Primary Care Practice supports in the Community Integrated Medical - PowerPoint PPT Presentation

Primary Care Practice supports in the Community Integrated Medical Home Niharika Khanna, MBBS, MD, DGO Associate Professor Family and Community Medicine University of Maryland School of Medicine Director Maryland Health Care Innovations Collaborative

Ackn knowled wledgeme gements nts • Department of Health and Mental Hygiene  Medicaid  Community Health Resources Commission – Initial Funder of the Maryland Learning Collaborative  Maryland Health Care Commission  DHMH Center for Chronic Disease Prevention  Howard County Local Health Improvement Coalition • Commercial Carriers – Aetna, CareFirst, CIGNA, Coventry, United Health Care, Maryland MCOs • Tricare • Plan Sponsors  State of Maryland Employee Health Plan  Federal Employee Health Program  Maryland Health Insurance Program • Maryland Learning Collaborative- Practice Transformation Leaders and Advisors  Dept of Family and Community Medicine , University of Maryland School of Medicine  University of Maryland School of Nursing  Johns Hopkins Community Physicians and Guided Care at Johns Hopkins • Health IT Adoption and Optimization – CRISPHEALTH • Pharmaceutical Sponsors Abbott   Teva Respiratory Novo Nodisk  • Outreach  Societies of Family Medicine, Pediatrics and Hospital Medicine, Maryland Chapter ACP, MedChi  Mid-Atlantic Business Group on Health  Merck & Co., Inc.  Pfizer Inc.  Sanofi-Aventis • Consultants  Remedy Health Care Consulting – Practice Transformation  IMPAQ International, LLC – Evaluation Consultant  NCQA – Recognition  Discern Consulting LLC – Payment Development  Social and Scientific Systems – Data Aggregation and Attribution 2

Patient Centered Medical Homes Reducing readmissions and improving care across settings IMPROVING CARE Within settings Between settings Across numerous settings, over time Within disciplines Among disciplines Across clinical and 3

Core tenets of the new model of care  Greater Access  Advanced access scheduling systems  Availability by email and phone  Coordination of care  Management of information  Secure patient portals  Working with structured data  Performance reporting and improvement  Health Information Technology optimization 4

Popul pulation ation Hea ealt lth h Improvement ment at at All All Levels els of Heal alth th Ne Need Slide Courtesy Howard County LHIC 5

Primary Care Team Structure Slide Courtesy AHRQ TeamSTEPPS 6

Change Concepts for Advanced Primary Care Patient Engaged Quality centered Leadership Improvement interactions Team based Care care Coordination

Hospital CCT determines identifies need high utilizers Notifies CCT Follows patient for 90 days PCMH Communication Patient visit Flagging practice - include CHW team in visit, as - Pre-visit planning, reviews -Identify patient as eligible for appropriate data, labs and ENS program -send visit summary to CHW - Determine patient plan of - Place flag in EMR team care

CCT determines need, Notifies CCT with communicates Practice referral, CHN with practice, & completes final sends care plan identifies determination of high utilizers patient’s program eligibility. Follows patient for ≈90 days Identify patients – All of the following: • 2 or more chronic conditions • 2 or more hospital admissions in 12 months • Howard County Resident Communication Flagging Patient visit PCMH - Pre-visit planning, reviews - Identify patient as eligible for - Include CCT at visit, as data, labs and ENS practice program appropriate - Determine patient plan of - Place flag in EMR -Send visit summary to CCT care

SHARED CARE PLAN Critica tical l in Linking nking Pa Patients, ents, CHW, , Clinical cal Team with h complement ntar ary y roles From Edwin Fisher,MD AAFP Together on Diabetes

Healthy Howard Community Care Team

Patient-Physician(Clinician) Partnership Supported by Community Health Workers Results in Patient Centered Care for the Patient

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