1. Chronic Disease and Health Maintenance Registries
Clinical Workflow
October 2015

2. Ochsner Quadruple Aim

3. Population Healthcare has arrived So, what is it?
“Today we are primarily in the business of delivering care one patient at a time. By contrast, a population health practitioner is concerned with achieving healthy outcomes for an entire population.”
-Steven Lefar, Sg2 President and CEO

4. Evolution of Primary Care at Ochsner

5. Registries and Pre-Visit workflows
How do we do it?
Registries and
Pre-Visit workflows

6. Population Health: Care TOuch
Identify
Care Gaps
Patient
Pre Visit Work
Visit Work
Population Work
Orders can be placed using the
Primary Care
Written Order Guidelines (WOG)
Registry work –place bulk orders and
patient notifications
Close care gaps

7. Ochsner LPN CCC Model Ochsner LPN CCC PCP Teams 1:8 Care Gap Closure
Insurer Care Coordinators + Registry Input
Ochsner LPN CCC
PCP Teams
1:8
Care Gap Closure
Registry
HEDIS
Health Screening
Care Gaps
PHN
Humana
BCBS
Written Order Guidelines and Bulk Ordering

8. Pre Visit Work Staff Physician WHO: LPN Care Coordinator WHAT:
Check registry for care gaps
Check Health Maintenance for screening gaps
Place orders (using WOG) pre lab or same day
WHEN:
2 weeks prior to patient visit
WHAT:
Sign orders placed
Return results coming back from pre-visit lab work

9. Visit Work Staff Physician WHO: Practice MA/LPN WHAT:
Check registry and Health Maintenance
Place any needed orders (using WOG)
Encourage patient to complete gaps
WHEN: day of visit
WHAT:
Encourage patient to close care gaps
Look for pre visit results - return results

10. Population (Panel) Work
Staff
Physician
WHO:
LPN Clinical Care Coordinator
WHAT:
Run registry gap reports for assigned physician practices
Place bulk (pend) orders (using WOG)
Notify patients
WHEN: 1st week of each month
WHAT:
Sign bulk orders
Return results

11. W O G
Physician signature
PCP attribution
LPN CCC
Registry
Care Gaps
Bulk orders
Care Touch
outreach
My Ochnser
letter
phone
Result to PCP
Lab draw

12. PCP determines management
Result to PCP
Normal
PCP determines management
Abnormal
See diabetes resource guides
Significant
PCP or APP visit
Pop Med Clinic referral
Not significant
Improved outcomes

13. Timing considerations
Diabetes Registry went live on April 1, 2015
Once orders are fulfilled the orders and gap disappear from the registry
Orders remain good for 1 year
Will recontact patients with open gaps quarterly
Patient Groups can be prioritized:
Humana Gold
MSSP (Medicare)
Employee Group
Blue Cross: Quality Blue Primary Care

14. Work in Progress
We are working with Registration on capturing the patient’s PCP in Epic
We are working with lab to create a walk up mechanism for several selected sites (other sites will need an appointment)
At this time bulk notifications will be sent as follows:
Portal Patients will be notified via the portal
Non-portal patients will be notified by phone or letter based on preference

15. Results to Date - September 2015
Registry
Enrollees
# pts with outreach
# pts responding to outreach
% pts responding to outreach
Diabetes
39,000
21,000
5064
24%
Tobacco
Hypertension
147,000
Mammography
108,000