Clinical Redesign Approach Centric to the LPN Coordinated Care Model Best Practice: Clinical Redesign Approach Centric to the LPN Coordinated Care Model Chad Braden, MD AMD – Primary Care – Ochsner BR October 22, 2015

CCC LPN Program - Overview Began in Baton Rouge in Quarter 4 2011 Expanded system wide to all of Primary Care in January 2015 Currently have 23 CCCs in place system wide – (ratio is about 1 CCC per 5-7 physicians)

CCC LPN Program - Goals #1 Goal is to close primary care gaps Place bulk orders based on the diabetes registry (Hgb A1c, urine for microalbumin, lipid panel) Call patients that have not been seen in a year to schedule an appointment Pre-visit planning – look at patients that will be coming in next 2 weeks to close care gaps

CCC LPN Program - Goals Referrals to outpatient case management Attend QBPC meetings on Fridays to address barriers with patients scheduled to see PCP in 2 weeks Teach providers about the metrics – roll out just beginning Meet with providers at least once every 2 weeks to review patient needs with scheduled appointments – align with HEDIS and STAR goals Other registries to come: HTN, COPD, Wellness, Immunization

Healthy Planet - Goals Other registries to come: HTN COPD Wellness in progress COPD role out spirometry to satellite clinics Wellness Immunization

Healthy Planet – Diabetes Registry Results Baton Rouge (~ inception through August 2015) Total # of patients in registry: 8804 Outreach: # pts who received a notification: 7381 Total # of labs/tests completed: 6022 Unique # pts that completed labs: 1560 Avg # of labs/tests completed by patient: 3.86 Percent of patients reached out to that completed labs: 21%