1. ECH Health Care Home

2. Why is Health Care Home important to Mayo?
The needs of the patient come first. The way we define and address our patient’s needs is changing.
We use a team approach, with all team members working to the full extent of their licensure.
We assess and address our patient’s needs beyond their chief complaint.
We address the needs of our patient population whether they are seeing us in the office or not.
We work more closely to coordinate care with the ED, hospital, care facilities and community partners.
Our goal is to provide the right care, at the right time, in the right location, with the right provider.
Don’t we do this already in Primary Care?
Sometimes, but we don’t accomplish these tasks consistently. When we are at work, with openings on our schedule, and our patients come in to see us, we do a decent job of this. When we are away, we don’t do this as well. When our patients aren’t in the office, we don’t do as well. When the office visit is focused on the acute complaint, we often don’t attend to their other health needs.
Why are we doing this now?
The traditional paradigm we use to care for our patients is unsustainable. We are responsible for ever increasing numbers of patients. Advances in medicine and public health have resulted in a much older and medically complex patient population. We are expected to effectively deliver a broad range of preventive and chronic care services to our patients who were not part of the traditional practice of medicine. A physician does not have time, resources or energy during a face-to-face office visit to accomplish this work. A new approach is needed.

3. The Adult Health Care Home Patient
Chronic issues expected to last a lifetime.
Medical equipment needed for daily living.
Receiving outside resources related to medical issues.
Patient/family unable to self-coordinate.
Two or more co-morbid conditions.

4. Health Care Home Team Patient Patient appointment Coordinators (PAC)
Clinical Assistants (CA)
Medical Secretary
Nurses: Triage, Care Teams
Transition Program
Social Workers & Discharge Planners
Provider
RN Care Manager/Care Coordinator
Language Department
review the role descriptions and the flow diagram

5. Who is the Health Care Home Team?
Communication with School District
Transition from
the Hospital
Subspecialty Consult
Patient and
Primary
Care Healthcare Team
Patient-Centered Care
Communication with Public Health Nurse
Transition to a Nursing Home

6. Patient Stories Patient-centered Care 81 year-old male
50 year-old female

7. Services Provided Coordinating Specialty appointments
Home advice for the home health agency
Acute calls from the family
Medication renewals
Follow up calls after hospitalization
Care Conference Coordination
Home Health Agency coordination
Arranged medical equipment
Language, literacy, & cultural adaptations

8. Lead Local Community Resources for Seniors with Disabilities
Olmsted Co. Public Health Services:
Long Term Care Consultation
Personal Care Assessments (PCA)
Case Management
Community Alternatives for Disabled Individuals (CADI)
Elderly Waiver
Workforce Center:
Counseling (Vocational Rehab. Specialist)
Training
Finding & Keeping a Job
Assistive Technology
Follow-up Services

9. Community Resources
Southeastern MN Center for Independent Living (Rochester SEMCIL):
Senior Companion Program
Disability Linkage Line ( )
Transition Service
Assistive Technology
Nursing Relocation
Independent Living Skills
Peer Mentor Services
Ramp Project & Accessibility Services

10. Community Resources Extended Employment Long Term Support
Ability Building Center (ABC)
Additional resources:
Senior Linkage Line:
United Way 211 ( )
Intercultural Mutual Assistance Association (IMAA):
Elder Network:
Rochester Senior Center:

11. Final Thoughts