Patient-Centered Medical Home Transformation
Improving patient engagement by sharing provider notes Nationwide Children’s Hospital Aarti Chandawarkar, MD Cheryl Pippin, MD
Improving care coordination in patient-centered medical homes Central Ohio Primary Care Larry Blosser, MD, Medical Director Judy Minaudo, RN, Quality Improvement Manager
www.hcgc.org
Patient Centered Medical Home •One of the first 9 Medical Homes in the Columbus area
•Since 2013 all COPC primary care practices have received – 44 total Level 3 NCQA Patient Centered Medical Home accreditation
Medical Management through the Continuum of Care
CHF, DM, MI, COPD, PNEUMONIA
HighRisk Patients
5% of patients Typically have complex disease(s) and comorbidities
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DM with A1c >9, DM Smokers, COPD
Rising-Risk Patients
15-35% of patients
May have uncontrolled conditions and risk factors
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CAMPAIGNS using PATIENT PORTAL
Low-Risk Patients
Source: The Advisory Board Company, 2013
60-80% of patients Typically have minor conditions that are easily managed
Hospital Discharge (Aetna MA, Humana MA, Anthem MA and MediGold only)
Home
Automatic referral to Care Coordinator: CHF, DM, MI, COPD, or PNEUMONIA
SNF
TCN will refer to Care Coordinator if TCN feels patient is eligible with an explanation of current concerns
TCN will message PCP; TCN will message CC if currently enrolled
TCN will follow in SNF if FALL RISK, diagnosis of WEAKNESS or CHF, DM, MI, COPD, PNEUMONIA
Automatic referral to Care Coordinator at time of Discharge for above reasons
Care Coordination Roles
Assessment of Risk Factors
Help Patient with Setting Goals
Disease Education and Prevention
Assessment of Patient and Family Needs
Connection to Community Resources
Home Health & DME Referrals
Patient Centered Medical Home
• “PCMH is just a building permit to do Population Health Management” • - Bill Wulf, CEO
Rising Risk & PCMH Initiative • Provide long-term patient centered multidisciplinary team approach= PCMH techniques • Team consists of: – Physician Champion – Site Rep – Clinical lead
• Conditions: – Diabetes with A1c >9 – Diabetic Smokers – COPD for 2015
Continuum of Care
Healthcare Transformation Learning Session December 5, 2014
Upcoming Regional Learning Sessions
Thank you for joining us today… We need each of you to complete the brief evaluation and leave on your chair!
Please save these dates from 8:30-11:30am: May 15, 2015 August 21, 2015
Happy Holidays!
December 4, 2015