Knowing your population and providing access to care in an advanced care model ______________________________________________________________________________________________________________________________________.

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Presentation transcript:

Knowing your population and providing access to care in an advanced care model ______________________________________________________________________________________________________________________________________ ________________ Oregon Primary Care Association July 21, 2014

What is our aim? Provide the right care, at the right time, in the right place by the right people Engage and “own” the target population Gain an understanding of the individual needs and tailor services to those needs Optimize our care team resources

Defining Access For whom? To what? For what purpose? Where? How? When?

If you were a commercial company what would you do?

As a Care Organization what do you need to do? Existing Patients

Collaborative Care: Proactively engaging patients Innovate on the Provider Exam Locums Group Visit Group On-boarding Home Visit Virtual Visit Mobile Clinic Fast Track Urgent Care Urgent Care Extended Hours Provide Team Care Behaviorist Medical Assistants Nurse/ Complex Care Manager Pharmacy Visits LCSW Community Linkage On demand education programs Care (Health) Navigators Community-based delivery Health Fairs Follow Up Health (Patient) Portal /Secure Message Nurse Advice Call Lines Call Center Connect to Peer Support Lay-led groups Web-based support Promotoras Gather Clinical Data Proactive outreach phone/mail/ text IVR Calls Remote monitoring Gather Patient Experience Health Risk Assessment PAM/ HARMS-8 PREPARE CONNECT ENGAGE Triple Aim Improved Population Health and Well Being Excellent Patient Experience Team Engagement & Retention Reduced Cost

As a Care Organization what do you need to do? New Patients

Reaching All: Considerations for New Patients Expand face- to-face access using team-based care (Bodenheimer) Expand face- to-face access using team-based care (Bodenheimer) Progressive Visits (Virginia Garcia) Progressive Visits (Virginia Garcia) Group On-Boarding (Centering Pregnancy) Orientation Clinic (Chinatown Public Health) Orientation Clinic (Chinatown Public Health) Population Stratification (New Mexico)

“If you always do what you’ve always done, you’ll always get what you’ve always got.” - Henry Ford

New partners or team members supporting patients… MA specialist MA Health Coach Nurse complex care manager Clinical Pharmacist LCSW Group Visits Care coordinator MA specialist MA Health Coach Nurse complex care manager Clinical Pharmacist LCSW Group Visits Care coordinator In the practice? Health fairs Care navigators Peer led classes Community based care delivery Mobile clinics Promotoras Urgent Care Health fairs Care navigators Peer led classes Community based care delivery Mobile clinics Promotoras Urgent Care In the community? In the community? /secure message Text Phone calls Virtual visits Home visits Nurse call lines/advice lines Web-based peer support /secure message Text Phone calls Virtual visits Home visits Nurse call lines/advice lines Web-based peer support In their homes? In their homes?