Breaking News on Primary Care

Michigan Multipayer 

Primary Care Review Nov-Dec 2022

Michigan Multipayer Initiatives (MMI) convenes payers, practices, and Physician Organizations to lead the transformation of primary care and improve care value, equity, quality, and patient experience in Michigan. To be added to our distribution list, send an email with “Add Me to Newsletter Distribution ” in the subject line to Our website is at To share an idea or ask a question, please contact Diane Marriott ( or 734 740 0511).  

New 2023 HEDIS Measure on Social Determinants of Health Screening and Intervention

The Healthcare Effectiveness Data and Information Set (HEDIS) is one of health care’s most widely used measure sets. In 2023, a new HEDIS measure on Social Need Screening and Intervention (SNS) will be added that focuses on the unmet social needs. The new measure will assess the percentage of members who were screened at least once during a measurement period for unmet food, housing and transportation needs and, if screened positive, received a corresponding intervention. Examples of interventions include assessment, assistance, coordination, counseling, education, evaluation of eligibility, provision of a service, or referral to an organization.

The idea is to better understand social factors that drive many disparities in care and outcomes. To allow for an apples-to-apples comparison of performance among plans, a list of acceptable screening tools for the measure have been announced:

  • Accountable Health Communities
  • AAFP Social Needs Screening Tool
  • Health Leads Screening Panel®1
  • Hunger Vital Sign™
  • Safe Environment for Every Kid (SEEK)
  • We Care Survey
  • WellRx Questionnaire
  • Housing Stability Vital Signs™
  • Comprehensive Universal Behavior Screen (CUBS)
  • USDA Food Security Survey

What does this mean for primary care practices? It is likely that there will be increased attention to making sure that people are screened for SDoH needs, and to coordinating efforts among community-based organizations, health systems and providers, and plans. Coordination has many advantages, including minimizing duplicate screening and patient burden, as well as to ensuring that data is exchanged in a safe, secure, and coordinated manner to close SDoH gaps when members desire assistance.

Upcoming MDHHS SDoH Events:  You’re Invited!

MDHHS will host two sessions focusing on social determinants of health (SDoH) gap closure in the near term. Here is information on each:

  1. December 13 SDoH Partner Session: You can register at this link for the event which will take place from 1:30 to 3pm.  At this event, MDHHS will continue the community discussion on opportunities to connect and improve SDOH efforts in Michigan.
  2. January 24-26, 2023: MDHHS will host an SDoH Summit with details and registration links on the event details webpage.  The summit will coincide with the Governor’s issuance of a proclamation calling attention to the need and work being done to address SDoH and health equity. The Summit event will serve as a “call to action” to draw all partners together to address the topics focused around the SDOH initiatives. Phase 2 of Michigan’s Roadmap to Healthy Communities will also be launched at the summit. Phase 2 will explore:
  • Community health worker expansion and alignment to support health equity.
  • Community information exchange to maximizes a person-centered approach that incorporates social care information, promoting streamlined access to health enhancing, non-clinical services (e.g., social services and supports), helping to coordinate care across a variety of clinical and non-clinical partners, and using data on existing community resources, needs, and gaps to drive policy change.
  • Bridging food security, housing stability, and built environment efforts to develop a Chronic Disease SDOH Accelerator Plan with mini grants to fund local models of community engagement.

Get Up to Speed Quickly on the Latest on Telehealth Policy

The Center for Connected Policy offers a series of very useful policy explainers at    They are structured as easy-to-digest videos, most under seven minutes long. The Center is funded by the Health Resources and Services Administration (HRSA) to operate as the federally designated National Telehealth Policy Resource Center. They also host a series of free, interactive webinars that feature leading telehealth experts.

An Update on the Implementation of the CMS Innovation Center’s Strategy

A year ago, CMS and the Center for Medicare and Medicaid Innovation (CMMI) released a strategy refresh that described a bold and constructive vision. This November, progress on the first year’s implementation was released in Person-Centered Innovation – An Update on the Implementation of the CMS Innovation Center’s Strategy.  The document is well-written and has much to offer relating to primary care, including increased attention and action in the following areas:

  • Creating greater care coordination between primary care doctors and specialists.
  • Considering the release of new advanced primary care model with a special emphasis on safety net and Medicaid providers.
  • Encouraging new tools to (e.g., e-consults, enhanced referrals) to facilitate data exchange to ensure effective follow-up of high clinical value.
  • Increasing safety net provider participation in demonstrations.
  • Incentivizing reducing disparities in care and outcomes through payment incentives, quality measures, beneficiary data collection on demographic characteristics, and identification and resolution of social needs.
  • Announcing and launching new accountable care models that increase access to advanced, high-quality, primary, and preventive care, and make multi-payer alignment possible, including for Medicaid beneficiaries, to ensure a focus on underserved populations.

The Training Corner

To better serve you, we have expanded the array of care management and team-based care training sessions. We are fortunate to have MiCMT, Mi-CCSI, MiCHWA and PTI to provide expert training on important topics in primary care. Here is a summary of their upcoming training sessions.

Michigan Institute for Care Management and Transformation (MiCMT) – Training and Webinar Announcement

A list of upcoming trainings, including live webinars, can be found in the News and Events section of MICMT’s website: For an at a glance view, please find the event calendars and event flyers in the “News” section here.   Questions and concerns can be shared at

The Michigan Center for Clinical Systems Improvement (Mi-CCSI) – Training and Webinar Announcement

This on demand program 12-module series provides practical guidance to care teams seeking to elevate the level of care provided to patients with substance use disorder (SUD). The odd-numbered modules in this series are focused on clinical best practices. The even-numbered modules in this series are focused on operational aspects of office-based addiction treatment (OBAT) and include interviews from practice, where practices who have implemented the materials covered in that module provide testimonials via brief interviews.


Additional training programs can be found in the “TRAINING” section of Mi-CCSI website:

Or to select by Topic, simply go to:

  2. Hover over “TRAINING”
  3. Select offering by name from dropdown menu

 Practice Transformation Institute (PTI)

 A list of upcoming trainings can be found in the Events section of the PTI’s website: offerings include Introduction to Team Based Care, Foundational Care Management Codes and Billing Opportunities, Patient Engagement and Unconscious Bias in Health Care.


 Community Health Worker Certification Training

The curriculum is designed to train front line workers to provide culturally responsive services in Michigan communities. The 126 training hours include 25 hours for independent self-study.

Register HERE. For more information contact: Holly Joseph | 231-316-8558