1. Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013

2. SJGH Primary Care Clinics

5. Do  Implement disease registry and Provider specific reports  Restructured leadership for the task at hand  Implementation team with weekly/biweekly Quality improvement meetings  Communication boards in clinics.  Dedicated meeting times for the whole clinic team.  Anticipate change fatigue/work arounds Don’t  Survey length to get best response.  Change/feedback cannot be delayed  Take on other new projects  Bite what you cannot chew and swallow  Forget to involve providers.  Create extra work for staff. PCMH Transformation Lessons Learned

6. PCMH Initiatives  Population management(i2i),Titration clinic  Clinic huddles  Quality Improvement PDSA meetings  Visit pre-planning  Standardized orders  Joint doctor / clinic staff meetings monthly  Advanced access.  Patient Experience review (Pext,CGCAHPS)

7. Community Medical Center - Channel

11. San Joaquin County Behavioral Health Older Adult Services (OAS)

13. Patient Success Story  Patient is 70-year-old female with Schizoaffective Disorder with Diabetes  Transferred to Older Adult Services in 2005 from Adult Services  Long history of Mental Health services, including State Hospital admissions starting in her 20’s  More than twelve inpatient psychiatric admissions since 1992  Psychiatric inpatient admissions usually involved medication noncompliance  Physical health issues resulted in 5 hospitalizations prior to Sept. 2012  Unstable living situations, including Crisis Residential and evictions from several board and care facilities  First Health Home visit was 9/19/12 o No hospitalizations of any kind since that date o Significant improvement in medication compliance o Client told us she wants us to be proud of her… o Regular follow-up with Primary Care Physician o Stable housing—client lives independently in an apartment o Vision exam scheduled o Routine Health Home lab work revealed undiagnosed UTI and under diagnosed thyroid condition o Client comes in regularly to OAS for fingersticks o Client and significant other appear happy and content o Client eager to continue Health Home despite change in medical providers So this lady’s story deserves a song… “Come and Listen to a Story ‘Bout a Gal Named Sal”

14. Patient Centered Medical Home (PCMH) Cost Report

15. SJGH-HPSJ Emergency Room Costs

16. SJGH-HPSJ Inpatient Costs

17. SJGH-HPSJ Medication Costs

18. CMC-HPSJ Emergency Room Costs

19. CMC-HPSJ Inpatient Costs

20. CMC-HPSJ Medication Costs

21. HPSJ, CMC, SJGH Overall PCMH Costs