1. Team Presentation Providing and Documenting Planned, Proactive and Comprehensive Care St. Vincent’s Family Medicine Residency Program, Jacksonville Learning Session 2 April 27-28, 2012

2. Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. Core Improvement Team John Waidner MD Helena Karnani MD Deidra Amendola DO Caroline Daniels LPN Bonnie Davila

5. St. Vincent’s Family Medicine Residency Program  Jacksonville, FL  30,000 Square Foot Family Medicine Center  3500-4000 Patient Visits Monthly, about 25- 30% of these are pediatric patients  30 Residents in training at any given time  10 Family Medicine Faculty, 2 Full time OB faculty and 1 Full Time Pediatrician

6. St. Vincent’s Family Medicine Residency Program: Unique Challenges  Trainees… lots of providers with different experience levels  Turnover… every year we lose 10 doctors and get 10 new ones!  Less time in clinic than typical private practice or outpatient clinic  Change is slower to occur, and harder to sustain in a larger organization

7. At the beginning… our initial AIM Statement

8. Initial AIM statement  By March 2012, The St. Vincent’s Family Medicine Residency Program will aim to improve our medical home by focusing on potential ways to improve our processes to provide family centered care.  We will achieve this aim by using the medical home tools and resources so that we: a) Indentify a primary care physician for 90% or more of all FMC patients b) Ensure that 90% of health maintenance visits are done by the assigned PCP and that 90% of ALL visits are done by either the PCP or a member of that PCP’s team c) Work on system level changes to: I. Ensure that follow up appointments are scheduled prior to the patient leaving the clinic II. Identify and promptly reschedule both No-show and parent cancelled appointments to ensure follow up needs of the child are met

12. New AIM Statement for the next cycle:  By October 2012 the Family Medicine Center at St. Vincent’s will accomplish the following 3 goals: Create disease databases for ADHD, Obesity and Asthma and begin to target these populations with disease specific education and interventions Increase parent partner involvement through the development of a larger parent partner group, with monthly information gathering Increase case management and distribute more meaningful care plans, particularly for our most medically needy patients through periodic case management sessions with local CMS nurses.

13. Connan Database Manager Actively developing disease databases for Asthma, ADHD and Obesity Diedra 3 rd Year Resident Developing community resources list with focus on Asthma, ADHD and Obesity resources

14. Parent Partner.. Our Initial Experience and Goals for the Future

15. Case Management and Care Plans -We are currently giving “Clinical Care Summaries” to patients at all visits -CMS nurses are currently giving our complex CMS patients Care Plans -Late February we had our first Case Management meeting with local CMS nursing…initial assessment was this was very productive… quarterly meetings planned for the most difficult cases -Jacksonville Partnership for Child Health: Kid’s N Care Program for Foster Children: Nurses come to office and develop “Comprehensive Behavioral Health Assessments” -Continued refinement of EMR based care plans

18. Questions/Comments/Ideas ?