01 section name goes here addressing population health within the patient-centered medical home...
TRANSCRIPT
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Addressing Population Health within the Patient-Centered
Medical Home (PCMH) Coco Lukas, MPH – Quality Coordinator Rick Reifenberg, MD – Associate Medical Director
Sheila Allen, MPH – Chief Compliance and Quality Officer
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HealthNet is a Federally Qualified Health Center (FQHC)
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Health Centers
School-Based Clinics
HIP Clinic/Shelters
HIP Housing Sites
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Providers• ~70 MD/DOs – IM/Peds, Peds, FP, ObGyn, Psych
• ~45 Advanced Practice Nurses – Certified Nurse Midwives, Ped NP, FNP, Women's Health NP, Psych NP
Staff • 630 Full-Time Employees
HealthNet is a Federally Qualified Health Center (FQHC)
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Joint Commission Accredited for:
HealthNet is a Federally Qualified Health Center (FQHC)
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• Health Center
• Laboratory Services
• Patient Centered Medical Home (PCMH)
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Services Provided
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• Primary and Preventive Health Care
• Dental Services
• Behavioral Health Care
• Homeless Programs
• Support Services (e.g., WIC, social work)
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2014 By the Numbers
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• 59,286 patients
‒ Serves 20% of all Hoosiers covered by Federally Qualified Health Centers
• 263,167 family visits
‒ More outpatient visits than Riley Hospital for Children, which serves patients statewide
• 3,748 women obtained prenatal care
• 2,216 OB deliveries
• 3,092 homeless clients served
• 7,857 patients received dental care
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Payor Mix
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Patient-Centered Medical Home
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Patient-Centered Medical Home
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1. Pre-visit identification and scheduling
2. During patient care visits
3. Post-visit reporting
Population Health Implementation in 3 Phases
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• PHASE 1: Identification and scheduling
Population Health Implementation in 3 Phases
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‒ Reports to identify children due for well child care and those with chronic diseases (diabetes, asthma) that were overdue for visits.
‒ Data used to schedule patients during week and also on special Saturday Clinics.
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The report is emailed monthly to clinic managers. The patients have had the majority of their WCC at that clinic. Patients who are in the system who haven’t had a WCC go to ALL clinic managers
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• PHASE 2: During patient care visits
Population Health Implementation in 3 Phases
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‒ Templates
‒ Standing Orders
‒ Flowsheets
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• Well child assessment, nutrition/exercise counseling, and billing codes
• Mandatory question on pediatric templates re: vaccine status
• Required age-specific standard templates that include tobacco use and referral questions
• Asthma and Diabetes templates
• Nurse visits (e.g. Depo-Provera) with billing
Templates
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Templates
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• Standardized nursing based Standing Orders that mirrored new EHR work flows put in place HealthNet-wide.
• Staff are able to enter labs and vaccines on office visits prior to the Provider seeing the patient.
• Depression (PHQ2, PHQ9) and Anxiety (GAD7) done automatically when patient checks in.
Standing Orders
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Standing Orders
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Standing Orders
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• Helpful for documenting Cancer Screening (Colon and Cervical).
• Diabetic Flow Sheet tracks LDL and
Aspirin use.
• Health Maintenance Flow Sheet tracks
Cancer Screening and Aspirin use.
Flow Sheets
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Flow Sheets
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• PHASE 3: Post-visit reporting
Population Health Implementation in 3 Phases
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‒ Gathering and Reviewing the Data from the Outcomes from Phase 1 and 2 as noted on the prior slides.
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Pediatric Measures
• Well Child Checks 0-15 months
• Well Child Checks 3-6 years
• Adolescent Well Care 12-21 years
• Weight Assessment and Counseling
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Well Child Checks
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Weight Assessment and Counseling – Peds
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OB Measures
• First Trimester Entry
• Low Birth Weight Deliveries
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First Trimester Entry - OB
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Low Birth Weight Deliveries
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Adult and Chronic Disease Measures
• Weight Screening and Follow Up
• Tobacco Assessment and Counseling
• Asthma Pharmacologic Therapy
• Hypertension – Blood Pressure Control
• Diabetes – A1c Control
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Weight Screening and Follow-Up – Adults
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Adult Tobacco Assessment and Counseling
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Asthma Pharmacologic Therapy
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Hypertension Blood Pressure Control
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Diabetes A1c Control
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Questions?
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Contact Information
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Coco Lukas, MPH Quality Coordinator [email protected]
Rick Reifenberg, MDAssociate Medical Director [email protected]
Sheila Allen, MPH Chief Compliance and Quality Officer [email protected]