Provider Resources

Providers are eligible to participate in the ACO who are a MD, DO or Primary Care NP and a member of the medical staff of Franklin Memorial Hospital, LincolnHealth, Maine Medical Center, Memorial Hospital, Mid Coast Hospital, Pen Bay Medical Center, Southern Maine Health Care, Stephens Memorial Hospital, St. Mary’s Regional Medical Center or Waldo County General Hospital. To begin the process of joining the MaineHealth ACO, please email us to request an application packet.

Participants 

• Providers Participating in the MaineHealth ACO (updated monthly) (webpage) 

Clinical Documentation Improvement Training (webpage)
Annual Compliance Training (PDF)
Annual Compliance Training Attestation Form (PDF)
Medicare Advantage Special Needs Plans - 2020 Model of Care Training (PDF)
Attestation Fax Cover (PDF)
Code of Ethical Conduct (PDF)

COPD Resources

• COPD Assist: Diagnosis, Treatment and Referral Resources for PCPs (webpage)
• Improving the Care of Patients with Lung Health Issues (PDF)

 

Colorectal Cancer Resources 

• CRC Best Practice Framework (PDF)

 

Diabetes Resources

• A1c Best Practice Framework (PDF)
• Diabetic Eye Exam Best Practice Framework (PDF)
• Diabetes: Hemoglobin A1c>9 Quality Measure (PDF)
• Diabetes Prevention - Episode 1 (podcast)

 

End-of-Life Resources

• Code Status Discussions with Patients: Video and Pocket Guide (webpage)
• MaineHealth Regional Palliative Care Contacts and Resources (PDF)

 

Heart Failure Resources

• ACO Insider: Target Weight at the Center of Heart Failure (video recording) 
• ACO Insider: Advanced Heart Failure: When and How to Refer (video recording) - available upon request. Please contact ContactMHACO@mmc.org
• Heart Failure and Diuretics: Tricks of the Trade (PDF)
• Heart Failure Fundamentals: Target Weight (PDF)
• HTN Best Practices Framework (PDF)

 

Hypertension Resources

• BP Link: An Initiative to Improve Provider-to-provider Communication in Support of Hypertension Control (webpage)
• Peer-to-Peer Hypertension Control (webpage)
• St. Mary's "Obtaining Accurate Blood Pressure" Protocol (PDF)
• Test Your BP Taking Skills (PDF)

 

Adolescent & Pediatric Resources

• ACO Insider: Adolescent Well-Care Visit (PDF)
• Adolescent Well Care Visits Best Practice Framework (PDF)
• MMC/MMP Pediatric Referral Guidelines (webpage)
• Peds BMI Best Practice Framework (PDF)

 

Tobacco Resources

• Tobacco Screening, Counseling & Referral to Maine Tobacco Helpline Best Practice Framework (PDF)

 

ACO Insider: Annual Wellness Visits and Clinical Documentation (video recording)

Annual Wellness Visit Best Practice Framework (PDF)

MaineHealth Annual Wellness Visit Webpage (webpage)

Making Annual Wellness Visits Work (PDF)

Reimbursable Preventative Services (webpage)

Beneficiary Information Notice
Voluntary Alignment Fact Sheet with Instructions for Beneficiaries
Voluntary Alignment Fact Sheet for Practice Staff
Office Poster 8.5x14 (PDF)

Coding Documents

• CARE Coding Document - Falls Screening
• Diabetes A1c>
• Hypertension Control
• Depression Remission at Twelve Months
• PREV Coding Document – (Breast CA, Colorectal CA, Flu, Depression Screen, Statin CVD)

Key Measures

• Quality Measure Release Notes
• CARE-2 Falls Screening for Future Risk
• DM-2 Diabetes A1c>
• HTN-2 Hypertension Control
• MH-1 Depression Remission at Twelve Months
• PREV-13 Statin Therapy for Patients at Risk for Cardiovascular Disease
• PREV-5 Breast Cancer Screening
• PREV-6 Colorectal Cancer Screening
• PREV-7 Influenza Immunization
• PREV-10 Tobacco Use Screening and Cessation Intervention
• PREV-12 Depression Screening and Follow-up

  

Practices that participate in the ACO's MSSP contract are automatically enrolled in a special MIPS payment model created for ACO participants called the MIPS APM. Because the ACO reports some categories of data on behalf of its participants, this model places a reduced reporting burden on practices, compared to those enrolled in the standard MIPS model. 

Promoting Interoperability (PI) - Each ACO participant TIN (tax ID number) is required to report for the Promoting Interoperability (PI) category, or apply for and receive a hardship exception from CMS. 2015 Edition CEHRT EHR is required to report for the PI category. 

Participants must submit collected data for specific measures from each of the 4 objectives (unless an exclusion is claimed) for 90 continuous days or more during 2020:

1. e-Prescribing
2. Health Information Exchange
3. Provider to Patient Exchange
4. Public Health and Clinical Data Exchange 

A Security Risk Analysis measure is required but not scored for 2020. 

Specifications for each required measure are below:

• Clinical Data Registry Reporting (PDF)
• Electronic Case Reporting (PDF)
• E-Prescribing (PDF)
• Immunization Registry Reporting (PDF)
• Provide Patients Electronic Access (PDF)
• Public Health Registry Reporting (PDF)
• Query of Prescription Drug Monitoring Program (PDMP) (PDF)
• Security Risk Analysis (PDF)
• Support Electronic Referral Loops by Sending Health Information (PDF)
• Support Electronic Referral Loops by Receiving and Incorporating Health Information (PDF)
• Syndromic Surveillance Reporting (PDF)

HARP (HCQIS access roles and profile system) Account Information: The Quality Payment Program Portal requires you to have a login and password. If you already possess a HARP account / QPP login you may continue to use it. However, if you do not have an account, please follow the process outlined in the documents below.

1. Before You Begin
2. Register for a HARP Account
3. Connect to an Organization
4. Connect as a Clinician
5. Security Officials Manage Access

If you have any questions, please contact Susan Whittaker at swhittaker@healthcentricadvisors.org or (207) 406-3970.

Health Plans with MaineHealth ACO Value-based Agreements (PDF)  

2019 MaineHealth ACO Agreements (PDF)

Payer e-updates (PDF)

Clinical Documentation Improvement (webpage)

A series of Best Practice Frameworks designed to provide a standard set of strategies and tools specific to help you improve care provided in the ambulatory environment.

Best Practice Frameworks (Webpage)

The MaineHealth ACO Skilled Nursing Facility Index assesses how effectively individual facilities provide high value, patient-centered care that is compatible with MaineHealth ACO and MaineHealth system priorities. Specifically, the Index measures facilities’ engagement with endorsed protocols, care pathways, and quality improvement activities that enhance patient care and reduce the potential for avoidable readmissions and emergency department transfers. The Index is based on a unique set of measures and is meant to complement other sources of data and measurement. It is not intended to replace other quality data sources such as the CMS Nursing Home Compare star ratings, nor is it intended to be a blanket endorsement of the clinical care provided by participating facilities. Discharge planners and patients should consult all resources available to them when making a decision about post-acute care.

The 2020 Index reflects performance during 2019. 31 skilled nursing facilities that are members of the MaineHealth Senior Living Collaborative participated. Facilities received points for performance on 16 metrics. Points earned were applied to a level designation using the following framework:

 

 

2020 Designations:

 

 

 

 

 

 

 

 

For more information, please email us at contactmhaco@mmc.org

 

• 2021 Heat Map Quality Metrics Guide