1. UPMC Matilda Theiss Health Center

2. UPMC hospital-based clinic  Only federally qualified health center within UPMC Serving a total of 1600 patients  ~30% are uninsured  ~60% are Medicare/Medicaid Offering full primary care services  Disease state management  Health education  OB/GYN services  Social, counseling, and health promotion services  Medication dispensing through on-site dispensary  Clinical pharmacy services Who We Are MTHC

3. Our Team UPMC MTHC Physicians, medical residents, social workers, pharmacists, nurses, administrators and front desk staff all work together as a team to improve our patients’ health

4. The Changing Landscape of Medicine In 2000 the WHO(World Health Organization) outlined changes that would transition medical care systems from pay for performance models to quality of care models The medical community in the United States responded by taking measures to advance idea the healthcare outcomes should measured in terms of quality and not quantity In 2007, response to the new WHO standards of care we began researching the new model of medicine

5. Becoming a Patient Centered Medical The Medical Home Model Utilizes 8 change concepts which have been identified as drivers of quality care. These concepts are the building blocks of the medical home model, but they can hard to visualize and even harder to implement. To assist our team with understanding and implementing each change concept, we enlisted the help of the Pittsburgh Regional Health Initiative. The change concepts are as follows: Engaged Leadership Enhanced Access Patient centered Interactions Care Coordination Organized, evidenced based care Empanelment Quality Improvement Strategy Continuous Team Based Healing Relationships

6. Enhanced Access In 2008 we surveyed are patients prior to initiating the Medical Home model at our Health Center Access to care was identified by our patients as the number one problem with healthcare at our facility In January of 2009 we began a modified open access scheduling system to meet the access need of our patients ~ Instead of appointments booked as far out as 90 days, appointments are booked in within 48 hours, and follow ups no longer than two weeks out.

7. Empanelment Not long after beginning Open access Scheduling, we discovered that Empaneling all our patient to one physician only would be key to moving forward with medical home Empanelment provided us with ability to form teams(Continuous Team Based Healing) around a physician's panel and it is a driver of (Care Coordination).

8. Engaged Leadership Patient care teams at Matilda Theiss consist of: Doctor/provider Nurse/Medical Assistant Front Office clerk Pharmacist/pharmacist resident Social Worker/social work intern or fellow

9. Patient Centered Interaction Patient PCPNurse Front Office Social/ pharmacy

10. Evidenced Based care and Quality Improvement Quality of care can be hard to measure, but not impossible. Internal quality measurements were put in place to help us collect data on how well we were doing We used data collection tools such as: ~PDSA cycles ~Patient satisfaction surveys ~Process Flow Charts ~Fish Bone Diagrams ~Toyota quality measures

11. NCQA Certification In June of 2013, after one year of planning and four years of transforming, Matilda Theiss Health Center received level 3 Medical Home Certification

12. What We’ve Accomplished Established leadership commitment  Culture of quality and safety  Partnership with the University of Pittsburgh School of Pharmacy Developed an integrated multi-professional care team  Physicians, medical residents, nurses, social workers, and pharmacists Established full time on-site clinical pharmacy services  Provided by pharmacy residents Established patient-centered Medical Home  Consistently engaging patients and families  Consistently providing culturally appropriate care

13. What We’re Tracking Diabetes Control  # of patients whose A1c is ≤ 9%  Monthly patient reviews in EPICCare LDL Control  # of patients whose LDL is ≤ 100 mg/dL  Monthly patient reviews in EPICCare Blood Pressure Control  # of patients whose blood pressure is ≤ 130/80  Monthly patient reviews in EPICCare Patient Safety  # of patients receiving CPS in previous month  Clinical Pharmacist Encounters Spreadsheet  # of adverse drug events potential, actual, prevented  ADE and Clinical Pharmacy Services Tracking Form

14. What We’re Working On Integrated care delivery and patient-centered care  Received Level 3 NCQA Medical Home Accreditation in June 2013 Patient engagement  Monthly diabetes group  Monthly calls to all PoF patients Diabetes, LDL, and blood pressure control  Implementing Diabetes Report Card and Goal Setting Worksheet Patient safety  Completion of Clinical Pharmacist Encounters Spreadsheet and ADE and Clinical Pharmacy Services Tracking Form for each patient encounter Sustainability  Maintenance of current CPS and expansion of services