Federally Qualified Health Centers in Cleveland NFP is one of 5 - PowerPoint PPT Presentation

Federally Qualified Health Centers in Cleveland  NFP is one of 5 FQHCs in Cleveland; 43 in Ohio

Neighborhood Family Practice  Founded in 1980  6 locations serving the near west side  Served 16,092 patients in 2014  Bilingual staff & providers  Integrated Primary Care and Behavioral Health  30 Medical & BH Providers on staff--9 Family Practice MDs, 10 Family Practice CNPs, 3 Certified Nurse Midwives, 1 Psychiatrist, 1CNS, 6 LISWs or LPCCs, 1 Psychologist  Focus on the medically underserved population

Neighborhood Family Practice - Facts  Recognized by NCQA as a Patient Centered Medical Home (PCMH)  Accredited by the Joint Commission  Focus on families  Growing midwifery program  Sole refugee provider for Cuyahoga County  30% of patients are Hispanics  Patients are able to access services on a sliding scale  Over 60% patients are on Medicaid  Uninsured rate has dropped from 23% + to 10% with the ACA and Medicaid expansion in Ohio through the work of our Patient Benefits Department

Neighborhood Family Practice  Primary Care  Behavioral Health  Midwifery  Refugee Clinic  School Based Health

Why Care Teams?  Working from NFP’s 2009 -2011 Strategic Plan, NFP identified the following areas to be addressed:  Implementation of EMR system in 2010  Improvement of patient’s health and safety  Improvement in NFP’s financial performance  Increased provider, staff and patient satisfaction  Becoming an NCQA Patient Centered Medical Home

Care Teams  A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

Care Team Composition  Two to Three Providers — combination of Family MDs, Family CNPs, and one Midwifery Team with 3 CNMs  Two RNs  One Patient Advocate  Medical Assistant for each Provider  Front Office representative at each team meeting  Behavioral Health representative at each team meeting

NFP Circles of Care Front Office Administrative Management Billing & & Executive PBS Leadership Providers, NFP IT CNMs & Patient Staff & Behavioral Medical Health Records Information Clinical Technology Nurses, MAs, Community OCHIN/ Contract Patient Agencies Epic IT Staff Advocates

Care Team Innovations  Enabling Providers to practice at highest scope. Professionals will work at the top of their licenses if:  They have people they can delegate to. At NFP this was done by increasing the skill set of:  Medical Assistants  Patient Advocates  There are effective communication methods  Ex: In-basket messages within the EMR to make clinical communication efficient  Fostering a Culture of Improvement and Change  Team trainings help decrease hierarchical systems (TEAMSTEPPS, Practice Coaching)  Team meetings for peer and cross professional feedback  Tracking and monitoring operational and clinical goals of the Health Center  Developing policies and procedures for EMR system and Care Teams at NFP  Developing new procedures around scheduling, registering patients & directing phone calls to teams

Staffing Innovations  Medical Assistants  Train Standard duties  Increase EPIC entry fields and consistency  Train to be proactive and anticipate provider needs, and increase assessment and documentation skills  Patient Advocates  Use of standing orders and protocols allow PAs to unload the provider and nursing workload and address health disparities  Use registries to identify gaps in healthcare  Identify high risk patients for case management by nurses  Increase patient’s access to the Care Teams by helping with patient communication and correspondence  Nursing Role  Redesigned nursing staff structure to provide individual nurses to care teams.  Work at the top of their license as a member of the Care Team

Support Services  Available In-Office Support includes:  On-site Behavioral Health  On-site Clinical Pharmacist  RNs provided by insurance companies  Wellness Coordinator  Medication Assistance Program

NFP Behavioral Health Services  NFP offers BH services to established patients  Psychotherapy, Psychiatry, Therapy with Children & Families  Services offered at all locations  Integrated approach —  Therapists are included as members of the primary care team  Therapists are steps away from the primary care providers and are available for warm and hot hand- offs  7,349 visits provided in 2014

NFP Midwifery Program  NFP's Certified Nurse Midwifery Program has been providing a unique birthing option on the near west side of Cleveland since 2006.  Prenatal care, education for the mother and family, nutrition education, and supportive, healthy births are all important components of the Midwifery Program.  CenteringPregnancy is a group model of care offered at NFP with excellent outcomes for participants.

NFP and the Refugee Population  Sole refugee screening provider in Cuyahoga County  Consists of two visits:  Health history, appropriate screening labs, immunizations  Complete physical exam  NFP is the only site in Ohio able to see (former) refugees for regular primary care after the screening process is complete (80% of which do return).  NFP welcomed approximately 700 refugees in 2014 alone

NFP School-Based Health  NFP began exploring school-based health in summer 2014 and initiated mobile van services at a local elementary school in February of 2015  Services offered  Immunizations  Urgent/sick visits  Sports physicals  Routine office visits  Medication management  Routine bloodwork  Follow-up care

What we are currently working on  LEAN/Six Sigma Efficiency Project  3 year partnership with GE in their Developing Health Program to seek solutions that can help the health center increase efficiency and standardization  Decreasing Wait Time  Integrated care at current sites and a new behavioral health agency  Working on a new partnership to offer primary care in a behavioral health agency setting  EMR optimization  Continuously examining the system and its utilization to drive improved workflows  Optimizing Care Management  Continuously examining the roles of MAs, Patient Advocates and Nurses to ensure that NFP is operating with the highest level of support to the provider  Patient engagement via the use of technology  Signing up patients for MyChart/educating them/testing tools such as p thx questionnaires and piloting MyPreventative care which provides health personalization and self management tools.  Collaboration and Partnerships in the community  Optimizing the Clinical Pharmacist & Wellness Coordinator Roles

What are we measuring ?  Clinical Outcomes  Chronic Disease Management — specifically measurements around DM and HTN control  Financial Performance  Patients per hour  No show rates  Patient Satisfaction  Efforts to decrease waiting time  Overall satisfaction with NFP and providers

Questions ???