Interdisciplinary Care in the Primary Care Office Lydia Jackson PA-C I am an PA at Virginia Garcia Memorial Health Center. The organization is a comprised of 5 major clinics, a women’s health and OB clinic, multiple small school based clinics, and associated dental clinics that serve the underserved population in Washington and Yamhill Counties. I have been working at our Hillsboro location since 2008. I have had the privilege in these almost 10 years to watch our clinic go from a provider- patient paradigm that did not incorporate interdisciplinary care at all to a patient centered medical home with a focus on interdisciplinary care. - Environment

FQHC Preventative Health Services Dental Services Mental health and Substance Abuse Services Serve an underserved area or population Offer a sliding fee scale Provide comprehensive services (either on-site or by arrangement with another provider), including: Preventive health services Dental services Mental health and substance abuse services Transportation services necessary for adequate patient care Hospital and specialty care https://www.fqhc.org/what-is-an-fqhc/ Serve an underserved area or population https://www.fqhc.org/what-is-an-fqhc

Team Based Care "...the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care." As defined by the National Academy of Medicine … https://pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care

Medical Home= Patient Centered Care Patient Care Team: Provider PCC RN TA MA CTL s a patient centered model, where the patient is the driver of their healthcare needs. There is a team approach to taking care of the patient rather than the provider being the patient’s sole care taker The medical home looks slightly different in clinics across the state and country, but the concept will be similar. At Virginia Garcia each patient has one patient care team that consists …….This team will be in charge of seeing the patient in clinic and contacting patient in between visits to follow up on all of their healthcare needs There are other resources housed within the clinic that the patient will have immediate access to if needed. These are Behavioral Health and Clinical pharmacy. Each clinic has their own pharmacy as well that can access their providers in a timely fashion should any medication questions arise. There are a multitude of other resources that the organization has to offer as well. The medical home allows for individualized care plan for each patient involving all the key players needed to optimally improve their health.

The Team Provider: MD, PA, NP, DO, ND Patient Care Coordinator (PCC) Team Assistant (TA) Nurse (RN) Medical Assistant (MA) Clinical Team Lead (CTL) The team is the basic unit of interdisciplinary care in our clinic. There are five teams in our clinic that each care for a fifth of our patient population.

Medical Home= Patient Centered Care Patient Care Team: Behavioral Health & Mental Health Provider PCC RN TA MA CTL s a patient centered model, where the patient is the driver of their healthcare needs. There is a team approach to taking care of the patient rather than the provider being the patient’s sole care taker The medical home looks slightly different in clinics across the state and country, but the concept will be similar. At Virginia Garcia each patient has one patient care team that consists …….This team will be in charge of seeing the patient in clinic and contacting patient in between visits to follow up on all of their healthcare needs There are other resources housed within the clinic that the patient will have immediate access to if needed. These are Behavioral Health and Clinical pharmacy. Each clinic has their own pharmacy as well that can access their providers in a timely fashion should any medication questions arise. There are a multitude of other resources that the organization has to offer as well. The medical home allows for individualized care plan for each patient involving all the key players needed to optimally improve their health.

Behavioral Health Work alongside providers to care for the behavioral aspect of uncontrolled chronic diseases Works with patients to effect behavior changes Develop coping skills Foster motivation Help with referrals and communication with outside mental health agencies

Mental Health Mental Health Therapist- provides counseling to our patients Mental Health NP- consultation appointments to make recommendations for mental health medication therapy MH Clinical Pharmacist- follows patients taking mental health medications to help with lab monitoring, and meets with patients to discuss benefits and side effects of their medications

Medical Home= Patient Centered Care Patient Care Team: Behavioral Health & Mental Health Provider PCC RN TA MA CTL s a patient centered model, where the patient is the driver of their healthcare needs. There is a team approach to taking care of the patient rather than the provider being the patient’s sole care taker The medical home looks slightly different in clinics across the state and country, but the concept will be similar. At Virginia Garcia each patient has one patient care team that consists …….This team will be in charge of seeing the patient in clinic and contacting patient in between visits to follow up on all of their healthcare needs There are other resources housed within the clinic that the patient will have immediate access to if needed. These are Behavioral Health and Clinical pharmacy. Each clinic has their own pharmacy as well that can access their providers in a timely fashion should any medication questions arise. There are a multitude of other resources that the organization has to offer as well. The medical home allows for individualized care plan for each patient involving all the key players needed to optimally improve their health. Clinical Pharmacy & Pharmacy

Clinical Pharmacy Provide direct care to our patients with chronic diseases to help with medication adjustment and lifestyle change Diabetes and Hypertension Address barriers to care and advise for further services for the patient Work with team to get medical supplies Do medication reconciliations for patients with polypharmacy Provide teaching to staff about pharmacologic updates Ensure appropriate drug therapy in clinic protocols With pts to get diabetes supplies With TA- f/u on DM Sharing patients with BHP to identify barriers to help address With RN- answering questions, support RN protocol questions, developed a lot of the protocols and ensure drug therapy is appropriate Manage chronic disease states, medication reconciliations, provided teaching via newsletters, presentations

Medical Home= Patient Centered Care Patient Care Team: Behavioral Health & Mental Health Provider PCC RN TA MA CTL s a patient centered model, where the patient is the driver of their healthcare needs. There is a team approach to taking care of the patient rather than the provider being the patient’s sole care taker The medical home looks slightly different in clinics across the state and country, but the concept will be similar. At Virginia Garcia each patient has one patient care team that consists …….This team will be in charge of seeing the patient in clinic and contacting patient in between visits to follow up on all of their healthcare needs There are other resources housed within the clinic that the patient will have immediate access to if needed. These are Behavioral Health and Clinical pharmacy. Each clinic has their own pharmacy as well that can access their providers in a timely fashion should any medication questions arise. There are a multitude of other resources that the organization has to offer as well. The medical home allows for individualized care plan for each patient involving all the key players needed to optimally improve their health. Diabetic Ed Community Outreach Wellness Center Dental Services School Based Health Services Acupuncture/OMM/Naturopathy Clinical Pharmacy & Pharmacy

Other Resources Diabetic Education program taught by Clinical Pharmacist specializing in diabetic education Acupuncture Naturopathy DO provides OMT- Osteopathic Manipulation therapy TOC Team- Internist, PA, pharmacist, BHP, social work, PT/OT, PA student Outreach workers School based health centers Dental Wellness Center

PCC & TA - proactive panel management BHP Armando 58 yo male Uncontrolled Diabetes Uninsured MA PCP Outreach Worker RN PCC The PCC and TA work on proactive panel management (describe) and identify Armando a 58 yo male with DM that is overdue for his DM visit. The PCC notices that his DM is uncontrolled and so makes a plan for a warm hand off to the BHP at the time of the visit The MA and provider scrub the chart and make a plan for the apt on the day of the visit prior to the patient’s arrival MA rooms pt and gets DM labs BHP sees pt prior to PCP apt to assess patients motivation to make lifestyle changes, barriers for change, and willingness to engage further with behavioral health t help with lifestyle changes that will help DM and schedules f/u apt with her BHP briefly talks to PCP about any lifestyle changes pt is thinking about making so the PCP can reinforce these PCP sees pt- they make a decision to start insulin PCP brings in PCC to teach patient about using a glucometer, then PCC and Pharmacy work together to get pt the medical supplies he will need to use insulin RN teaches pt how to inject insulin while in clinic so pt more likely to start at home PCC returns to the room and schedules pt to DM classes available for nutrition and starting insulin and schedules f/u with pharmacy PCP puts in a referral for the patient to work with the clinical pharmacist to help adjust the patient’s insulin. They will come back to see the clinical pharmacist on a weekly or biweekly basis based on complexity and need, CPS and BHP may discuss shared pt to further identify barriers If social and financial barriers are identified pt can be connected with the community outreach worker that can direct them to appropriate community resources Clinical Pharmacist Diabetes Education

Teaching in an Interdisciplinary Clinic Inter-professional experience for clinical year students Learn how to utilize a team and other specialist within a healthcare system Spend time with other specialties to see primary care from their point of view

Patient Benefits Improves access to office visits Optimizes time in clinic More comprehensive care More empowered to navigate primary care system Team has better system to outreach to patient Patient is a key player in their care More empowered to navigate the primary care system- easier access to clinic personnel, more timely responses

Staff Benefits Empowers each team member to take pride in the care they give Closer interactions with patients Smaller group of patients to manage Working at top of license Co-location leads to better communication Working on a team to accomplish patient goals Most of all the staff really enjoy working on a team to accomplish patient goals. There is a greater sense of camaraderie, less if the hierarchical feel that medicine can have, and ultimately the days work is being spread among a group of people, which offers each provider an extra level of support allowing them to manage more complex patients and helps prevent provider burnout.

Healthcare System Benefits Breaking down patient barriers to access to care Reduces healthcare costs Proactive medicine Improves health outcomes of populations Reducing ED visits and hospitalizations Makes the healthcare system easier for the patient to navigate Rising healthcare costs is one of the biggest issues in medicine currently. The medical home model aims to reduce these expenditures by practicing proactive care, reaching out to the patients before their illnesses worsen and in turn helps to keep patients out of the emergency room and hospital. By creating a system that is easier for the patient to access, the patient will be more likely to go to their PC office rather than seek urgent or emergent care elsewhere. The American College of Physicians estimates the widespread implementation of a medical home model would lead to a $175 billion reduction in US healthcare expenditure over 10 years.

Barriers Change is difficult across professions and disciplines Remembering and utilizing the wealth of resources the clinic has falls on the provider initially

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