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Yakima Neighborhood Health Services
YNHS 2012• 5 sites -- 64,580 encounters• Health Coverage
• 33% uninsured• 53% Medicaid
• Ethnicity• 66% Hispanic
• Living in Poverty= 74%
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Yakima County Profile• Health Coverage
• 15% uninsured• 13% Medicaid
• Ethnicity• 40.8% Hispanic/Latino
• Living in Poverty = 16.1%
Southeast Community Center Central WA Comp Mental Health
Neighborhood Connections @Triumph Treatment Services
Homeless Resource Center- Partnership w/ Homeless Network
YNHS – Sunnyside Campus
Supportive Housing Programs – Private Landlords, YWCA, Triumph, Housing Authority
YNHS Satellites
5 years ago …
• Successfully passed 3 Joint Commission surveys• All reporting was EPM driven – diagnoses and
procedure codes• Diabetes Collaborative (PECS !)• Evidence Based clinical outcomes and population
management
• Health Care for the Homeless expanded “patient centered care” to include recuperative respite and housing
• EHR was fully implemented for medical services, but learning curve was still steep;
Journey to PCMH
• PCMH work group established -- COO, CMO, QI Coordinator and Medical Assistant Supervisors
• Goal -- showcase current integration and patient-centered care to obtain Level 3 Recognition. “Play on our Strengths”.
• MA’s “lead the horse to water” in DM templates and medication reconciliation (open the templates as part of patient intake).
• Strengthen EHR report-writing, and ability to know what matters.
5 years later…
• NCQA- Level 3 Recognized (2008 Standards) for 2 sites in June 2011.• Applying in June 2013 for 4 sites ((2011 Standards)• Open templates,• Sharing across programs— dental, behavioral health, outreach, public
health• allergy lists, medication lists, histories, chronic problems, vitals
• QI Projects: Meaningful Use, Immunization Rates, Cervical Cancer Screening
• No noticeable changes in overall patient satisfaction ratings. New questions added related to self-management support and safety practices with high ratings received. (4.86 and 4.96, respectively, out of 5)
• Staff satisfaction higher than average CHC’s (Staff Pulse)• 68 % of medical/dental patients leave with an individualized Patient
Plan
MA Vitals Report
SSRS report that allows us to monitor completion of vitals by medical assistants.
Pre-visit Summary
Our “virtual” huddle – automatically emailed to provider and team for next day’s appointments.
Challenges & Obstacles We’ve Overcome
Challenges• Balance between
population management and individual care
(resources)• Creating maximum
access AND connection to one PCP
Lessons Learned• Providers will use the
template if it is there for them
• A team approach to care is better for the patient and better for the team