Implementing Change in a Hospital Based Community Health Center
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1 Implementing Change in a Hospital Based Community Health Center March 5, 2010 Maxine Landers, M.B.A. Vice President, Clinical Services and Sue Cotey, R.N. Diabetes Educator
2 Clinical Services & Programming PRIMARY CARE SPECIALTY and SURGICAL SERVICES WOMEN S HEALTH and PEDIATRICS CHRONIC DISEASE CENTER Collaboration / Outreach / Education EMERGENCY DEPARTMENT SOCIAL SERVICES and NAVIGATION EDUCATION COMMUNITY and OUTREACH EXTERNAL PARTNERSHIPS PI / QUALITY Trauma Clinic EMS Outreach Medical Home Social Worker Benefit Bank Patient Navigators Financial Billing Registration Coding Training Programs - Endocrinology - Internal Medicine - General Surgery - Podiatry - Ophthalmology - Orthopedic School of Nursing Medical Assisting Quarterly Screenings Physician Speaker s Bureau Adopt-a-Class Boot Camp for Dads Stork s s Nest Mammogram Mondays Community Navigators Hyperbaric Program CWRU Dental School NEON WIC Free Clinic Competency Training Discharge Documentation Monthly Chart Audit Department PI Plans Accreditation Readiness
3 Community Health Center Population Demographics Ethnicity 4% Caucasian Median Income Primary Insurance 34% Medicare 96% African American 0% Hispanic $26,099 30% Medicaid 8% Commercial 0% Other/Not Reported 27% Self Pay
4 Community Health Center Patient Visits IM & Med Spec Surg & Surg Spec Total
5 2500 Community Health Center Ophthalmology, Podiatry & HBOT Visits Ophthalmology Podiatry Hyperbaric
6 Chronic Disease Services Cardiac Rehab CHF Coumadin Clinic Pre-Kidney Transplant Clinic Nephrology Diabetes Management
7 Lennon Diabetes Center Staffing Endocrinologist Diabetes Educators Program Coordinator Nurse Champions Programs Certified Diabetes Education Outreach and Screening Support Groups Nurse On-Call Patient Led Advocacy Community Partnerships Extended Care Facilities Community Centers Cleveland Sight Center Diabetes Assoc. of Greater Cleveland ADA
8 8000 Lennon Diabetes Center Patient Statistics Unique Patients OP Visits IP Discharges
9 Community Health Center Better Health Greater Cleveland Results Measure BMI 2008 Results 0% Retinal Exam 35% Micro Urine Albumin 62% HbA1C 51% Pneumovax 0%
10 Better Health Greater Cleveland Action Steps in Response to 2008 Results ADMINISTRATIVE SUPPORT RESIDENT MEETINGS & EDUCATION PHYSICIAN MEETINGS & COLLABORATION STAFF MEETINGS & RETRAINING
11 HURON HOSPITAL EMR IMPLEMENTATION ADOPTION EXPECTATIONS RESULTS IMPROVEMENT ELECTRONIC MEDICAL RECORD IMPACT OF EMR ON PROCESSES CHART AUDIT GO LIVE SEPTEMBER 2008 IP and OP INTEGRATION
12 Lennon Diabetes Center Action Steps in Response to 2008 Results INPATIENT MANAGEMENT Daily Review of Lab Results Glucose Control Hypoglycemic Episodes MEDICAL MANAGEMENT IP and OP Physician Rounding Daily Reminder Calls for Labs and Medication Adjustment EDUCATION Noon Conference Grand Rounds Department Meetings Physician Meetings QUALITY / PI Coordinated PI w / CHC Study Collaboration PATIENT EMPOWERMENT Diabetes Passport Education Focused on Taking Ownership STAFF ACCESSABILITY Problem Pager Expanded Roles
13 Community Health Center Response to 2008 Results ENHANCE EMR SNAPSHOT PRE-VISIT REVIEW in EMR DEVELOPED SCREENING PROTOCOL ACTION STEPS STAFF RETRAINING EMR CHART AUDITS MULTIPLE DEPARTMENT TEAMWORK
14 COMMUNITY HEALTH CENTER DIABETES PATIENT VISIT MODEL Review Previous Visit Notes, Orders, Labs, etc. to Determine if Patient Completed Items Ordered Yes No Confirm Appointment Tests Remain Incomplete Coaching Patient Completes Tests Reschedule Appointment
15 Community Health Center Better Health Greater Cleveland Results Measure Results Results BMI 0% 37% Retinal Exam 35% 40% Micro Urine Albumin 62% 86% HbA1C 51% 45% Pneumovax 0% 17%
16
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