Suzanne (Sue) Hanna, RN, BSN, CHC Shenandoah Physicians Clinic Medical Home and Patient Care Coordinator

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1 Suzanne (Sue) Hanna, RN, BSN, CHC Shenandoah Physicians Clinic Medical Home and Patient Care Coordinator 10 PCPs 8Physicians 2 ARNP 2 OB/GYN Physicians & 1 ARNP 1 ARNP Mental and Behavior Health Provider 2 ARNPs Walk-In Clinic, Shenandoah 1 ARNP Walk-In Clinic, Sidney (also a PCP) 20+ Specialty Physicians 1

2 March, 2015 we saw 3,832 patients Daily average is around 150 Varies greatly with number of specialty providers at the clinic that particular day Surgeon who sees patients at our clinic Employed by the Shenandoah Medical Center March, 2015, surgeon saw 127 Community Health Needs Assessment Community Care Coordination Initiative Zip Codes County Health Rankings EDs and Walk-In Clinics Medicaid/Stratification Lists EHR Reports 2

3 Life Flight helicopter services Nurses in Shenandoah schools New fitness/wellness facilities Cancer Care / Kidney Dialysis Excellent surgeons / OBGYN Fitness trail / Health Fair Veteran Health Care New hospital facilities in Clarinda Low poverty level in area 3

4 More single-parent homes than state average Unemployment slightly higher than state norm Immunizations rank lower than state average High rate of pregnant women who smoke and low rate of breastfeeding Preventable hospital stays are higher than state norms Mental and behavioral health have shown a 3 year increase in services Health risk indicators (smoking, obesity, drinking, inadequate social support, physical inactivity, poor mental and physical health) show higher percentages than the norm Local Charity Care (bad debt no pay) has steadily increased Heart disease major cause of death Mammogram screening rate is low in Fremont; Page county s rate higher Diabetic screening in on par 4

5 Received grant of $10,000 At beginning stages of forming our Community Care Team Several public health agencies on team Finding populations in need CHNA ranked immunization as a No. 7 concern At present this is a No. 1 concern with public health Instigated changes at the clinic Vaccine For Children form including change of address Large amount of return notifications to parents/guardians Making sure we give VFC immunizations when eligible children here for visit Attended CCC meeting in Mason City 2/20/15 Attended the CCC meeting at the Methodist Jennie Ed Hospital in Council Bluffs 3/10/15 One comment was that until this team got together, the hospital was not even aware that there was an actual public health office in Council Bluffs The CCC is making a huge impact in Finding Populations in Need 5

6 Should your zip code determine how long you live? Zip code better predictor of health than genetic code. /zip-code-better-predictor-of-health-thangenetic-code/ 6

7 Page County ranked 71 out of 99 Premature death 7,367 (5,200) Mental health providers 1,209:1 (386:1) Children in poverty 25% (16%) Teen births 43 (20) Drinking water violations 17% (0%) Access to exercise opportunities 79% (92%) ED and Walk-In Clinic patients Many ED and Walk-in Clinic patients use these facilities as their PCP Use this opportunity to educate the importance of a PCP and proper use of the ED Transitional Care Make an appt for the patient at the clinic to establish care prior to their leaving these areas Follow-up with phone reminder prior to their appt 7

8 Developing the PCMH Program--May, 2014 Ran data reports finding the vulnerable population Medicaid patients Stratification List from the State = 1,672 Our clinic count = 1, met criteria for the medical home (46.5%0) Waiver patients = = dual eligible (both Medicaid and Medicare) 458 = eligible (not duals or waivers) Laying the ground work for the PCMH Ran data reports on different diagnoses to find our main patient focus Elderly population in ours and surrounding communities Diabetes Mellitus I and II > 500 Obesity Tobacco abuse 8

9 Stratification List Listed diagnoses that are eligible for the PCMH, whether they had none, several, or all of them Diabetes Obesity Tobacco abuse Asthma Mental/Behavioral Health Hypertension Heart Disease (major cause of death in our county) Can enroll in the PCMH if they have two of these diagnoses Can enroll in the PCMH if they have one of these diagnoses and at risk for another one Such as obesity at present is not diabetic but has family history of diabetes 9

10 Biggest is we have three different EHRs servicing our organization One for the ED One for the clinic One for the hospital Only way to track vaccinations at present is through IRIS No Registries in EHR No notification of when visits, labs, x-rays, immunizations and other services are needed No notification when a patient has made an appointment Unable to track referrals via the EHR 10

11 Current clinic EHR is actually built to service approximately five to seven providers There are 13 providers on this system Fairly frequent down time Performs slow Trouble with interfacing Getting labs, radiology reports to transfer over from hospital system to the clinic system One provider describes it as a VW bug pulling a fully loaded semi-trailer GOOD NEWS is that we go live with our new EHR August 1 st and should solve many of our challenges, such as having registries, interfacing with IRIS, notifications 11

12 Made registry Excel spreadsheets developed using Standards of Care Diabetes Asthma General COPD/Emphysema PATIENT REGISTRY--DM NAME D.O.B. DX: Risk Albumin Creatinine Micro Flu Pneumo Smoking Foot Retinal Factor Creat/ratio Urine Albumin Vac Vac Status Exam Exam Date Physician HT. WT. BMI BP A1c Choles LDL 12

13 PATIENT REGISTRY--ASTHMA NAME D.O.B. DX: Asthma Asthma Action Quit Exercise Oxygen Pneumo Control Plan in EMR Spirometry Smoking Smoking Pulm Use Vac Test 4 11yrs Adults or Peds Q 24 mos. Status Plan Rehab Date Physician HT. WT. BMI BP O2 Sat Flu Vac ABGs PFTs > 8 yrs PATIENT REGISTRY GENERAL NAME D.O.B. DX: Pneumo Oxygen Smoking Date Physician HT. WT. BMI BP O2 Sat CXR Flu Vac Vac Use Status 13

14 PATIENT REGISTRY--COPD/EMPHYSEMA NAME D.O.B. DX: Quit Exercise Pneumo Oxygen Smoking Smoking Pulm Vac Use Status Plan PFTs Rehab Date Physician HT. WT. BMI BP O2 Sat CXR Flu Vac ABGs Insert the patient s last six or seven visits Insert past testing/visits often have to check all three EHRs Lab work Radiology Vaccinations (only in IRIS) Respiratory Therapy testing Dietary visits PT/OT reports ER visits Specialty physician visits Add any column that you feel is pertinent 14

15 The day before the next business day, check all patients who have appointments (time consuming) Update registries of all in the PCMH Had lab work or any other testing? Are they due for lab work, mammo, etc. Any additional vaccinations since last seen? ER visit? Is ER report in clinic EHR? Specialty physician visit? Is clinic note in EHR? Any med changes from visits? No current way to track office visit notes/reports from specialty referrals Once referral is made, often times this is where it can fall through the cracks Some referral reports are scanned into current clinic EHR and others scanned into our hospital s EHR 15

16 Nov 14 A B C D E F G H I J K L M N O 1 Referral Tracking Sheet Notes/ Comment STAT Specialist Medical Pt KEPT Date s Appt 2 Urgent Date Pt Left Msg to Records appt Yes / Provider document No show: Referral Routine Appt Date notified of to Call schedule Provided No notified of scanned Call made Last name First name Provider made to: Diagnosis (S U R) & Time Appt back Y / N Y / N comment Results into chart to pt Lab results especially those that are sent out and done at an outside lab Reports from other departments, such as dietary consults and PT/OT reports Sleep studies, PFTs, EEGs, EMG studies (these tests/reports take longer at our clinic) 16

17 Downloaded the Referral Tracker on the everyone file Each provider/nurse has one for their own practice Necessary as sometimes other nurses fill in for different providers due to vacations/illness. Must make it a daily/weekly ritual to check the Referral Tracker Need to develop a plan for alerting the medical home coordinator that a member has made a same day appointment/cancelled appointment Each scheduler would have to know who s in the medical home Some type of alert for the schedulers Schedulers would have to message the PCMH coordinator 17

18 Questions and Comments 18

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