1. Lower Lights Christian Health Center Columbus, Ohio A Faith based, Non Profit Community Health Center MISSION OF LLCHC LLCHC ministers the love of Christ as a model full service medical home, focused on whole person wellness, available to all in Central Ohio who need it regardless of ability to pay VISION STATEMENT LLCHC transforms the overall health of Central Ohio, serving one individual and family at a time

2. Facts Services 5 Sites 2 Counties 9,774 Users/Patients 45,000 Annual Visits 25% of Patients with a depression diagnosis receive counseling at LLCHC >70% of Patients at LLCHC have a Comorbid Mental Health or Substance Abuse diagnosis Primary Care Prenatal Care Behavioral Health Enabling Dental Vision Pharmacy Spiritual Care Nutrition

3. Peer Review Frequency We have 20 Medical Providers (~ 13.58 FTE’s) who all participate in Peer Review Currently, there are 4 types of reviews done (1 per month, 3 times per year) and a check on coding for billing purposes – General Review – Diabetes Patients – Hypertensive Patients – Patients with Hyperlipidemia Note: – Coding accuracy is added to one of the reviews above 2x per year – If you are just starting Peer Review, start with something basic and work into other areas that you want to focus on

4. Basis for Each Peer Review There are care guidelines documented for each Peer Review type The guidelines tie in to UDS measures where applicable Each Provider is looking at the patient’s encounters and documentation to ensure that we are meeting our guidelines for Diagnosis, Treatment Goals and Medical Management

5. Process Overview

6. Peer Review Preparation Each month Peer Review is prepared, monitored and tracked in our Quality Department by our Clinical Care Coordinator Our Medical Director reviews the peer review guidelines and questions periodically to make sure that we are covering the information that we think is most important In our monthly Provider meetings, our Medical Director reviews, with the staff, the guidelines and instructions for the Peer Review taking place that particular month

7. Peer Review Packets Each provider receives the following information each month in our Provider Meeting: – The Patient and Encounter numbers of up to 4 patients to review – A sheet with the care guidelines related to the type of Peer Review – Directions to complete that particular Peer Review – A scoring sheet with questions to be answered for each patient reviewed – Feedback/results from their previous month’s Peer Review – with comments from our Medical Director

8. Oversight Each month, Peer Review is reviewed in our CQI Meeting – We review the practice results over time from the peer review “type” that was just completed – If there are concerns about any results, they would be discussed in this group with the Medical Director and any additional actions would come from this meeting – The CQI meeting includes members of our Board of Directors as well as representatives from all areas of the Health Center – If there was determined to be a significant issue, it would go to the full Board of Directors

9. Additional Information Peer Review is mandatory in our facility – Providers cannot “opt out” - it is punitive if you do not participate Peer Review results are a part of the Provider’s annual review For FQHC’s, Peer Review needs to be monitored by your Medical Director and not only tied to performance but, to re- appointment to staff. This should be a documented process in your facility HRSA views Peer Review as a way of holding people accountable No peer review should be kept in patient charts or Provider files. It should be kept separate as Peer Review to keep it legally protected.

10. Future Plans for Peer Review We would like to use Peer Review as a form of process improvement and develop new reviews around UDS measures that would allow us to put an added focus on a particular measure

11. Questions??