1. MAKING CCOS WORK: LEVERAGING PATIENT-CENTERED PRIMARY CARE HOMES Dr. Elizabeth Powers Winding Waters Clinic Enterprise, Oregon Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County.

3. What do we do differently as a PCPCH? Proactive (vs. Reactive) Team-Based Care Chart Scrubs Daily Huddle Chronic Care Model – ACTIVE management of ongoing conditions. Outreach for Preventive Care Patient Education Shared Decision Making (utilizing decision aids) Community Outreach: Marketing and Patient Education regarding PCPCH/Access Diabetes and Asthma Education Living Well with Chronic Conditions (Stanford Curriculum) Patient Engagement via Patient Advisory Council Staff Engagement via QI Committee and Project Champions

4. PCPCH – How to get there: Lay the foundation Engaged Leadership Quality Improvement Strategy Build Relationships Empanelment Continuous, Team-Based Healing Relationships Change Care Delivery Patient-Centered Interactions Organized, Evidence-Based Care Reduce Barriers to Care Enhanced Access Care Coordination

5. PCPCH – Care Coordination: Goals: Keep our patients as healthy as possible. Get them involved in making decisions regarding their own health. Help them utilize the services offered throughout the community. How we make this happen: Build Trust Care Touches over Time Community Linkages

7. Creating non-traditional alliances and community linkages: Wallowa County Network of Care: Our Vision: 100% ACCESS, 0% DISPARITY Our Mission: Better Health and Better Living… …Through Community Collaboration and Education Our Values: Communication, Collaboration, and Creativity Initial goals: Develop an integrated network that includes ALL community providers. Provide access for ALL clients to ALL services when they walk through the door of any WCNC location.

8. PCPCH – Enhanced Access Access Improvements in 2010: Open access scheduling Walk-in urgent care Expanded hours Care teams 24 hour telephone access to MD On-line access to care team (patient portal)

9. Winding Waters Clinic Annual Outpatient Visits ER Visits for Wallowa County Winding Waters Clinic Annual Inpatient Visits Ongoing trend of decreasing ER visits. Shift to increased number of Outpatient Visits 12 months after EHR adoption (median of 901). Improved WWC access

10. ER/Readmissions Data Dont have any before data. 410 visits to ER/hospital in 6 months 23 pts (5.6%) with more than 2 ER visits/hosp. admissions 6 with psychiatric comorbidity 5 with substance abuse comorbidity 3 deceased (end of life) 11 >65, 7 >80 # Repeat ER visits since tracking – 7 (Same patient, same issue) # Hospital readmissions since tracking – 3 (Same patient, same issue, within 6 months)

13. Barriers to PCPCH transformation Knowledge Time Culture Change Financial Resources Staff Shortages

14. What do we need from a CCO to continue as a highly functioning PCPCH? Reliable Payment Structure PMPM Payments (stratified based on PCPCH functionality) Additional payments for quality outcomes. Data Standardization Standard Monthly Scorecard with Universal Benchmarks Community-Specific Scorecard Based on local QI Projects

15. What do we need from a CCO continued… Technical Assistance Quality Improvement Training Team Training starting with Communication Skills: motivational interviewing, Team STEPPS, etc. Educational Assistance Financial support for community education. Outside resources to train local people (ex. Living Well Classes). Ongoing training for behavioral health specialists and community health workers. Survey Assistance Cover cost of CAHPS survey. Work with communities to measure patient and care team engagement.

16. We are proud to be a PATIENT CENTERED Primary Care Home! In our little corner of Oregon, we are taking it one patient at a time and we are positively impacting those patients lives. We cant yet prove that our impact is community-wide, but we are improving patient engagement and education. The only way we can stem the tide of health care spending AND improve the health of our communities is to be champions for all patients, one patient at a time. HOWEVER, we cant keep doing this work without a system that supports us. If we build the system around what each patient needs, we will move in the right direction. We need a liaison present as part of our care team and network to gain an understanding of our community, our practice, and most importantly, our patients.

17. A Transformative Innovation for CCOs: Practice Enhancement Coordinator: Like a member of a CCT from the insurance company! Know and understand each community. Know the individual practices within each community. Help practices move along the continuum of PCPCH. Ensure that CCO policies support PCPCH success. Help build trust among providers in each community. Focus CCO attention and resources on key areas to truly improve community health.

18. Winding Waters Clinic Elizabeth Powers, MD – Managing Partner drpowers@windingwatersclinic.org Keli Christman – Practice Administrator keli@windingwatersclinic.org Wallowa Valley Network of Care Chantay Jet – Secretary chantay.jett@gobhi.net Alder Slope Family Medicine Alpine Chiropractic Board of County Commissioners Building Healthy Families Community Connections Department of Public Health Olive Branch Family Health Inc. Olive Branch Pharmacy Safeway Pharmacy Wallowa Memorial Hospital Wallowa Mountain Acupuncture Wallowa Mountain Medical Wallowa Valley Center for Wellness Winding Waters Clinic Windspirit Medicine