Henry J. Austin Health Center Kemi Alli, M.D. Chief Medical Officer May 8, 2013

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1 Henry J. Austin Health Center Kemi Alli, M.D. Chief Medical Officer May 8, 2013

2 Henry J. Austin Health Center Presentation Outline 1. Henry J. Austin Health Center s Background 2. Building a Primary Care foundation 3. Questions

3 Henry J. Austin Health Center For over 43 years, Henry J. Austin has provided high quality, comprehensive primary health care services to our local community. We are the largest provider of ambulatory primary care services in the city and have been Joint Commission Accredited since 1999.

4 3 Locations

5 Services Adult Medicine Pediatrics Gynecology Dental Services Nutrition Laboratory on-site Pharmacy on-site Pediatric Asthma Management Mental/Behavioral Health Services Social Services Senior Health Promotion & Outreach Health Education Bilingual Services Transportation Translation HIV Counseling & Testing & Treatment Specialty Services: Eye Care and Podiatry

6 Patient Age Characteristics 2012

7 Income as Percent of Poverty Level per patient 2012

8 More Demographic Data % are Homeless 53% African American, 39% Caucasian 32% Latino

9 Primary Care Enhancement Initiative

10 New Beginnings and Primary Care Enhancement This is a 3 phase process, Primary Care Enhancement Initiative which began in April 2011 and has its foundation in the Triple Aim. Phase I Improve the patient s Access to Care Phase II Improve the patient s Healthcare Experience Phase III Improve patient health outcomes through Population Management

11 Building a Primary Care foundation

12 Advance Access Integrated Care Health Literacy Social Determinants Primary Care Medical Home (PCMH) Population Management (Chronic Disease Management) Technology based platforms Electronic Medical Record or Health Center Controlled Network

13 Advance Access Primary Care Medical Home (PCMH) Population Management (Chronic Disease Management) Technology based platforms Electronic Medical Record or Health Center Controlled Network

14 Electronic Medical Record (EMR) EMR is critical for the following : Panel Management Demand and Supply assessment Continuity measurement and accountability Quality and performance improvement work Population Management

15 Phase I Improve Access to Care This phase involves creating SAME DAY ACCESS for ALL of Henry J. Austin s patients. Patients get an appointment on the day they request an appointment. In September of 2010 the Third Next Available (TNA) or average wait for an appointment was 37 days. * For an established patient*!!

16 TNA for an Established Patient in 2012

17 Electronic Medical Records & Data April June Aug Oct. Dec Feb April June Series1 Linear (Series1)

18 Example of TEAM Continuity 100% 90% 80% 70% 60% 50% 40% 97% 90% 97% 91% 91% 90% 80% 90% N/A N/A 60% 50% 96% 100% 75% N/A 72% 35% Percent of Time Provider in Office Percent Patient Continuity with Provider

19 Health Center Controlled Network Data sharing and information exchange Enhanced use of community data for quality improvement Best practice for system use and system optimization Practice transformation and alignment with the health care landscape

20 Phase III Population Management Phase III will focus on improving the quality of care delivered at Henry J. Austin for our. Our aim is to improve patient outcomes and reduce disparities for of our patients, not just those that walk through our doors!

21 Phase III Population Management Population Management is one of the corner stones of the Triple Aim and it relies almost entirely on patient centered, team coordinated care. According to Berwick a precondition for the pursuit of the Triple Aim is having a system that acts differently assigning much more value and many more resources to monitoring and interception of early signs of deterioration.

22 Improved Health Outcomes

23 Continuity and Improved Health Outcomes

24 Improved Health Outcomes Clinical Measure HJA Calendar Year 2012 UDS Report Number of patients in each category (denominators) % SM 2012 Compared to HJA 2011 Cervical Cancer Screening (Pap testing) % 11% Immunization complete by 2nd BD % 8% Tobacco assessment recorded % 6% Tobacco users cessation counseling done % 5% Asthma medication therapy ordered % 3% Hypertension controlled at <140/ % 2% Adult BMI recorded & plan if needed % 7% Childhood BMI% recorded & counseling for activity and nutrition % 1% Diabetes controlled with HbA1c 9% or < % 10% Coronary Artery Disease treated (CAD) % 1st year- baseline Colorectal Screening completed % 1st year- baseline Ischemic Vascular Disease with Aspirin ordered (IVD) % 1st year- baseline

25 New Beginnings and Primary Care Enhancement The goal of this entire process is to create a MEDICAL HOME for ALL Henry J. Austin patients a patient centered multifaceted source of primary health care. It is based on a relationship between patient, family and their medical team, formed to improve the patient s care across a continuum of referrals and services.

26 Questions Thank You

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