1. The Future Family Physician
John Saultz, MD
Professor and Chairman
OHSU Family Medicine
January, 2014

7. GP SW

8. Mittelstaedt TS, Mori M, Lambert WE, Saultz JW
Mittelstaedt TS, Mori M, Lambert WE, Saultz JW. J Am Board Fam Med 2013; 26(4):

9. SW Inpt Svc Readmissions 11/12-10/13
Pts from FM clinic
Pts from CHC’s

10. How did we develop data-driven care?
Choose and implement a highly functional EHR- 2 years
Build our own data team-1 year
Clean the data by changing practice work-flows-1 year
Standardize and continuously improve reporting structure- ongoing
Change our practices using data- starting

11. A new model of population health care is emerging
Primary care is no longer an appropriate name
Includes population health management without losing highly personal relationship-based care
Is interdisciplinary with integrated public health, specialty care, and mental health care
The new model adheres to well-established principles, enhanced by information and communication technology
Access, Continuity, Coordination, Comprehensiveness, Patient-centered and contextual
The new model is based on personal and team responsibility
The new model is rooted in the patient’s experience, not the medical office, and includes institutional care

12. Population Care Model: 2014
Institutional
care
Hospital Care
Emergency care
Nursing Home Care
Home
Care
Urgent
Care
Hospice
Care
Common Acute Problems
Common Chronic Problems
Common Behavior Problems
Coordination of Specialty care
Ambulatory care
Preventive Care