1. w w w. l a m p r e y h e a l t h. o r g 1 LAMPREY HEALTH CARE MEDICAL HOME

2. w w w. l a m p r e y h e a l t h. o r g Unique Facts About LHC New Hampshire's oldest and largest community health center 16,000 patients served each year Urban and rural locations The newest LHC site, is located in Nashua and one of 13 primary care practices located in a mental health setting

3. w w w. l a m p r e y h e a l t h. o r g Goal for Presentation Strategic Plan Current Staff Design Review framework used to achieve, expand and sustain Medical Home Efforts

4. w w w. l a m p r e y h e a l t h. o r g Goal for Presentation Impact on – Teamwork – Access – Population – Planned, Coordinated Care – Patient & Family-Centered Care

5. w w w. l a m p r e y h e a l t h. o r g Strategic Objectives 2009-2011  Patient Centered Care  Clinical Quality and Patient Safety  Workforce Retention, Recruitment and Development  Efficiencies and Financial V  Patient Growth  Capital Plan – Nashua Building

6. w w w. l a m p r e y h e a l t h. o r g 6 Board of Directors LHC Reporting Structure For Performance Improvement Committee Board PI Medical Leadership LHC PI Committee Site Audit

7. w w w. l a m p r e y h e a l t h. o r g Framework For Achieving and Maintaining a Medical Home Dartmouth – A microsystem is a place where: Care occurs Quality, safety, reliability, efficiency occur Staff morale and patient satisfaction occur

8. w w w. l a m p r e y h e a l t h. o r g Assessment Theme Global Aim Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 Global Aim 1 2 3 Dartmouth Microsystem Improvement Curriculum

9. w w w. l a m p r e y h e a l t h. o r g

10. Teamwork Health Coach- Facilitator Initial Microsystems Team Established –April 2009 Provider, Nurse, MA, Patient Advocate and Team Coordinator Weekly Meeting Scheduled Data Collected PDCA Cycle

11. w w w. l a m p r e y h e a l t h. o r g Patient-Centered Medical Home Phase I Initial Projects Prescription Refill Process Length of time until refill Number of hand offs Number of patient and pharmacy inquiries Triage Process

12. w w w. l a m p r e y h e a l t h. o r g Teamwork: Working to Scope

13. w w w. l a m p r e y h e a l t h. o r g Access Developed booking templates to accommodate patient requests Open access piloted with provider Standardized metrics organization wide

14. w w w. l a m p r e y h e a l t h. o r g Access to Care: Acute Appointment

15. w w w. l a m p r e y h e a l t h. o r g Population Management Driven by Clinical Quality Goals PREVENTATIVE: Cervical cancer screening PERINATAL: Low Birth Weight < 2,500g PEDIATRIC: Childhood immunization status ADOLESCENT: Use of adolescent risk assessment ADULT: Cholesterol Screening GERIATRIC: Percent receiving flu shots CHRONIC DIEASE MANAGEMENT: HbA1c Testing, Asthma severity assessment, self-management goals

16. w w w. l a m p r e y h e a l t h. o r g Patient Engagement Give Us a Grade Annual Patient Satisfaction Survey Patient Ask Three – What is my main problem? – What do I need to do? – Why is it important for me to do this?

17. w w w. l a m p r e y h e a l t h. o r g 17 Patient Safety: Patient Ask 3

18. w w w. l a m p r e y h e a l t h. o r g Patient-Centered Medical Home Phase II Using the principals of the medical home apply the Clinical Microsystems approach to surveying the current clinical measures and the NCAQ/Meaningful use measures Need for redundancy

19. w w w. l a m p r e y h e a l t h. o r g Patient-Centered Medical Home

20. w w w. l a m p r e y h e a l t h. o r g Accomplishments..... In the past year we have increased access to care Increased the percentage of patients with self-management goals to over 80% of the population Decreased the average A1c to < 7.3 Decreased provider turnover from 23% to 4%

21. w w w. l a m p r e y h e a l t h. o r g Next Steps Move the model organization wide Increase clinical measure alignment (meaningful use, BPHC, NCQA, etc) Improve patient access to data via the web

22. w w w. l a m p r e y h e a l t h. o r g Q/A and Tour