents in their practice who were like, well, Saturday would be great if it weren't also the day when all youth sports leagues are meeting. And I'm running around with my kids from soccer to to baseball to dance class, whatever it is. We got no time on Saturdays. I would rather have evening hours or early morning hours. They didn't talk to the the the the parents. So making sure that not only you've spoken to your patients and and seen when they need or when they, what kind of care, what kind of appointments would be best for them and what times, but doing that regularly because lives change, people change, resources change, needs change, all that kind of thing. So you may need to adjust that. But I think the other, aspect of this that's really important and and one of the few silver linings from the the COVID pandemic has been our understanding that telehealth works really well. So in the times you can use telemedicine telehealth as a as a replacement for in person care, it's typically much more convenient for the patients, and they're far more likely to make those appointments. And, again, that's gonna help you reinforce those messages, keep that self management going, and keep patients motivated to to keep those those those care, indicators up. And, of course, care management, you're focused on those complex patients, hoping to reduce some of the duplicative care and service and also unnecessary care. If you can keep folks that are really complex healthier, then they're not going be ending up in the emergency department. They're not going to be ending up, admitted to the hospital. That's going to be, better for your metrics, but also, better for the patients where they're, obviously in better health. Of course, in the care, coordination excuse me, in care transition area, this is one of those also where, it can be a lot of work to, promote better communication and information sharing. And some of this is is now being done with technology. I've heard sort of, you know, sort of positive and negative about things like HIEs and RIOs and what and whether they're really that effective, in sharing information. Obviously, the the ultimate would be to have, electronic health records that talk to each other. And someday, we will get out of nineteen ninety five word processing land. I I I do believe that we will where we will have, the ability to share, information across different platforms. I always explain to people now, those of us who are old enough to remember when you had an Apple product and you had a PC product and you couldn't share files between them. Right? It was a real it was a real issue for a long time. Now we don't think anything of it. We want we wouldn't even know what computer somebody else was using. Everything is sort of, very, interoperable, and that's where we need to get to. But for the for the the meantime, trying to improve those communications and getting you know, when reporting is still manual or when you even with an HIE, you've gotta be putting that information in. You've gotta be taking looking for it and and and downloading it if if needed. All of that means that you still have to sort of have a commitment to that kind of information sharing. And we still have folks that will use HIPAA that will say that, no. No. I can't share information because of of privacy concerns when the HIPAA regs are pretty clear. If you're treating the same patient, there's almost nothing that isn't shareable. You know, psychotherapy notes are the one big exception. Pretty much everything else is shareable because you never know what is gonna be the important, information. Those of us, those of you who remember the the movie, the big sick from a few years ago, and I'm blanking on the comedian's name who's of Pakistani descent, but it's a true story. I mean, it's based on the true story of he and his wife, and they wrote it together. But it was a a throwaway comment that he made to the doctor where they realized, oh, this is what's really happening, with this one this mysterious illness that she had, and they were able to to to save her life, basically. And it was you know, you really never know what small piece of information. And, of course, medical shows love to love to do that, as well with a a key piece that changes the whole perspective, but that can really happen. So making sure that that that information sharing and that reporting is there, and that may require a lot of in person sort of work with some of these providers, some of the institutional providers, particularly, to really make it clear that they need to be to to sharing, you know, these kinds of information. And, of course, when you get into quality improvement, we have, you know, you're you're monitoring all these key measures. You're identifying those areas, and that's obviously gonna help you improve. And I think, certainly, my my experience, at NCQA is almost thirty years now. One of the things that that is so important in quality improvement is not just looking at what your numbers are doing, but why they're doing that. Why are our numbers the way they are? The qualitative questions, think, are the really key ones. And those you wanna ask broadly across your staff, across, you know, whatever patient advisory council or patient board that you're using for that input. You know, what could be causing these kinds of things? We have, you know, there there's always the problem of the of the ready, fire, aim issue, which is you assume you know why a problem exists, and so you end up, doing the wrong thing and and and intervening in ways that aren't going to improve the, the actual, care at all. You're not gonna move the quality metric because you don't really know what the problem is. And I remember years ago when I was doing a series of of, my job for NCQA was to go run different health plans and talk about our new HEDIS measures and how to improve them. And I went to, one location. And one of the things I would do is I would always make sure I could watch the nightly news, the the local news the night before I would speak at one of these health plans because there was always information about what was going on in the community. It was fascinating that one half hour or hour long local news program could give me insight into some of the challenges that that community was facing. And I could work that into my presentation and talk about, well, I know that this is going on here and that may impact these kinds of numbers, and people love that. That was a was a very simple thing to do, but just watching that local news. And one place I went to, what was highlighted on the local news was this health plan was basically being sued for late payments to their providers, which was not a, you know, not a great thing. Now the health plan was under new management at this point, so they were taking steps to improve that. But it was a a diplomatic struggle for me to walk into that that practice or into that that health plan and talk about our HEDIS measures and talk about sort of generally the ways to improve them. And and one of the the quality folks said, look. We have the same network as everyone in our area. We have the same types of patients. We still have worse quality indicators, and and we just can't figure it out. And I had to sort of diplomatically come up with a way of saying, well, you're not paying your providers. So you know that whatever you know, that negative information is coming back to the patients. Right? I I can easily see doctors saying, oh, we'll we'll we'll, you know, we'll we'll order this for you, but your health plan probably won't even pay for it. They haven't paid my bill in, you know, nine months or six months or whatever. And then, you know, they're this much late or whatever, which is undermining confidence in the health plan, but also you're not necessarily promoting the idea that this is really important for you to go and get this care if you're saying your the health insurance that you have is faulty and and defective and not working. So those negative messages were getting in, and they were having a real effect on their quality measures. And it would take a long time, you know, with that kind of a of an issue to build back up and and get your reputation back to being positive. So sometimes those why questions can be very tough, but I think they're the most important in understanding, you know, where your numbers are moving and how to best, move them forward. And, of course, the the worse you're doing in the QI measure, the easier it is to move things. Right? If you're really at the bottom of the barrel, or the the lowest rated practice in the state, pretty much anything you do is going to improve that. Sometimes just the mere act of measuring something will improve it because it puts in that measure into into people's mind, into the front of folks' mind, and they're thinking, oh, yeah. I've gotta I've gotta do this. So, what gets much more complex, of course, is if you are starting to get up to that sort of eighty percent compliance rates, and everyone knows that last twenty points of of of QI measure, are the hardest to to do. So that's really where those why questions and and and breaking down into subpopulations. You don't have to only intervene, with one population or or or the same across your whole population. There may be different ways you can intervene with different subpopulations that are going to have equal, and positive impacts as well. So but all that, of course, is gonna help you with any kind of value based care arrangement where they're expecting you to achieve certain markers, certain measures, certain levels. So we'd love to hear if if folks have experiences with, sort of value based care and and if, PCMH has been helpful. We don't have a lot to cover today. We're actually, toward the end of our slide deck. So I just wanna reinforce the idea that, you know, as we move into these new payment systems, are looking at performance versus sort of, sheer amount of work you're doing, Adopting the the PCMH model, you know, it's about more than sort of dotting i's and crossing t's for NCQA purposes. It is about, maximizing the effectiveness and efficiency and and helpfulness of your staff, of your practice to be able to keep those quality, metrics, where you want them to be. And I'll get off the soapbox now. So, again, we'd love to see if there are any questions or, feedback you'd like to provide. We did we were scheduled for an hour, but we don't always, need to take that full hour. And, again, this is also an opportunity for you to ask questions not just about what I'm covering in terms of the slides, but anything else about the program itself. Couple key things to remember. We do have some trainings coming up, in, the fall. We're we're doing a whole technology series, which we just started to promote. Looks like we may have to change some dates, though, because there's been some, issues with some of the the process here. So we're gonna, be looking into that. So so be aware of that. We're also gonna be, NCQA will have a booth at the NAC meeting next week in Las Vegas. I'm leaving on Saturday, in fact. I'll be manning the booth. Most of the time there, I'm also doing a speech, on Sunday doing a little one of their little TED talks that one of the twenty minute talks on the future of primary care and where NCQA is sort of going, at a very, sort of conceptual basis. Not not a lot of concrete, kind of programming, material, but more, understanding what what our philosophies are and things like that. So it should be a good talk. And if you're gonna be that that neck, please stop by the booth and, certainly come. I think I'm speaking in one of the the pinion ballroom or something. I can't remember exactly, but, but we're excited about that. So, any future value based payments, for BH and or diabetes. So in terms of, HRSA sort of reimbursement, they are reimbursement reimbursing for behavioral health integration, that that distinction program. They haven't yet, started paying for the diabetes, and I'm not sure about sort of I mean, obviously, having behavioral health integration is gonna be a real benefit, I think, to any quality indicators, certainly, because those comorbid behavioral and medical, patients can be some of the more complex. And also having a comorbid behavioral health issue may impact your ability to manage medical care and and vice versa. Right? So, so I think that can still be helpful. But in terms of HRSA, all right now right now, what they have added to our contract, is the behavioral health distinction. Diabetes, not at this point. And I see a question about monitoring state policies regarding, PCMH and value based care. The insurance companies do not pay for PCMH per se. And and that's certainly, I think I have to look in sort of our state and federal policy folks if they are if they're if they're, looking into those at this point, but that's an interesting aspect. So will my talk be recorded, on our website? I don't I don't know that we're planning on doing it on our website. It may be available through NAC. That is a great question. I'm actually filling in for someone. One of my colleagues had a personal issue and has not been able to attend. He was going to. So I'm kind of filling in. I I've only gone through the slides once or twice at this point, so I'm more concerned about getting that done at this point. But I'll double check on that and and let folks know, if it is recorded and available after the presentation. So a comment that one of, some centers using, HBA, HBAI codes, is I'm reading that correctly, within the integrated behavioral health model. Unfortunately, the Medicaid program has not, open these codes, but the the center is piloting their program with Medicare. Yeah. I know there's a a lot of issues with also dealing, it's more efficient if you can provide behavioral health care and medical care at the same time, but a lot of times you have to decide which you're going to get reimbursed for and what you're not, because of of some rules about, sort of double booking or or providing both sets of types of care at the same time. And I'm not sure. I I assume that's what you're talking about there. So interesting about the pilot, but, yeah, I think, that's still a struggle that a lot of centers talk to us about. Great feedback, though. Thank you. Alright. Any final comments or questions? So a question about specifically, annual reporting, with AC one. So the the concern is that if you don't have sort of the right questions in your survey, you can't really fix that, during, annual reporting, and how do we deal with that. So that's I I wanna bring that back to our policy folks if we can be more explicit about what we're looking for that or sort of the types of questions that would meet. I understand they don't wanna preapprove stuff, but certainly, we can look look and be more explicit about the types of questions we're looking for. I do know that they have started the corrective action program as well down in our operations folks so that if you miss some of the AR, standards, you're not necessarily gonna lose your recognition or have to go through transforming again. But, obviously, being on a corrective action plan isn't great either. So, I think that's actually a good suggestion that we we try to, expand some of that, both for for AR, for AC one and in QIA four, but factoring specifically into the AR. Because, obviously, if you're if you're, going through transforming, you have some time to sort of, at least if not fix the questions in your survey, do a sort of a mini work mini workaround that you wouldn't be able to do in AR. So I will bring that back to policy as a suggestion. K. And then Interesting question about the we're just talking about whether or not it would be possible to sort of do a a quick survey during the period between reporting and, anniversary dates. Again, something to bring up with our with our ops folks. Absolutely. Thank you. And then New York State, we're going to be audited on four clinical quality metrics, to maintain our bone and bone. Do you know what the the format from the state? I don't. I don't know. I do not work on the New York State program, and we are not we don't know we no longer have a contract in New York State to sort of promote PCMH. I mean, obviously, we're still renewing, the the centers that have, recognition in New York State, and we still have the New York State specific program that that where they have electives that they, require the, the the practices to to answer. But I don't know about the those audits. Sorry about that. Alright. Great questions, though. Thank you. Are there any resources about value based care, how to get started, what to look at? I don't know about stuff that we've done, but but, I will, check with our education folks to see if we have done that. And if not, certainly sounds like sort of a beginner training might be something that we'd want to, to think about. Interesting idea. Thank you. If you can't tell, I've got the questions over on the screen. So if two PCMH recognized sites are relocating to a new location, what timeline do you recommend we submit for AR? Well, I don't recommend you you change your timeline for AR. What I recommend is you follow the merger acquisition and consolidation policy, which is in your standards book. Like, I haven't answered that question before, but, no, we do have a MAC policy. It's one of the appendices, or it's the part of the front matter. I can't remember which in the transforming standards. You do have to alert NCQA if you're particularly because it sounds like you're merging two locations into one. If they're both PCMH recognized, it shouldn't be an issue, but you do have to alert us. And then they will adjust whatever timeline, with you once once we figure out. So they'll they'll have to determine if we have to go through a macro review, which is an internal review for any outstanding questions, and then they will help you. Your rep will help you, streamline and figure out what the new timeline will be for for those sites. Remember also, though, if you're relocating, you're probably gonna have to create a new site in, you may have to create a new site in QPass where we may end up including it as as or editing one of your existing sites and then retiring the the the other one. But remember that for HRSA purposes, any even even if you're just relocating one site to a new location without merging, that's a new site. So you will also have to update the site ID. You will definitely get a new site ID for that site, and you will have to update that in QPASS. So, in terms of regional trainings, we actually I'm in the middle of one right now for Maryland. We're finishing up this afternoon, and then we have one at the end of the month for, region seven eight, Montana. Region eight. We also are doing region five in October, and and, I can actually share those with you. I I apologize, Don, if I I didn't share the other ones. And we are actually looking for potentially a region four partner PCA to do one more training. We have one more slot this year, and we we're holding it for a potential in person that isn't gonna happen. So if you've got, if you're interested in trainings, let us know because we we are looking for a partner PCMH in region four. Have to have to reach out to those. So interesting. I know we focus on BH integration. Is there any thought of producing a a dental health integration? And and that's actually another strength for health centers, absolutely, dental care. I know we look I think we looked into that at one point, and then the the issue was there may not be enough to look at if you weren't, if you weren't providing full dental care that, and and so I think we did look into that a while back but but haven't but haven't added that in yet. But I'll bring that back to policy as well. And thank you. You're gonna reach out to the region four folks. That's great. Thank you. Can we attend a training if we're not in that preferred region? Yes. In fact, we do allow folks from other regions to attend. I can, if you want, you can send actually, let me give you I'm gonna I'm gonna stop sharing my slides here, and I am going to get out of this slideshow. And let me, make sure I've got the, correct address here. But I'm gonna give you our our, sort of general initiative address for the whole HRSA team here at NCQA. So if you wanna reach out and Just wanna make sure I have the correct email address. Copy that. Okay. Chat to everyone. So if you are interested in a training, we've either already done your region or we're not gonna hit your region this this year. Please just send a request to us, and we can send you the registration links. Alright. Any other questions, comments? You so much for all this feedback. This is exactly why we do these these office hours, so they're very helpful to get. Alright. Well, thank you all very much. I'll give you about fifteen minutes of your day back. And, as far as the TA program, I'm not sure if we have any spots open at this point because we're getting to end of the task order, but we are gonna be doing a new task order. So stay tuned because I think we'll be having a new round of enrollments in, October. So, where can I find map of regions for trying to find those that Texas belong to? Actually, just Google HHS regions. They'll show you the map. But Texas, I can tell you, is in region, six because we just finished their training last week. Alright. Well, I hope everyone has a great day and a great weekend. And, those of you who are coming to NAC, next week, I will see you then. Please do feel free to stop by. Alright. Thank you all.