1. CMHI - for CHI Pilot, Dec 2009

2. Welcome to our Medical Home!
Facts: 45+years (est1965) Private Practice
2 locations
16 physicians, 11 mid-levels, 2 Dieticians, 3 Health Educators
40K active patients
EMR since 2003
Web site with simple patient access, videos, patient surveys, refill and referral requests, patient portal, ability to CX appts via
Hospital coverage at PMC, nursing home coverage at 2 Facilities.
ADA certified Diabetic Management Program ( Working on NCQA Certification)
Medically supervised weight loss and lifestyle modification programs
30+ support staff, in addition to a call center, and business office
Goals: Review our metamorphosis, trials and tribulations
Our Questions? Training Staff, Engaging Physicians, Helping each other
CMHI - for CHI Pilot, Dec 2009

3. Pilot Members - Updates
Heather Staples -
CMHI - for CHI Pilot, Dec 2009

4. Medical Home – What’s Different?
TAPPP Approach
Team/teamwork
Access /communication about access
Population Approaches
Planned Coordinated Care
Patient & Family-Centered Care
CMHI - for CHI Pilot, Dec 2009

5. Teamwork -
5 pods with appx. 3-4 physicians, 3 mid-levels, 3-5MA’s and 1-2 nurses
Increased staffing/support
Huddles concept (but not always the reality)
Recent discussions on how to include front staff and call center as part of the team
Medical Home team (politicians)- 5 Providers, 1 RN , 1 Administrator
Quality team (police)- 5 Providers, 2 RN’s, 1 Clerical staff, 1 Administrator
Clinical meetings (Monthly- All Clinical Providers)
Intranet: medical home newsletters, updates, polls, questions, blogs
How do you change behavior with punishment/incentives?
Created the ‘wall of shame’
Monthly quality reports and non-compliance letters
Accomplishment letters
Highlighting those processes that are successful
QA team chart reviews and feedback
CMHI - for CHI Pilot, Dec 2009

6. Access Call Center open 7:30am-6pm to take patient calls.
Physician Call coverage nightly (24/7 EMR access)
Hours: Monday-Thursday 8AM – 8PM
Saturday Hours: 8:00-12:00
Open Acute appointments available each day, depending on the day.
On Site Lab in both locations ( bi-directional lab interface)
Limited On Site Specialty Access
On Site Imaging: Derry
Evening and weekend hours
Mammogram tracking and recalls
CMHI - for CHI Pilot, Dec 2009

7. Population Phytel Medical Technology Company
Establishes patient Registries
Proactive Patient Outreach
PQRI Reporting Tools
CMHI - for CHI Pilot, Dec 2009

8. Planned, Coordinated Care
New Diabetes Program (ADA certified)
New Weight Management Program
New Lifestyle Modification Program
Creation of disease based templates in the EMR for patient visits
New Controlled Substances Policy and Implementation
Work on active tracking of care through the EMR and crystal reporting through our PM system
In the process of creating workflow/patient follow up procedures for the Nursing and MA staff.
CMHI - for CHI Pilot, Dec 2009

9. Patient & Family-Centered Care
Direct Communication with Specialist
Work with CLM to improve access for counseling and psychiatric
Increasing time spent with patients particularly those with CHF/CAD/DM
Improving coordination of care through the team
Communication through the Internet/Practice Website (H1N1)
New Medical Home Pamphlets
Tracking of Hospital Discharges ensuring follow-up
Call back all acute visits after 3 days to ensure improvement
New outreach through technology: , phone, text
CMHI - for CHI Pilot, Dec 2009

10. Patient Engagement Patient Engagement
Starts with the call center and hits all aspects of the team, front desk reviews last CPE and books appt. if pt not up to date, MA’s review chart and identify health maintenance needs even for acute visits, MD’s update medication and problem lists at every visit, patient are directed through the web site and care coordinated though local programs
Creation of a Patient Centered Diabetic Work Group
New Practice Survey-Jan 2010
Accessed through our web site
Patients notified at their visit and on the back of the follow-up appointment card
Survey Monkey allows for analysis of data
CMHI - for CHI Pilot, Dec 2009

11. Tour – Taking a Walk About….
Walk through the office with a patient/family perspective
Review some of the patient information we have created
Questions/Suggestions?
CMHI - for CHI Pilot, Dec 2009

12. Flexible funding
If we had some flexible funding to support innovations, we would attempt to achieve the following medical home activities:
Establishment of a permanent Medical Home Director & additional staff for data extraction and tracking
Additional time for Physician Training
Increase the number of programs offered
Increase access through
CMHI - for CHI Pilot, Dec 2009

13. Q & A Questions & possibly Answers…
Anything else you like to know about us?
CMHI - for CHI Pilot, Dec 2009

14. Summing Up In the last 6 months to 1 year we have focused on
Improving Diabetic Care
We know there have been real changes for diabetics enrolled in our Diabetes Program because75% of those patients now have A1c’s<8 and 48% have A1C’s less than 7
We have achieve these changes through a program we created after hiring a medical specialist for Diabetes and a Diabetic Nutritionist
We wanted to, but were not able to work on or improve the consistency of data capture for all diabetics
Significant barriers include EMR limitations and lack of consistent documentation
CMHI - for CHI Pilot, Dec 2009

15. What’s next for us EMERGENCE! (some day)
CMHI - for CHI Pilot, Dec 2009