1. Clinical Redesign Approach Centric to the LPN Coordinated Care Model
Best Practice:
Clinical Redesign Approach Centric to the LPN Coordinated Care Model
Chad Braden, MD
AMD – Primary Care – Ochsner BR
October 22, 2015

2. CCC LPN Program - Overview
Began in Baton Rouge in Quarter
Expanded system wide to all of Primary Care in January 2015
Currently have 23 CCCs in place system wide – (ratio is about 1 CCC per 5-7 physicians)

3. CCC LPN Program - Goals #1 Goal is to close primary care gaps
Place bulk orders based on the diabetes registry (Hgb A1c, urine for microalbumin, lipid panel)
Call patients that have not been seen in a year to schedule an appointment
Pre-visit planning – look at patients that will be coming in next 2 weeks to close care gaps

4. CCC LPN Program - Goals Referrals to outpatient case management
Attend QBPC meetings on Fridays to address barriers with patients scheduled to see PCP in 2 weeks
Teach providers about the metrics – roll out just beginning
Meet with providers at least once every 2 weeks to review patient needs with scheduled appointments – align with HEDIS and STAR goals
Other registries to come: HTN, COPD, Wellness, Immunization

5. Healthy Planet - Goals Other registries to come: HTN COPD Wellness
in progress
COPD
role out spirometry to satellite clinics
Wellness
Immunization

6. Healthy Planet – Diabetes Registry Results
Baton Rouge
(~ inception through August 2015)
Total # of patients in registry:
Outreach: # pts who received a notification:
Total # of labs/tests completed:
Unique # pts that completed labs:
Avg # of labs/tests completed by patient:
Percent of patients reached out to that completed labs: 21%