Patient-Centered Medical Home Transformation

www.hcgc.org

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

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

5% of patients

Typically have complex disease(s) and comorbidities

15-35% of patients

May have uncontrolled conditions and risk factors

60-80% of patients

Typically have minor conditions that are easily managed

High- Risk

Patients _____________

Rising-Risk Patients

______________

Low-Risk Patients

Source: The Advisory Board Company, 2013

CHF, DM, MI, COPD, PNEUMONIA

DM with A1c >9, DM Smokers, COPD

CAMPAIGNS using PATIENT PORTAL

Hospital Discharge

(Aetna MA, Humana MA, Anthem MA and MediGold only)

Home

Automatic referral to Care

Coordinator: CHF, DM, MI, COPD, or

PNEUMONIA

TCN will refer to Care Coordinator if TCN feels patient is

eligible with an explanation of

current concerns

SNF

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

• 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

Rising Risk & PCMH Initiative

Continuum of Care

Healthcare Transformation Learning Session December 5, 2014

Thank you for joining us today…

We need each of you to complete the brief evaluation and leave on your chair!

Happy Holidays!

Upcoming Regional Learning Sessions

Please save these dates from 8:30-11:30am: May 15, 2015

August 21, 2015

December 4, 2015