2. Disclosure I, Michael Kaiser, MD, have no relationships with commercial interests to disclose. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

4. LSU Medical Home DIABETES CHF HIV KIDNEY DISEASE KIDNEY DISEASE CANCER ASTHMA THROMBOGENIC STATE CONTROL BLOOD PRESSURE CONTROL GLYCEMIC CONTROL LIPID CONTROL SMOKING CESSATION DIETEXERCISEWEIGHT CONTROL SCREENING

7. This is the diabetes “composite” control measure.

12. Our heart failure admission rates have been steadily falling

13. Although we just starting tracking this measure, the fraction of inpatient discharges with PC visits within 30 days has been increasing for some time.

36. This is the fraction of “ready to quit” smokers who select some sort of assistance.

38. This is median LOS (in minutes) for non- behavior health patients, discharged to home, with triage levels 4 & 5

40. These are our current medical home patient population estimates. The system-wide total is 134,181. These are likely rather conservative estimate.

41. Initial State – Analytic Assignment

42. Medical Home Correct Verified at Each Visit

43. First set of results from the new medical home patient perceptions instrument. Our most positive perceptions were on “friendly.” The least positive pertained to wait times in the clinic (i.e., time spent between arrival and seeing the doctor.)

44. Pelican Implementation Medicaid Managed Care Behavioral Health Managed Care Obama Care Value-Based Purchasing and hundreds of new measures and reporting requirements Budget Cuts

46. Numbers we serve – throughput Reduce delays in primary care Decrease utilization of ED for primary care and primary support

48. From EDMedical Home From InpatientMedical Home From Medical HomeSpecialty From SpecialtyMedical Home

50. Patient self-management skills Medication adherence Disease Education Goal setting and behavior change System navigation

51. Patient Our Vision Value Leader Our Mission Treat and Teach Our Values Information Information Innovation Innovation Improvement ImprovementIntegrity Tactics ResourcesTeachingResearchRevenue AccessQualitySafetySatisfactionService Foundational Elements Medical Home Integrated Info Systems Disease ManagementCenters of Excellence Performance Improvement Low Cost Distributed Services High Quality Excellence Excellence Equity Equity Execution Execution Explainable Explainable Empathetic LSU Hospitals --------------- Strategic Overview

54. Targeting In-person contact Access to timely information on hospital and ER admissions Close interaction between care coordinators and primary care physicians Patient assessment, planning, education, monitoring, and coaching with social support

57. CLIQ Documentation

63. Current Plan Currently we are planning to develop measures in the following domains: 1.Patient engagement 2.Access to primary care 3.Access to specialty care 4.Primary care efficiency 5.Wellness 6.Chronic disease management 7.Reduction of adverse events 8.Patient perceptions of MH experiences 9.Provider perceptions of MH experiences Our current medical home measures plan calls for measures in these 9 domains. The next five slides show five initial measures now being added to the site visit reports.

64. This is our ED visit rate per person-year for the total medical home patient population.

65. This is the median days to wait for a new patient appointment

66. This is the median days to wait for a non-follow- up appointment for established patients.

69. Medical Home: Satisfaction & Patient Perceptions We continue to use our patient satisfaction survey which assessed post-visit impressions of the recent visit. We have begun using a “medical home patient perceptions” survey. – Conducted in clinics prior to visits – Assesses perceptions among existing (not new) medical home patients – Summarized quarterly, based on surveys done one or two days per month by each MH clinic.

70. Medical Home Designation and Documentation CLIQ Summary Screen Update CLIQ Powered by: LSU HCSD Medical Informatics Team

71. Initial State – No Medical Home

72. Medical Home Fields Blank

73. Medical Home Fields Populated

74. Two Initial States

75. Documenting A Medical Home

76. CommCare Medical Home

77. LSU Medical Home

78. Non-LSU Medical Home

79. LSU Medical Home

84. Updating/Viewing Medical Home Data

85. Questions

92. Patient Our Vision Value Leader Our Mission Treat and Teach Our Values Information Information Innovation Innovation Improvement ImprovementIntegrity Tactics ResourcesTeachingResearchRevenue AccessQualitySafetySatisfactionService Foundational Elements Medical Home Integrated Info Systems Disease ManagementCenters of Excellence Performance Improvement Low Cost Distributed Services High Quality Excellence Excellence Equity Equity Execution Execution Explainable Explainable Empathetic LSU Hospitals --------------- Strategic Overview