1. Bella Vista Medical Center Medical Home

2. Care Team  3 Physicians, 3 Advanced Practitioners  Case Manager  Care Team Coordinator  Chaplain  Clinical Pharmacist, Diabetes Educator  Clinical coworkers – RN, LPN, MA, Lab, X-ray  Nonclinical coworkers  Management  Patient Advisory Board 2

3. Advantage of the team approach The team allows us to meet the demands of a varying patient population. The strengths and skills of the team members blend, overlap and complement each other as parts of a whole.

4. Care Team Coordinator  Medicare Annual Wellness Visits Prevention, screenings  Patient registry  Epic superuser  Emmi/patient education coordinator  Telemedicine monitoring  Clinical expert “go to person”

5. Annual Wellness Visit  Scheduled in 2 parts – scripting for schedulers  Care Team Coordinator visit preventative, wellness, screenings referrals (i.e. polypharmacy, Emmi education) places orders per protocols  Reimbursed by Medicare for both visits  Provider visit – focus on medical issues

6. Case Manager  Case Management referrals - provider  Home visits  Telemedicine set up and monitoring  Problem solver – social/medical issues/barriers  Educator  Liaison with outside groups – OT,PT,Home Health, DME, etc.

7. Pastoral Services/Chaplain  Referrals to Pastoral Care - provider  Patients experience a higher level of wellness when spiritual, emotional care is the needed piece to complete their total health  Coworkers become a more cohesive community with like goals and are uplifted and more loved and loving as a result  The burden of providing emotional and spiritual care is removed from the providers and taken over by someone educated in theological and clinic assessment and support

8. Investment in Coworker Team Staff Development with weekly meetings  Buy in to the team culture  Consistent education  Standard processes  Feedback from all areas on patient satisfaction  Problem solving  Attended by all coworkers and providers  Retreat, teambuilding

9. Investment in the Provider Team Two meetings a week – 1 with all providers, 1 with Dr Lee and Advanced Practitioners  Continuing medical education  Standard of workflow and documentation  Model for training – establish templates  Make it easy for Advanced Practitioners to do the right thing and hard to do the wrong thing  Support functioning at highest level of license

10. Communication  Weekly staff meetings  Weekly provider meetings  E newsletter  Patient Advisory Board  Transparency and openess

11. Growth Potential  Expand PharmD role Provider and coworker education Expanded patient visits Management of HTN, other protocols  Partnering with outside groups PCPS medication safety CMS pilot Grants/research  Satellite clinic/extended hours/new facility

12. New Bella Vista Multispecialty Clinic Anticipated Completion 2014