CMHI - for CHI Pilot, Dec 2009

Welcome to our Medical Home! Facts: 45+years (est1965) Private Practice 2 locations 16 physicians, 11 mid-levels, 2 Dieticians, 3 Health Educators 40K active patients EMR since 2003 Web site with simple patient access, videos, patient surveys, refill and referral requests, patient portal, ability to CX appts via email Hospital coverage at PMC, nursing home coverage at 2 Facilities. ADA certified Diabetic Management Program ( Working on NCQA Certification) Medically supervised weight loss and lifestyle modification programs 30+ support staff, in addition to a call center, and business office Goals: Review our metamorphosis, trials and tribulations Our Questions? Training Staff, Engaging Physicians, Helping each other CMHI - for CHI Pilot, Dec 2009

Pilot Members - Updates Heather Staples - CMHI - for CHI Pilot, Dec 2009

Medical Home – What’s Different? TAPPP Approach Team/teamwork Access /communication about access Population Approaches Planned Coordinated Care Patient & Family-Centered Care CMHI - for CHI Pilot, Dec 2009

Teamwork - 5 pods with appx. 3-4 physicians, 3 mid-levels, 3-5MA’s and 1-2 nurses Increased staffing/support Huddles concept (but not always the reality) Recent discussions on how to include front staff and call center as part of the team Medical Home team (politicians)- 5 Providers, 1 RN , 1 Administrator Quality team (police)- 5 Providers, 2 RN’s, 1 Clerical staff, 1 Administrator Clinical meetings (Monthly- All Clinical Providers) Intranet: medical home newsletters, updates, polls, questions, blogs How do you change behavior with punishment/incentives? Created the ‘wall of shame’ Monthly quality reports and non-compliance letters Accomplishment letters Highlighting those processes that are successful QA team chart reviews and feedback CMHI - for CHI Pilot, Dec 2009

Access Call Center open 7:30am-6pm to take patient calls. Physician Call coverage nightly (24/7 EMR access) Hours: Monday-Thursday 8AM – 8PM Saturday Hours: 8:00-12:00 60-120 Open Acute appointments available each day, depending on the day. On Site Lab in both locations ( bi-directional lab interface) Limited On Site Specialty Access On Site Imaging: Derry Evening and weekend hours Mammogram tracking and recalls CMHI - for CHI Pilot, Dec 2009

Population Phytel Medical Technology Company Establishes patient Registries Proactive Patient Outreach PQRI Reporting Tools CMHI - for CHI Pilot, Dec 2009

Planned, Coordinated Care New Diabetes Program (ADA certified) New Weight Management Program New Lifestyle Modification Program Creation of disease based templates in the EMR for patient visits New Controlled Substances Policy and Implementation Work on active tracking of care through the EMR and crystal reporting through our PM system In the process of creating workflow/patient follow up procedures for the Nursing and MA staff. CMHI - for CHI Pilot, Dec 2009

Patient & Family-Centered Care Direct Communication with Specialist Work with CLM to improve access for counseling and psychiatric Increasing time spent with patients particularly those with CHF/CAD/DM Improving coordination of care through the team Communication through the Internet/Practice Website (H1N1) New Medical Home Pamphlets Tracking of Hospital Discharges ensuring follow-up Call back all acute visits after 3 days to ensure improvement New outreach through technology: email, phone, text CMHI - for CHI Pilot, Dec 2009

Patient Engagement Patient Engagement Starts with the call center and hits all aspects of the team, front desk reviews last CPE and books appt. if pt not up to date, MA’s review chart and identify health maintenance needs even for acute visits, MD’s update medication and problem lists at every visit, patient are directed through the web site and care coordinated though local programs Creation of a Patient Centered Diabetic Work Group New Practice Survey-Jan 2010 Accessed through our web site Patients notified at their visit and on the back of the follow-up appointment card Survey Monkey allows for analysis of data CMHI - for CHI Pilot, Dec 2009

Tour – Taking a Walk About…. Walk through the office with a patient/family perspective Review some of the patient information we have created Questions/Suggestions? CMHI - for CHI Pilot, Dec 2009

Flexible funding If we had some flexible funding to support innovations, we would attempt to achieve the following medical home activities: Establishment of a permanent Medical Home Director & additional staff for data extraction and tracking Additional time for Physician Training Increase the number of programs offered Increase access through e-mail CMHI - for CHI Pilot, Dec 2009

Q & A Questions & possibly Answers… Anything else you like to know about us? CMHI - for CHI Pilot, Dec 2009

Summing Up In the last 6 months to 1 year we have focused on Improving Diabetic Care We know there have been real changes for diabetics enrolled in our Diabetes Program because75% of those patients now have A1c’s<8 and 48% have A1C’s less than 7 We have achieve these changes through a program we created after hiring a medical specialist for Diabetes and a Diabetic Nutritionist We wanted to, but were not able to work on or improve the consistency of data capture for all diabetics Significant barriers include EMR limitations and lack of consistent documentation CMHI - for CHI Pilot, Dec 2009

What’s next for us EMERGENCE! (some day) CMHI - for CHI Pilot, Dec 2009