1. 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care Prompt access to care Coordination of care Template of the future Building Blocks of High-Performing Primary Care The Share-the-Care TM Model

2. Level 3: 5% Complex healthcare needs Level 2: 80% Multiple chronic conditions: diabetes, HTN, COPD Level 1: 15% Uncomplicated chronic disease or risk factors: obesity, pre- diabetes Complex Care Management Team : RN, SW, Health Coach Primary Care Team: PCP, continuity NP, RN, MA, Clerk, Behaviorist Primary Care Team: PCP, continuity NP, RN, MA, Clerk, Behaviorist SF Partnership for Population-focused care SFCCC, CEPC, SFDPH, SFHP

3. Team memberRoles RN Care Manager  Initial assessment and Care Plan  Complex clinical issues and medication issues  Clinical back-up for Health Coach Medical Assistant Health Coach  Outreach to patients  Coaching toward care plan goals  Focus on self-management  Primary point of contact for patients Provider (Resident, attending, or NP)  Refer patients  Collaborate with CM team  Titrate medications, plan diagnostic work ups Coordinator  Manages referrals, data tracking, reporting Social Worker  Referrals to entitlements and community-based programs Physician CM lead  Program development and evaluation  Clinical back-up to team  Lead quality improvement GMC Care Management Team Roles

4. Year prior to enrollment in CM During CMPercent reduction Hospital days per year per patient 9.375.7539% ED Visits per year per patient 1.481.0231% Utilization data for patients in CM for > 6 months (n=27)

5. 2012 Colorectal Cancer Outreach Project Joint effort: SFDPH-PC, CEPC, SFHP Training: colon CA, registry, outreach skills. Outreach Work - off site, early evening. Mass mail out, phone banks CEPC: In Time training on registry use, scripts + role play talking to patients, coaching during phone banks 10 clinics, 35 staff – 4900 postcards mailed (4 languages), 6 phone bank sessions: 2400 calls, 1200 FIT tests done in outreach group Repeated in Sept 2012 Screening rate 10 participating clinics up 19% over baseline from 02/2012 to 11/2012 (at 54% 11/2012) Slide Courtesy of Lisa Golden, M.D.

6. 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care Prompt access to care Coordination of care Template of the future Building Blocks of High-Performing Primary Care The Share-the-Care TM Model