Citizen’s Health Initiative Presentation March 24, 2010

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Presentation transcript:

Elliot Family Medicine at Bedford Commons Patient Centered Medical Home Citizen’s Health Initiative Presentation March 24, 2010 Amy Dobson Director, EPN

Presentation Overview Care Team Development Addition of services within the Medical Home Patient Engagement

Care Team Development Morning Huddle Changing staff roles required redesign of clinical staff roles Perception of inability to take on expanded role with constant busy practice

Clinical Staff Needs Move from task oriented practice to patient oriented practice Staff Engagement Job ownership Professionalism Regular weekly meetings

Nurse Role Development Phone Triage Nurse Visits Patient Centered Nurse team member Assessment of complex patients After visit education

Nurse Health Coach Role Chronic condition support Follow up with hospitalized patients and patients discharged from the ED/UCC Support to our high needs patients

Behavioral Health on-site 08/09 Current Data: Rapid referral process Shorter intervention time Improved outcomes

Pharmacy on-site 08/09 Current Data: 30+ Coumadin Patients 9 Patients for medication management or Bp management

Patient Engagement Targeted Patient Survey Initiated February 2010 Patient Advisory Board Initiated March 24, 2010

Questions