Chronic Disease and Health Maintenance Registries Clinical Workflow October 2015

Ochsner Quadruple Aim

Population Healthcare has arrived So, what is it? “Today we are primarily in the business of delivering care one patient at a time. By contrast, a population health practitioner is concerned with achieving healthy outcomes for an entire population.” -Steven Lefar, Sg2 President and CEO

Evolution of Primary Care at Ochsner

Registries and Pre-Visit workflows How do we do it? Registries and Pre-Visit workflows

Population Health: Care TOuch Identify Care Gaps Patient Pre Visit Work Visit Work Population Work Orders can be placed using the Primary Care Written Order Guidelines (WOG) Registry work –place bulk orders and patient notifications Close care gaps

Ochsner LPN CCC Model Ochsner LPN CCC PCP Teams 1:8 Care Gap Closure Insurer Care Coordinators + Registry Input Ochsner LPN CCC PCP Teams 1:8 Care Gap Closure Registry HEDIS Health Screening Care Gaps PHN Humana BCBS Written Order Guidelines and Bulk Ordering

Pre Visit Work Staff Physician WHO: LPN Care Coordinator WHAT: Check registry for care gaps Check Health Maintenance for screening gaps Place orders (using WOG) pre lab or same day WHEN: 2 weeks prior to patient visit WHAT: Sign orders placed Return results coming back from pre-visit lab work

Visit Work Staff Physician WHO: Practice MA/LPN WHAT: Check registry and Health Maintenance Place any needed orders (using WOG) Encourage patient to complete gaps WHEN: day of visit WHAT: Encourage patient to close care gaps Look for pre visit results - return results

Population (Panel) Work Staff Physician WHO: LPN Clinical Care Coordinator WHAT: Run registry gap reports for assigned physician practices Place bulk (pend) orders (using WOG) Notify patients WHEN: 1st week of each month WHAT: Sign bulk orders Return results

W O G Physician signature PCP attribution LPN CCC Registry Care Gaps Bulk orders Care Touch outreach My Ochnser letter phone Result to PCP Lab draw

PCP determines management Result to PCP Normal PCP determines management Abnormal See diabetes resource guides Significant PCP or APP visit Pop Med Clinic referral Not significant Improved outcomes

Timing considerations Diabetes Registry went live on April 1, 2015 Once orders are fulfilled the orders and gap disappear from the registry Orders remain good for 1 year Will recontact patients with open gaps quarterly Patient Groups can be prioritized: Humana Gold MSSP (Medicare) Employee Group Blue Cross: Quality Blue Primary Care

Work in Progress We are working with Registration on capturing the patient’s PCP in Epic We are working with lab to create a walk up mechanism for several selected sites (other sites will need an appointment) At this time bulk notifications will be sent as follows: Portal Patients will be notified via the portal Non-portal patients will be notified by phone or letter based on preference

Results to Date - September 2015 Registry Enrollees # pts with outreach # pts responding to outreach % pts responding to outreach Diabetes 39,000 21,000 5064 24% Tobacco Hypertension 147,000 Mammography 108,000