1. Mary Blankson DNP, APRN, FNP-C Chief Nursing Officer

2. Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities. CHC Inc. Profile: Founding Year - 1972 Primary Care Hubs – 13 ; 218 sites Organization Staff – 650; active patients: 130k Disciplines: Medical, Behavioral Health, Dental Specialties: CDE, Nutritionist, Podiatry, Chiropractic Care Specialty access by eConsults Top Chronic Diseases Cardiovascular DiseaseObesity/Overweight DiabetesChronic Pain AsthmaDepression

3. Three Foundational Pillars Clinical Excellence Research & Development Training the Next Generation Elements of Model Integrated primary care teams/pods Integrated medical, dental, BH EMR PCMH Level 3 TJC Patient Home School Based Health Centers across CT “Wherever You Are” HCH program Innovations Postgraduate Training Programs Weitzman Institute Project ECHO –CT (pain, opioid addiction, QI) Specialty access by eConsults

5. Facilities and Physical Model Interdisciplinary Pods that Promote Team-Based Care Open office structure Collaboration throughout the workday

6. Exam rooms and therapy rooms Reducing stigma of seeing other disciplines Seamless transition between Disciplines 05/14/20146 Facilities: One Corridor Care

7. What does an Integrated Record Look Like?

8. 00/00/008 Data Driven: the Right Data at the Right Time EHR ETL Process Data Warehouse Structured Data Pulls Dashboards Scorecards

9. Additional on-site specialties  Nutrition  Diabetes education  Chiropractic  Podiatry  Retinal screening Care that is Comprehensive: IPCP Team PATIENT MedicalBHNursing Pharmacy PrenatalDental

10. 4 Clinical Chief positions:  Chief Medical Officer  Chief Nursing Officer  Chief of Behavioral Health  Chief Dental Officer Leadership Support  Executive Mentoring  Interdisciplinary Chief Meetings  Leadership Meetings Collaboration/Integration among departments  QI Projects/Microsystem work  Clinical Initiatives/Policies MU2/PCMH/UDS Interdisciplinary Leadership

11. Onsite Clinical Directors  OSMD  Nursing Managers  OSBHD  OSDD Collaboration/Integration among departments  Integrated Microsystems  Integrated Care Meetings  Clinical/Pod “Huddles” Leadership Support  Leadership Skills Training  Leadership Meetings Interdisciplinary Leading

13. Interdisciplinary Care “Every CHC Patient has Team!”

14. 00/00/00 Interdisciplinary Care Initiatives

15. Figure 1. Diabetes Dashboard by Provider

16. Team-Based Care: Tele-Ophthalmology Rooms Patient Collects Vitals Captures Images MA Diabetes Education Self-Management Goal Setting Nurse Reviews Images Sends Diagnosis & Recommendations Electronically Specialist Sends results to PCP through EHR Sets Recall for Future Visit AmeriCorps Member Reviews Results Creates a Referral when needed PCP

17.  Collaboration/Integration among departments  Training/Competencies  Program Oversight  Developing Standing Orders  Chair of the Pharmacy & Therapeutics Committee  MU2 Implementation  PCMH, UDS Reporting & TJC  MA/RN recruitment  Nursing Informatics  Promotion of Research & Translation  Mentor/Coach to the Nurse Managers  Relationships with Professional Schools Leadership for RNs and MAs: The Role of the CNO in Team-Based Care

18. POD design  2 Medical Providers  1 Registered Nurse  2 Medical Assistants  1 Behavioral Health Clinician  Additional members: podiatrist, dietician, Pharm-D, chiropractor, CDE  Student/Trainees The Interdisciplinary Team

19. Essential member of the primary care team and interprofessional activities (1) RN supports (2) primary care providers/panels Key functional activities:  Patient education and treatment within provider visits  Independent Nurse Visits under standing orders  Delegated provider follow up visits using order sets  Self management goal setting and care management  Complex Care Management; coordination and planning  Telephonic Advice and Triage via dedicated triage line  Quality improvement leaders, coaches, and participants  Leaders and participants in research  Clinical mentoring of RN students; Supervision and mentoring of Medical Assistants Domains of RN Nursing Practice at CHC, Inc.

20.  Uncomplicated UTI  Vulvovaginal candidiasis  Comprehensive diabetes visit with retinal screening  Pupil dilation  Titration of basal insulin  Pedi & adult vaccines  TB DOT  Bronchodilator testing in spirometry  Tobacco cessation  Emergency contraception  Pregnancy testing  Orders for emergency situations Nursing Standing Orders

21. Independent Nursing Visits

22. Chronic Illness Care National Advisory Council on Nurse Education and Practice

23.  Competency Fairs  Leadership Conferences  Facilitation Training  Comprehensive didactics for Complex Care Management Transition Care Medication Reconciliation CHF DM Asthma COPD Psych MI/SMG Training

24.  4-day comprehensive didactics for Care Coordination  Transition Care, Medication Reconciliation, CHF, DM, Pediatric Asthma, COPD, Psych, Motivational Interviewing, Self Management Goal Setting  Supervision Case Reviews via videoconference  EHR Templates  Structured Intakes/Follow up  Nursing Informatics/Outcome Measures  Dashboards (Population Management)  Community Engagement  Open House  Data Sharing RN Complex Care Management

25. Reason for Complex Care Management

26. Consider Possible Data Sources

27. Customizing the Sort

28. Additional Actionable Data

29. Complex Care Management Scorecard 00/00/0029

30. Complex Care Management Scorecard 00/00/0030

31.  Planned Care  Delegated Ordering  Panel Management  Scanning/Faxing/handling of incoming faxes  Retinal Camera Operation  QI/Microsystem Participants Role of the Medical Assistant

32. Planned Care Dashboard

33. 11/1/201436.5%2/1/201541.5% 00/00/0033 PCD—Birth Cohort HCV Screening Added to the PCD Baseline Screening Rates Final Data Collection Completed New Screening Rate

34.  As initiatives/responsibilities are added, redefining ratios  Refining workflows with EHR limitations  Recruiting RNs with ambulatory care experience  Training to our model of care  Working toward full MA certification Challenges

35.  Additional standing orders  Improve data driven performance appraisals for MA/RN teams  Improve structured data entry for team members (Informatics) to better document the impact of various care team members  Increasing the use of automated workflows  Continue to enhance front-line involvement and leading in initiatives Future Directions

36. Contact Information National Advisory Council on Nurse Education and Practice Mary Blankson, DNP, APRN, FNP-C Chief Nursing Officer (860) 852-0851 office (860) 227-5432 cell Mary@chc1.com