AW Medical PPS Care Team Meeting November 7, 2014.

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Presentation transcript:

AW Medical PPS Care Team Meeting November 7, 2014

Care Team Agenda November 7, 2014

Care Team Role 1.INTEGRATION 2. EFFICIENCY 3. EXTENSION OF THE PCP 4. EXPERTISE NEEDED, PLEASE SHARE

Project Status/Protocols

Project 2.a.i Integrated Delivery System Objective (from Project Toolkit): Integration – eliminate fragmentation and align provider incentives. Incorporate medical, behavioral health, post-acute, long term care, social service organizations and payers – migrate toward community-based care Population health strategies and participation in payment reform Requirements/Components: Care coordination (emphasis on Behavioral Health), alerts of any hospitalization and tracking of care after discharge (appropriate follow up services) RHIO connectivity – by Year 3 (potential to be earlier), PCMH and MU requirements Monthly meetings to discuss trends and utilization activity CBOs to assist with patient outreach and navigation Key process changes – office support to achieve DSRIP goals

Project 2.a.i Integrated Delivery System Status IT/Systems: Discussions with many IT solutions vendors to integrate with existing technology Includes designs of workflows and processes for interfacing Surveys have been distributed to understand capabilities for connectivity – majority have EHRs that can connect. Processes are being developed to integrate providers without EHRs. Clinical: Breakout sessions will discuss in greater detail ‘Gatekeeper’ model Discussion of the use of standardized tools to assist with projects

Project 2.a.i Integrated Delivery System

Workflows Defined and Systematic Integration of EHRs/Patient Charts (HIE) Protocol and Workflow Management Population and Risk Identification Patient Engagement Coordination and Tracking Reporting and Feedback (used to implement changes and improvements into processes) Performance Tracking and Incentive Distribution Project 2.a.i Integrated Delivery System

Breakout Sessions

NEXT STEPS KEEP LINES OF COMMUNICATION OPEN BE ACCESSIBLE FOR IT INTEGRATION NEGOTIATE CONTRACTS WITH PARTNERS / PARTNER TO PARTNER RELATIONSHIPS PRESENTATION WILL BE AVAILABLE ON THE WEBSITE: AWMEDICALPPS.COMAWMEDICALPPS.COM