01 Section name goes here Addressing Population Health within the Patient-Centered Medical Home (PCMH) Coco Lukas, MPH – Quality Coordinator Rick Reifenberg, MD – Associate Medical Director Sheila Allen, MPH – Chief Compliance and Quality Officer

01 Section name goes here HealthNet is a Federally Qualified Health Center (FQHC) 2 Health Centers School-Based Clinics HIP Clinic/Shelters HIP Housing Sites

01 Section name goes here 3

Providers ~70 MD/DOs – IM/Peds, Peds, FP, ObGyn, Psych ~45 Advanced Practice Nurses – Certified Nurse Midwives, Ped NP, FNP, Women's Health NP, Psych NP Staff 630 Full-Time Employees HealthNet is a Federally Qualified Health Center (FQHC) 4

01 Section name goes here Joint Commission Accredited for: HealthNet is a Federally Qualified Health Center (FQHC) 5 Health Center Laboratory Services Patient Centered Medical Home (PCMH)

01 Section name goes here Services Provided 6 Primary and Preventive Health Care Dental Services Behavioral Health Care Homeless Programs Support Services (e.g., WIC, social work)

01 Section name goes here 2014 By the Numbers 7 59,286 patients ‒ Serves 20% of all Hoosiers covered by Federally Qualified Health Centers 263,167 family visits ‒ More outpatient visits than Riley Hospital for Children, which serves patients statewide 3,748 women obtained prenatal care 2,216 OB deliveries 3,092 homeless clients served 7,857 patients received dental care

01 Section name goes here Payor Mix 8

01 Section name goes here 9 Patient-Centered Medical Home

01 Section name goes here 10 Patient-Centered Medical Home

01 Section name goes here 1.Pre-visit identification and scheduling 2.During patient care visits 3.Post-visit reporting Population Health Implementation in 3 Phases 11

01 Section name goes here PHASE 1: Identification and scheduling Population Health Implementation in 3 Phases 12 ‒ Reports to identify children due for well child care and those with chronic diseases (diabetes, asthma) that were overdue for visits. ‒ Data used to schedule patients during week and also on special Saturday Clinics.

01 Section name goes here The report is ed monthly to clinic managers. The patients have had the majority of their WCC at that clinic. Patients who are in the system who haven’t had a WCC go to ALL clinic managers

01 Section name goes here PHASE 2: During patient care visits Population Health Implementation in 3 Phases 14 ‒ Templates ‒ Standing Orders ‒ Flowsheets

01 Section name goes here Well child assessment, nutrition/exercise counseling, and billing codes Mandatory question on pediatric templates re: vaccine status Required age-specific standard templates that include tobacco use and referral questions Asthma and Diabetes templates Nurse visits (e.g. Depo-Provera) with billing Templates 15

01 Section name goes here 2

Templates 2

01 Section name goes here 3

3

3

Standardized nursing based Standing Orders that mirrored new EHR work flows put in place HealthNet-wide. Staff are able to enter labs and vaccines on office visits prior to the Provider seeing the patient. Depression (PHQ2, PHQ9) and Anxiety (GAD7) done automatically when patient checks in. Standing Orders 21

01 Section name goes here Standing Orders 3

01 Section name goes here Standing Orders 3

01 Section name goes here Helpful for documenting Cancer Screening (Colon and Cervical). Diabetic Flow Sheet tracks LDL and Aspirin use. Health Maintenance Flow Sheet tracks Cancer Screening and Aspirin use. Flow Sheets 24

01 Section name goes here Flow Sheets 5

01 Section name goes here PHASE 3: Post-visit reporting Population Health Implementation in 3 Phases 26 ‒ Gathering and Reviewing the Data from the Outcomes from Phase 1 and 2 as noted on the prior slides.

01 Section name goes here Pediatric Measures Well Child Checks 0-15 months Well Child Checks 3-6 years Adolescent Well Care years Weight Assessment and Counseling 27

01 Section name goes here Well Child Checks 28

01 Section name goes here Weight Assessment and Counseling – Peds 29

01 Section name goes here OB Measures First Trimester Entry Low Birth Weight Deliveries 30

01 Section name goes here First Trimester Entry - OB 31

01 Section name goes here Low Birth Weight Deliveries 32

01 Section name goes here Adult and Chronic Disease Measures Weight Screening and Follow Up Tobacco Assessment and Counseling Asthma Pharmacologic Therapy Hypertension – Blood Pressure Control Diabetes – A1c Control 33

01 Section name goes here Weight Screening and Follow-Up – Adults 34

01 Section name goes here Adult Tobacco Assessment and Counseling 35

01 Section name goes here Asthma Pharmacologic Therapy 36

01 Section name goes here Hypertension Blood Pressure Control 37

01 Section name goes here Diabetes A1c Control 38

01 Section name goes here Questions? 39

01 Section name goes here Contact Information 40 Coco Lukas, MPH Quality Coordinator Rick Reifenberg, MD Associate Medical Director Sheila Allen, MPH Chief Compliance and Quality Officer