2. NFP CARE TEAM PATIENT ADVOCATE New Roles, New Possibilities

3. Do you have what it takes to be a NFP Patient Advocate? We are looking for 6 people who: Can be an active member of the NFP CareTeam, supporting the providers and nurses with patient management and administrative tasks Can organize and utilize social services and linkages for patients and their families Is committed to improving: Access to Care Quality of Care Patient Outcomes

4. What does a Patient Advocate do?  Patient Advocates make sure patients are aware of and can access available services and are not lost to follow-up by eliminating the following barriers: Financial barriers (including uninsured and underinsured) Communication barriers (such as lack of understanding, language/cultural) Medical system barriers (fragmented medical system, missed appointments, lost results) Psychological barriers (such as fear and distrust) Other barriers (such as transportation and need for child care)

5. Philosophy Behind the Job  Increase access to care Identify changes needed to decrease barriers to care Enhance access to services and quality of care for all populations  Improve the quality of care Improve coordination of high-quality, compassionate care Increase patient satisfaction  Improve outcomes Increase retention and use of preventive care Increase positive outcomes in DM, HTN and other chronic diseases

6. New Roles, New Responsibilities  Meet the requirements of NCQA PCMH Accreditation, as well as other PCMH demonstration projects and pilots  Standardize responsibilities across all Patient Advocates  Co-locate Patient Advocates with Teams  Train Advocates and other staff on new roles  Monitor Job Performance

7. Standard Patient Advocate Duties  Coordination of Team Huddles  Form Preparation  Referral Assistance  Patient Engagement  Enabling Visits  Patient Resource Management  Partnering with MA, Nurse and Providers

8. Coordination of Team Huddles  Pull together team each morning to review day’s schedule  Provide input into areas where PA can be helpful  Be the Time Keeper—Ensure that huddle remains 15 minutes or less

9. Form Preparation  Prepare forms for provider signatures  These forms may include:  Disability  Work/school physical forms  Med certs—gas or electric  HEAP

10. Referral Assistance  Internal vs. External Referrals  Referral completion tracking  Obtaining specialist’s reports  Assist patient in obtaining appointments for referrals when complex or when patients face barriers.

11. Patient Engagement  Maintain patient/family engagement through proactive methods of communication:  Conducting reminder phone calls for well child checks, past due chronic disease management visits for diabetes and hypertension  Contacting patients that “no-show” for appointments.  Calling patients in advance of appointments with patient specific reminders (if needed): DM—bring glucometer numbers, meds, questions for provider HTN—meds, questions for provider  Follow-up calls to patients that have been hospitalized

12. Conducting Phone Calls  Monthly—reminder phone calls for WCC, DM & HTN (telephone encounter)  Daily—  calls to no-shows (use no-show tool),  hospitalized patients (telephone encounter),  review next day’s schedule for HTN and DM (add to appt. notes—PA DM Prep, PA HTN Prep)

13. Enabling Visits (face to face)  Provide enabling visits to patients of NFP. This involves:  Assessment of non-medical needs,  Linkage to internal or external resources,  Ongoing follow up to resolve issues and/or referral to appropriate level of care (whether behavioral or medical).

14. Patient Resource Management  Maintain a resource list to provide patients with the external resources they may need in relation to both medical and non-medical needs including: food, shelter, clothing, utilities, etc.  Utilize the online 211 tool  Share resources with each other, Alison will maintain database of resources.

15. Partner with the Care Team  Communicate, work together as a Team within the Care Team, the Provider office and within the Patient Advocate Department

16. Guidance  What can a Patient Advocate advise on?  Medical Advice vs. Orders

17. A question of EPIC proportions  Interim Notes-when patient is in the clinic, but is not part of the provider visit  Telephone Encounters—Patient Advocacy, Patient Education, reminder calls, med refills, patient messages  Office Visit/Addendums—patient advocacy is related to Provider visit, preferably document in visit note

18. You expect me to do all that?????

19. August 22 nd …..  Prepare forms  Conduct reminder phone calls for well child checks, past due chronic disease management visits for diabetes and hypertension and contacting patients that “no-show” for appointments, hospitalized patients.  Call patients in advance of visit with patient-specific reminders if necessary  Enabling Visits & Community Resource provision  Team Work  Weekly Meeting

20. And down the road…  Additional Training  Team Huddles  Referral Follow-up and processing  Additional Patient Engagement Activities  Additional Care Management Support Activities  Public program understanding

21. Questions and Open Discussion