1. Cultivating a Robust Primary Care Home Team

2. Team-Based Care 1.Who We Are, Early Steps and Successes 2.Developing Staff Buy-In 3.Work Streams and Barrier Analysis 4.Roles Definition Process 5.Our Team-Based Care Model and Roles 6.Next Steps

3. Who We Are Mosaic Medical is a 501(c)3 non-profit organization operating Federally-Qualified Health Centers since 2002. Our health centers are located in Prineville, Bend, and Madras, Oregon (and soon to be Redmond!).

4. Mission-Driven The mission of Mosaic is to improve the lives and health of individuals and families in the communities we serve. In 2011, Mosaic served over 14,000 patients. As from the beginning, each of our clinics offer high- quality, comprehensive, culturally competent primary care services, regardless of age, healthcare insurance coverage, language of origin or any other demographic characteristic.

5. Care: From volume driven to value driven

6. Early Steps Empanelment Empanelment process at Mosaic was developed – a cultural shift Significant education provided to all staff and patients regarding importance of continuity of care with one PCP Increased clinic access by adding a second evening clinic Electronic Medical Records Went live with Epic EMR Spring 2011 PCPCH Tier 3 Recognition All three Mosaic Sites Recognized as Tier 3 Fall 2011

7. PCMH Pilot Our Pilot Project 100 Medicaid patients with the HIGHEST medical bills in early 2010 Stay in regular contact with the patient ER Diversion by: Setting up standing orders, Nurse Visits, Care Coordination, Same-Day Access, Monthly planning meetings with ER Staff, Frequent Huddles with PCP, RNCC, ERCM, CHW, On-going connection with primary care team

8. A Success Story… A Rare Win-Win When the medical home program began, the goal was to reduce hospitalizations and emergency room visits by 5% By fall, 24% fewer emergency room visits & 20% fewer hospitalizations Reported in the Bulletin on 07-01-2011: Our program Decreased medical system costs by $621,000 PCMH Pilot Successes

9. Developing Staff Buy-In Initial PCPCH Meetings Monthly Site Meetings New Employee Orientation Huddle Boards Next Steps: Increasing Provider Participation

10. Clinical Improvement Teams Teams:Clinical Team – MA Focus Clinical Team – RN Focus Epic Workflows Team Members: 2 Providers 1 Clinic Medical Director 1-2 Medical Assistants 1 RN 1 Team Care Assistant PCPCH Specialist 2 Providers 1 Clinic Medical Director 1 MA 1-2 RN Care Coordinators 1 Team Care Assistant CHW & Referrals PRN PCPCH Specialist 2 Providers 1 Clinic Medical Director Epic Site Specialists Billing Manager IT Director Clinic Managers Nursing Supervisor PCPCH Specialist Tentative Topics: Huddles, Chart Scrubbing, Registries, Advanced Directives, After Visit Summary Transitions of Care, Care Plans, Referral Tracking, Pt Room Resources, Patient Self- Management Health Information Exchange, Test and Referral Tracking, MyChart, Implementing new facets of EPIC, Systematizing decisions made by other clinical groups

11. Barrier Analysis

12. Work Stream Analysis

13. Challenges Along the Way Leadership transition Remote locations Balancing patient care and meeting time Epic limitations

14. Defining Our Teams: Basic Model All team members operating at the top of their scope. Care Services, Education & Support also available to multiple teams.

15. Roles Definition Team-Based Planning Worksheet Full document available through Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials

16. Who Does What? ProvidersRegistered NursesClinical Support Staff Assess, diagnose and treat patients Prescribe, manage and reconcile medications Perform procedures Consult with specialists and facilities Lead the team(s) Lead the practices strategic QI plan Choose evidence based guidelines and establish standing orders Mentor, leader, role model Clinical advice expert Triage Interpret reports and plan for population management Planned care and group visit organizer and participant Care management, care coordination, patient education and self management support for high risk and complex patients Train and supervise team Assist with policies, guidelines, standing order development Mentor, leader, role model Patient flow Collect information and populate records Cue up orders, referrals Clinical list changes, RX refill requests Populate registry Planned care and group visit participant Care coordination Patient education and self- management support for less complex patients Use guidelines and standing orders to support evidence based care Source: Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials

17. Scheduler Operator Schedules patient appointments Screens symptom- based calls for urgency Routes to appropriate department

18. Education & Support Billing Front Desk Interpreting Health IT Patient Navigator Community Health Worker Referral Coordinator Medication Assistance Program

19. Community Health Worker Integrated in Clinic Care Team. Case management, home visits and support for high-need patients. Health promotion instructors. Staffing support for outreach events.

20. Referrals Coordinator: Processes and tracks all referrals. Coordinates authorized visits with patients and specialty offices. Maintains logs and tracking mechanisms. Medication Assistance Program Coordinator: Serves as liaison between pharmaceutical companies and the patient. Processes, tracks and dispenses all prescriptions ordered through pharmacy assistance programs.

21. Care Services Lab/phlebotomist RN Triage RN Lead Pharmacist (soon to come) Behavioral Health Mental Health

22. Mental Health Specialist Comprehensive Mental Health care. Individual/group counseling. Case management. Caseload consists of adults on OHP with a variety of mental health and alcohol/drug problems. Predominant focus is on solution-focused brief treatment, strengths based perspective, trauma therapy, group treatment, and case management responsibilities.

23. Longitudinal Care Plan Management RN Care Coordinator Team Care Assistant

24. RN Care Coordinator Education, coaching and follow-up to improve patients self-management skills. Manage a panel of complex patients Facilitates care coordination between others involved in the care of the patient, including the patient's primary care team, medical specialists, hospitals and health plans. Uses Motivational Interviewing techniques for education and health promotion.

25. Team Care Assistant Clinical and administrative support to optimize care coordination for the panel of patients assigned to the primary care team. Panel management Provider and patient support (including chart reviews, processing pharmacy refill requests, and assisting with patient messages) Assists with coordinating the patients care between other members of the care team.

26. Visit-Level Care Provider Medical Assistant

27. Patient-centered clinical support related to visit-level care. Facilitates the coordinated planning of office visits Initial rooming of patients during office visits (including medication reconciliation, risk factor review, and health maintenance review) Provider support Reviews with patient the plan of care and AVS Assists with follow-up as needed. In addition, the MA may also perform in-office testing and clinic services (phlebotomy, EKG, hearing and vision testing, etc.), preparation and maintenance of exam rooms, maintenance of patient records, and other tasks as requested by medical providers.

28. Next Steps Adoption of Clinical Guidelines and Standing Orders across sites Clinical Improvement Teams develop workflows Complex Care definitions Expanded Motivational Interviewing Training Continue to optimize Epic for team-based care coordination

29. Team-Based Care Feedback From the Staff My Diabetic patients HgA1Cs are quickly improving I am enjoying participating and being part of a team that is making a difference each day Although we are not 100% Patient-Centered – but once we have our teams 100% in place; we will be an amazing clinic. I feel important; my ideas about care and treatment plans can be shared with the provider and nurses. I go home on time feeling effective and fulfilled, having had the time to do a good job with each patient. From the Patients I love knowing the face of the nurse always helping me. None of my friends have their own health advocates---I have a lot of fighters for me. I am treated as an individual at Mosaic Medical. I dont just get medical care at Mosaic MedicalI get life care.