Patient Care Coordination Community Health Center Challenges Belma Andric, MD, MPH May 26 th, 2015

Care Coordination Patient - Specialty Referrals - Closing the “Feed Back” Loops Patient - ER Referrals - Closing the “Feed Back” Loops Patient – “Self” ER Referrals - Closing the “Feed Back” Loops Patient – Choosing to use multiple Community Health Settings PCMH model – Patient Navigators (Health Coaches) Care Coordination through insurance plans 2

Patient - Specialty Referrals Closing the “Feed Back” Loops 3 Provider Place Referral Order Referral Clerk Schedules Patient Appointment Referral Source Completes Appointment Referral Source Sends Consult Notes to PCP PCP Reveiws with Patient, and Finalize Referral Loop

Patient - Specialty Referrals Closing the “Feed Back” Loops 4

Patient - ER Referrals Closing the “Feed Back” Loops Ask patient to sign medical record release form (if situation allows) Make a follow up appointment (if situation allows) Inform the patient they will be receiving a call from the Clinic within 24 hours to see if the patient is still in the ER, admitted to the hospital or discharged home Print medication sheet, applicable notes from the encounter, and face sheet with demographics and provide to patient or paramedics. CM will place patient on the hospital tracking log (see attached) and ensure that all above is documented in the patient’s EHR. CM will do all reasonable attempts to contact the patient and/or hospital within 24 hours to follow up on the patient status. 5

Patient Card 6

Patient Card (cont’d) 7

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Patient Navigators (Health Coaches) PCMH Model Colorectal Cancer Screening Increase in CL Brumback PCC (from 27% in Jan 2015 to 58% in April 2015) 11

Care Coordination - Insurance Plans HCD Managed Care Magellan Complete Care 12