By Debra Davidson, PhD, MSA, MS Luciane Tarter, RN, BSN. SBIRT grant for Behavioral Health APCP. Mo Health Net Health Home Program SBIRT

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "By Debra Davidson, PhD, MSA, MS Luciane Tarter, RN, BSN. SBIRT grant for Behavioral Health APCP. Mo Health Net Health Home Program SBIRT"

Transcription

1 By Debra Davidson, PhD, MSA, MS Luciane Tarter, RN, BSN 1 2 Team Based Care for Chronic Illness Our journey: 24 months APCP: Advanced Primary Care Practice Grant for Medicare : NCQA Level 3 by 2014 MoHealth Net Health Home Initiative: per member per month to develop team based care Learning Collaborative SBIRT grant for Behavioral Health Meaningful Use Grant SBIRT APCP Learning Collaborative Mo Health Net Health Home Program Meaningful Use Grant 3 1

2 Brief Historical Perspective Institute of Medicine (IOM) Report 1999: To Err is Human: Building a Safer Health Care System At least 44,000 people to as many as 98,000 die in hospitals as result of medical errors, that could have been prevented Variety of factors contributing to the errors, including decentralized and fragmented Health Care Delivery IOM conclusion: it is NOT acceptable for patients to be harmed by health care system that is supposed to offer healing and comfort, a system that promises to first do no harm! 4 Crossing the Quality Chasm 2001 IOM U.S. Health care delivery system does not provide consistent, high quality care to all people Many factors contribute: Rapid change in technology Growing complexity of healthcare (more to know, more to do, more to manage, more to watch) 5 Crossing the Quality Chasm Public Health care needs have changed: Americans living longer, aging population, increased incidence and prevalence of chronic conditions such as heart disease, diabetes, asthma Health Care is poorly organized to meet these challenges Today s Health Care system remains overly devoted to dealing with acute, episodic care needs! 6 2

3 Crossing the Quality Chasm: 10 Rules for Redesign 1. Care is based on continuous health relationships 2. Care is customized according to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is Evidence Based 6. Safety is a system property 7. Transparency is necessary 8. Needs are anticipated 9. Waste is decreased 10. Cooperation among clinicians is a priority 7 The Chronic Care Model by Dr. Ed Wagner MacColl Institute for Health Care Innovation (first published 1998) 8 Patient Centered Medical Home 9 3

4 PCMH Key Change Concept (Safety Net Medical Home Initiative) Engaged Leadership Quality Improvement Strategies Empanelment Continuous and Team Based Healing Relationships Organized Evidence Based Care Patient Centered Interactions Enhanced Access Care Coordination 10 National Committee of Quality Assurance NCQA Recognition NCQA Recognition required by MoHealth Net Health Home Initiative and APCP initiative for CMS Medicare Level 3 Recognition for 4 clinics: VERY ambitious 11 Journey to Team Based Care NCQA/PCMH Team: Medical Director, COO, PCMH Director, Care Coordinator, Clinic Managers, QI Director We hired team members according to MoHealth Net guidelines RN Care Managers Care Coordinator Behavioral Health Consultant PCMH Director Medical Assistant LPN Provider Patient Care Coordinator RN Care Manager BHC 12 4

5 Change Concept: Engaged Leadership Leaders facilitate transformation of care: chart the course for change Identify and allocate resources: time, dollars, staffing, equipment, technology, support to implement and sustain the changes! 13 Engaged leadership: keys for change Provide visible and sustained leadership to lead culture and change Ensure PCMH transformation has time and resources needed to be successful Ensure providers and care team members have protected time to conduct activities 14 Executive suite education Board Commitment of resources required Executive team: CEO, CFO, COO: all need to have a full understanding of comprehensive nature PCMH transformation: it is not a band aid approach See the BIG picture 15 5

6 Resources needed: Time, Money, Commitment (and plenty of pizza) QI committee met monthly before PCMH NCQA/Empanelment committee: met WEEKLY during the highest change period (just prior to all policies and processes must be in place for 90 days before NCQA application submitted), then monthly (for 2 full hours) Closed our largest clinic for 2 days to complete Care Team Training! 16 Quality Measures Monthly meeting with QI team: QI Coordinator, PCMH Director, Medical Director, COO, clinic managers, clinic i Health Home coordinator, IT nurse QI measures and PDSA change cycles are reviewed monthly in QI committee

7 Pilot project: Cassville Clinic Functional chaos Providers were not empanelled No Care Teams established Patients saw whoever they could get in with Episodic and reactive care 19 Cassville Trial: a 45 day trial Step 1 met with Executive Committee (leadership support is vital) Step 2 met with providers (stakeholders); off site, scheduled, safe Step 3 met with support staff, front desk staff Step 4 empanel patients (started with 46,889 patients) Step 5 let providers review panels (make changes as appropriate) Step 6 move staff to teams ; practice basics (lunches, PTO, role change ) Step 7 policies, check job descriptions, review resource allocation Step 8 review/alter upcoming month of appointments, train front desk on recall appointment scheduling Step 9 set start date start monitor evaluate Step 10 change what needs changed support (staff and leaders) praise ENCOURAGE LISTEN PRAY 20 Cassville Pilot was a huge success! 21 7

8 ALL Staff Education: Patient Centered Medical Gnomes 22 Educational needs of staff RN care managers: came from acute care hospitals Care Manager: new role for RNs Role strain! Need education, support, need to feel of value to the team. Chronic Disease Education Clinical Competency Development Job Descriptions/Roles on Teams (share teams) Self Management Education Care Plans (NCQA) templates in EHR Motivational Interviewing 23 Educational Needs of the Staff Behavioral Health Consultants New Role SBIRT Chronic Disease Short visits with behavioral focus Documentation templates Coding visits SBIRT Weight Management BHC Job Description and competency list Chronic Disease Education Tobacco Cessation 24 8

9 Educational needs of the staff LPNs: Coumadin management, chronic disease benchmarks class, standing orders, MAs: chronic disease benchmarks, standing orders Clinical competencies: LPNs and MAs are checked off on competencies for foot exams, all clinical skills, performing in house labs, helping patients set self management goals 25 PCMH: Organized and Evidence Based Care Medical Director and PCMH Director researched and wrote Evidenced Based Guidelines for 8 major chronic conditions (using National Standards) Presented monthly to Medical Providers for approval Placed computers and each clinic was provided with hard copy of guidelines and supporting documentation Took an entire summer to complete the manual 26 Other Team Based Changes Morning huddles to review the day s schedule Pre visit Questionnaire Developed Standing Orders based upon the Evidence Eid Based Guidelines Improving open access using recall appointment system All patients receive a team card with name of their team, RN, LPN and MA names and how to contact Tracking logs: referrals, phone calls, diagnostic tests, Coumadin tracking logs, contacting patients who miss important visits 27 9

10 Diabetes Team Based Care: New DM Patient Night before: LPN prepares for Huddle, notes NEW DM patient to alert RN Care Manager/BHC and Provider Front desk: explains PCMH, gives brochure, and team card MA or LPN rooms the patient: all quality benchmarks are done LPN or MA schedules referrals RN care manager meets with ih patient to set up self management classes and self management care plan Patient scheduled for 5 week group class with CSI diabetes educator, and/or one on one education with RN nurse care manager RN puts patient in tracking notebook to check on, follow up with blood sugars, education, self management goals, labs etc In 3 months, patient is on recall list, front desk calls patient to schedule office visit, reminds patient to come in for any needed labs prior to office visit 28 Team Based Care for Chronically Ill Provider Front desk BHC CSI DM classes New Diabetic Patient RN CM MA LPN 29 Success Story 65 yo Hispanic male, uninsured, uncontrolled diabetes, hypertension, dyslipidemia, depression, obesity, was living in FEMA trailer Met with Care Team: provider, BHC, RN CM, LPN: assisted with application for Medicare/Medicaid, housing, employment, YMCA scholarship, dental program at community clinic Currently employed, moved to home, adherent with meds, attended diabetes education, dental plan completed A1C from 9.4 to 8.3; BMI 39 37, Microalbumin + to negative, LDL 159 to 106 and still improving! 30 10

11 Barriers Identified EMR: many, many issues Training needs Communication across system Change FATIGUE Click FATIGUE Physician/FNP buy in Reduced productivity Audits: seen as punitive Cost of care transformation Continued education 31 Team Based care works Patients like being part of the team Empanelment is a KEY change concept Huddles are key for success Supporting staff with changes is critical Maintaining the change is difficult There is NO turning back! Value Based Payment is here: QUALITY of care matters Lessons Learned 32 Making a Difference to One 33 11

12 Moving on to the next adventure as our journey continues! 34 12

Continuity of Care Guide for Ambulatory Medical Practices

Continuity of Care Guide for Ambulatory Medical Practices Continuity of Care Guide for Ambulatory Medical Practices www.himss.org t ra n sf o r m i ng he a lth c a re th rou g h IT TM Table of Contents Introduction 3 Roles and Responsibilities 4 List of work/responsibilities

More information

Utilizing a Registry for Health Care Management : A Team Perspective. Linda Follenweider MS PhDc FNP

Utilizing a Registry for Health Care Management : A Team Perspective. Linda Follenweider MS PhDc FNP Utilizing a Registry for Health Care Management : A Team Perspective Linda Follenweider MS PhDc FNP May 31, 2012 Commercial Disclosure I have no relevant financial relationships to disclose prior to presenting

More information

Davies Ambulatory Award Community Health Organization

Davies Ambulatory Award Community Health Organization Davies Ambulatory Award Community Health Organization Name of Applicant Organization: HealthNet, Inc. Organization s Address: 3403 E. Raymond St. Indianapolis, IN 46203 Submitter s Name: Sheila Allen,

More information

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid

More information

The Triple Aim. Two System Changes. PCMH Short Definition. Doctors Employed by Hospitals Exceed 100,000

The Triple Aim. Two System Changes. PCMH Short Definition. Doctors Employed by Hospitals Exceed 100,000 Doctors Employed by Hospitals Exceed 100,000 You May Be Hiring Physicians Is Your Primary Care Strategy Successful? 2004 64, 392 full time physicians were employed by hospitals In 2011 More than 100,000

More information

Columbus Regional Health. Diabetes Educators designing programs using Health Coach extenders in the PCMH.

Columbus Regional Health. Diabetes Educators designing programs using Health Coach extenders in the PCMH. Columbus Regional Health Diabetes Educators designing programs using Health Coach extenders in the PCMH. Objectives: Define what generated the need for the project. Discuss the delivery design model in

More information

Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York

Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York Capital District Physicians Health Plan, Inc. (CDPHP ) is featured as a high performer in cardiovascular care, identified

More information

Quality Improvement Case Study: Improving Blood Pressure Control in a 3- Provider Primary Care Practice

Quality Improvement Case Study: Improving Blood Pressure Control in a 3- Provider Primary Care Practice Quality Improvement Case Study: Improving Blood Pressure Control in a 3- Provider Primary Care Practice EXECUTIVE SUMMARY Organization Ellsworth Medical Clinic 1 is a family medicine practice in Wisconsin

More information

Direct Pay + FFS Visit Revenue. Joseph E. Scherger, MD, MPH Vice President, Primary Care Eisenhower Medical Center Rancho Mirage, CA

Direct Pay + FFS Visit Revenue. Joseph E. Scherger, MD, MPH Vice President, Primary Care Eisenhower Medical Center Rancho Mirage, CA Direct Pay + FFS Visit Revenue Joseph E. Scherger, MD, MPH Vice President, Primary Care Eisenhower Medical Center Rancho Mirage, CA Three Imperatives of Health Care Reform Cost Reduction Quality Improvement

More information

The Human Factor of Clinical Decision Support. Implementing Behavior Change as we Implement the Tools

The Human Factor of Clinical Decision Support. Implementing Behavior Change as we Implement the Tools The Human Factor of Clinical Decision Support Implementing Behavior Change as we Implement the Tools What is CDS (Clinical Decision Support) "Clinical decision support (CDS) provides clinicians, staff,

More information

Population Health Management Infrastructure

Population Health Management Infrastructure Population Health Management Infrastructure William Pagano MD, MPH SVP of Clinical Operations Doreen Colella RN, MSN AVP of Quality Interfaces The Azara reporting tool interfaces with multiple systems.

More information

Practice Readiness Assessment

Practice Readiness Assessment Practice Demographics Practice Name: Tax ID Number: Practice Address: REC Implementation Agent: Practice Telephone Number: Practice Fax Number: Lead Physician: Project Primary Contact: Lead Physician Email

More information

PPC 8: Performance Reporting and Improvement Element D: Setting Goals and Taking Action

PPC 8: Performance Reporting and Improvement Element D: Setting Goals and Taking Action PPC 8: Performance Reporting and Improvement Element D: Setting Goals and Taking Action sets goals and creates action plans as part of our annual preparation of our Federal Health Plan. Below are examples

More information

Mercy Hospital Columbus Community Health Improvement Plan (CHIP)

Mercy Hospital Columbus Community Health Improvement Plan (CHIP) Mercy Hospital Columbus Community Health Improvement Plan (CHIP) Created: August 28, Reviewed/Updated: September, PRIORITY AREA Provide clinical healthcare needs to the school district of Webb City, Missouri.

More information

The Medical Home: A Continuing Renovation Job. Paul Kaye, MD Executive VP, Practice Transformation February 22, 2012

The Medical Home: A Continuing Renovation Job. Paul Kaye, MD Executive VP, Practice Transformation February 22, 2012 The Medical Home: A Continuing Renovation Job Paul Kaye, MD Executive VP, Practice Transformation February 22, 2012 DISCLAIMER: The views and opinions expressed in this presentation are those of the author

More information

Webinar Description. Forming Your PCMH Team - How to Determine the Composition

Webinar Description. Forming Your PCMH Team - How to Determine the Composition Webinar Description Forming Your PCMH Team - How to Determine the Composition Transformation to a patient centered medical home requires that health centers evaluate and realign their current staffing

More information

Big Time, Big Deal. Strategies for Creating a Successful Organization-wide EMR. Charles B Wang Community Health Center Laminasti (Ina) Elbaar

Big Time, Big Deal. Strategies for Creating a Successful Organization-wide EMR. Charles B Wang Community Health Center Laminasti (Ina) Elbaar Big Time, Big Deal Strategies for Creating a Successful Organization-wide EMR Charles B Wang Community Health Center Laminasti (Ina) Elbaar 5 th Annual Asian & Pacific Islander Community Health Center

More information

Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home

Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home 104 A LOOK TO THE FUTURE Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home Background Management of chronic diseases can be challenging in primary care,

More information

Overview. Consider the materials presented in this webinar during your initial PCMH planning sessions

Overview. Consider the materials presented in this webinar during your initial PCMH planning sessions p. 1 Overview NCQA PCMH 2014 Standards Strategy to create a PCMH work plan Quality improvement planning A word about renewals Summary Consider the materials presented in this webinar during your initial

More information

Quality and Performance Improvement PATRICK SCHULTZ MS RN ACNS BC DIRECTOR OF QUALITY AND PATIENT SAFETY SANFORD MEDICAL CENTER FARGO

Quality and Performance Improvement PATRICK SCHULTZ MS RN ACNS BC DIRECTOR OF QUALITY AND PATIENT SAFETY SANFORD MEDICAL CENTER FARGO Quality and Performance Improvement PATRICK SCHULTZ MS RN ACNS BC DIRECTOR OF QUALITY AND PATIENT SAFETY SANFORD MEDICAL CENTER FARGO Crossing The Quality Chasm: A New Health System For The 21st Century

More information

MedStar Family Choice (MFC) Case Management Program. Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015

MedStar Family Choice (MFC) Case Management Program. Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015 MedStar Family Choice (MFC) Case Management Program Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015 Case Management Program Presentation Overview CM Programs Disease Management Complex

More information

Effective Care Management for Behavioral Health Integration

Effective Care Management for Behavioral Health Integration Effective Care Management for Behavioral Health Integration Title: Effective Care Management for Behavioral Health Integration A process improvement initiative focused on improving mental health outcomes

More information

HIMSS Davies Enterprise Application --- COVER PAGE ---

HIMSS Davies Enterprise Application --- COVER PAGE --- HIMSS Davies Enterprise Application --- COVER PAGE --- Applicant Organization: Hawai i Pacific Health Organization s Address: 55 Merchant Street, 27 th Floor, Honolulu, Hawai i 96813 Submitter s Name:

More information

Implementing Successful Patient Centered Medical Homes: Transforming Medical Assistant Roles at

Implementing Successful Patient Centered Medical Homes: Transforming Medical Assistant Roles at Implementing Successful Patient Centered Medical Homes: Transforming Medical Assistant Roles at the Union Health Center National Medical Home Summit March 18, 2014 www.unionhealthcenter.org 275 Seventh

More information

Myriad factors are challenging

Myriad factors are challenging Peter Anderson, MD, and Marc D. Halley, MBA A New Approach to Making Your Doctor-Nurse Team More Productive With proper training and delegation, your team can see more patients, deliver better care and

More information

Multnomah County Health Department Primary care clinic site visit, May 12, 2011

Multnomah County Health Department Primary care clinic site visit, May 12, 2011 Multnomah County Health Department Primary care clinic site visit, May 12, 2011 History and demographics Multnomah County is Oregon s most populous county, including the city of Portland. Multnomah County

More information

Greater New York Hospital Association. Emerging Positions in Primary Care: Results from the 2014 Ambulatory Care Workforce Survey

Greater New York Hospital Association. Emerging Positions in Primary Care: Results from the 2014 Ambulatory Care Workforce Survey Greater New York Hospital Association Emerging Positions in Primary Care: Results from the 2014 Ambulatory Care Workforce Survey Introduction.......................................................... 1

More information

SNMHI Summit 2011. Meaningful EHR Use: Technology Designed to Support the PCMH. Jeff Hummel, MD, MPH

SNMHI Summit 2011. Meaningful EHR Use: Technology Designed to Support the PCMH. Jeff Hummel, MD, MPH Summit 2011 LEARN SHARE TRANSFORM Meaningful EHR Use: Technology Designed to Support the PCMH Jeff Hummel, MD, MPH Medical Director for Clinical Informatics, Qualis Health Session 3C March 8, 10:30AM-12:00PM

More information

Parkview Health s Population Health Journey

Parkview Health s Population Health Journey Parkview Health s Population Health Journey Susan McAlister DNP, RN Director Enterprise Care Management Christine Howell BSN, RN Community Based Registered Nurse Objectives: By the completion of the webinar

More information

Integrating Home Blood Pressure Monitoring into Primary Care Practice: A Pilot Study

Integrating Home Blood Pressure Monitoring into Primary Care Practice: A Pilot Study Integrating Home Blood Pressure Monitoring into Primary Care Practice: A Pilot Study Barbara Holloway, RN, BSN, CDE Elizabeth Ciemins, PhD, MPH, MA March 12, 2016 About Us Quality care is delivered by

More information

CareFirst Safety Net Health Center as Patient-Center Medical Homes Grantees

CareFirst Safety Net Health Center as Patient-Center Medical Homes Grantees CareFirst Safety Net Health Center as Patient-Center Medical Homes Grantees Arlington Free Clinic, $350,000/ 3 years Enhancing Medical Care with a Safety Net Primary Care Medical Home Baltimore Medical

More information

Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed

Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Care Coordination The Embedded Care Manager Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Goals of Care Management The goals of care Management are consistent with the Triple Aim: Improve population

More information

Population Health Management: Using Quality Metrics to Drive Improved Patient Outcomes

Population Health Management: Using Quality Metrics to Drive Improved Patient Outcomes Executive Webinar Series Population Health Management: Using Quality Metrics to Drive Improved Patient Outcomes Presenters: Richard Hodach, MD, PhD, MPH Chief Medical Officer and VP, Clinical Product Strategy

More information

Success Story - University Medical Practice Associates (UMPA), St. Luke s - Roosevelt Hospital Center, part of Continuum Health Partners, Inc.

Success Story - University Medical Practice Associates (UMPA), St. Luke s - Roosevelt Hospital Center, part of Continuum Health Partners, Inc. Cover 1. Title: Driving Improvement of Diabetes Care in Upper West Side and Harlem neighborhoods of New York City through Clinical Decision Support and Analytics 2. Organization: University Medical Practice

More information

The Patient Centered Medical Home (PCMH): Looking at Examples. and Research on Staffing Models. Nancy Chang. GE-NMF PCLP Scholar 2013

The Patient Centered Medical Home (PCMH): Looking at Examples. and Research on Staffing Models. Nancy Chang. GE-NMF PCLP Scholar 2013 Running head: PATIENT CENTERED MEDICAL HOME 1 The Patient Centered Medical Home (PCMH): Looking at Examples and Research on Staffing Models Nancy Chang GE-NMF PCLP Scholar 2013 PATIENT CENTERED MEDICAL

More information

Continuous Quality Improvement using Centricity EMR

Continuous Quality Improvement using Centricity EMR Continuous Quality Improvement using Centricity EMR Jamie Howard, MD David A. Nelsen, Jr, MD, MS Associate Professors, UAMS Family & Preventive Medicine Sept 22-25, 2004 CLINICAL INFORMATION SYSTEMS 1

More information

Prevention and Wellness Advisory Board August 19, 2013. Cheryl Bartlett, RN Commissioner Massachusetts Department of Public Health

Prevention and Wellness Advisory Board August 19, 2013. Cheryl Bartlett, RN Commissioner Massachusetts Department of Public Health Prevention and Wellness Advisory Board August 19, 2013 Cheryl Bartlett, RN Commissioner Massachusetts Department of Public Health Today s goals: Review RFR Outline focusing on key areas Weigh in on final

More information

Patient Centered Medical Home. Nancy Chang, Adelante, Phoenix

Patient Centered Medical Home. Nancy Chang, Adelante, Phoenix Patient Centered Medical Home Nancy Chang, Adelante, Phoenix Introduction US healthcare system is broken Medical care is very expensive, but poor in quality and delivery Patient Centered Medical Home (PCMH)

More information

Share the Care TM : Who does it now?

Share the Care TM : Who does it now? Share the Care TM : Who does it now? Instructions: Share the Care is both a paradigm shift and a concrete implementation strategy. The paradigm (culture) shift transforms the practice from I to We. I refers

More information

Creating teams in primary care Breakout Series 1, Breakout A

Creating teams in primary care Breakout Series 1, Breakout A Creating teams in primary care Breakout Series 1, Breakout A Tom Bodenheimer MD Center for Excellence in Primary Care UCSF Department of Family and Community Medicine Objectives Discuss some nuts and bolts

More information

NCQA Patient-Centered Medical Home. Improving experiences for patients, providers and practice staff

NCQA Patient-Centered Medical Home. Improving experiences for patients, providers and practice staff NCQA Patient-Centered Medical Home Improving experiences for patients, providers and practice staff PCMH Recognition The patient-centered medical home is a model of care that emphasizes care coordination

More information

Connect4 Patients CCCM Primary Care Community. Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM

Connect4 Patients CCCM Primary Care Community. Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM Connect4 Patients CCCM Primary Care Community Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM September 17, 2015 Objectives: Describe innovative care management

More information

Maine Quality Counts Chronic Disease Improvement Collaborative 2. Request for Application

Maine Quality Counts Chronic Disease Improvement Collaborative 2. Request for Application Maine Quality Counts Chronic Disease Improvement Collaborative 2 Request for Application PDF VERSION for REFERENCE ONLY Only online applications will be accepted Introduction Thank you for your interest

More information

Pharmacist Involvement in a Patient-Centered Medical Home

Pharmacist Involvement in a Patient-Centered Medical Home Pharmacist Involvement in a Patient-Centered Medical Home Submitted by: Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE, Assistant Professor, Midwestern University College of Pharmacy, 555 31st Street,

More information

Patient Centered Medical Homes

Patient Centered Medical Homes Patient Centered Medical Homes Paul Kleeberg, MD, FAAFP, FHIMSS CMIO Stratis Health North Dakota e-health Summit November 20, 2013 REACH - Achieving - Achieving meaningful meaningful use of your use EHR

More information

10/21/2014. Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care

10/21/2014. Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care Robert A. Gabbay, MD, PhD, FACP Chief Medical Officer & Senior Vice President Joslin Diabetes Center Harvard Medical School

More information

EHR-Enhanced QI: Insights from the NYC DOHMH experience The Primary Care Information Project

EHR-Enhanced QI: Insights from the NYC DOHMH experience The Primary Care Information Project TITLE EHR-Enhanced QI: Insights from the NYC DOHMH experience The Joslyn Levy, BSN, MPH Dana Stephenson, MPH New York City Department of Health and Mental Hygiene PCPCC Presentation July 8th, 2010 AGENDA

More information

Using Data for Quality Improvement

Using Data for Quality Improvement Using Data for Quality Improvement MODERATOR: Katie Coleman, MSPH, MacColl Center for Health Care Innovation, Group Health Research Institute SPEAKERS: Lander Cooney, MS, CEO, Community Health Partners

More information

Leveraging EHR Data Reporting Anita Christie, RN MHA CPHQ MA Department of Public Health

Leveraging EHR Data Reporting Anita Christie, RN MHA CPHQ MA Department of Public Health Improve Population Health Outcomes Leveraging EHR Data Reporting Anita Christie, RN MHA CPHQ MA Department of Public Health Massachusetts ehealth Institute MBI MASSACHUSETTS BROADBAND INSTITUTE MeHI MASSACHUSETTS

More information

Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System

Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System Nursing Informatics Working Group Informatics Strategies & Tools to Link Nursing Care with Patient Outcomes in the Learning Health Care System Patricia C. Dykes PhD, RN, FAAN, FACMI Judy Murphy RN, FHIMSS,

More information

Building Performance Measurement Capacity in PHC Clinical Practice. Patricia Sullivan-Taylor Dr. Henry Siu May 29, 2013

Building Performance Measurement Capacity in PHC Clinical Practice. Patricia Sullivan-Taylor Dr. Henry Siu May 29, 2013 Building Performance Measurement Capacity in PHC Clinical Practice Patricia Sullivan-Taylor Dr. Henry Siu May 29, 2013 1 Presenter Disclosure Speaker: Patricia Sullivan-Taylor Canadian Institute for Health

More information

3/9/2011 ELECTRONIC HEALTH RECORDS: A NATIONAL PRIORITY. Mandate for electronic health records is tied to:

3/9/2011 ELECTRONIC HEALTH RECORDS: A NATIONAL PRIORITY. Mandate for electronic health records is tied to: To lower health care cost, cut medical errors, And improve care, we ll computerize the nation s health records in five years, saving billions of dollars in health care costs and countless lives. ELECTRONIC

More information

The Patient-Centered Medical Home & You: Frequently Asked Questions (FAQ) for Patients and

The Patient-Centered Medical Home & You: Frequently Asked Questions (FAQ) for Patients and The Patient-Centered Medical Home & You: Frequently Asked Questions (FAQ) for Patients and Families What is a Patient-Centered Medical Home? A Medical Home is all about you. Caring about you is the most

More information

KEVIN P. DURGEE, CMPE MANAGER, BUSINESS INTELLIGENCE

KEVIN P. DURGEE, CMPE MANAGER, BUSINESS INTELLIGENCE BUSINESS INTELLIGENCE AND DATA ANALYTICS - CHANGING CULTURE THROUGH VISUAL DATA DISCOVERY KEVIN P. DURGEE, CMPE MANAGER, BUSINESS INTELLIGENCE HOLLY CONWAY, CMPE SENIOR ADMINISTRATIVE DIRECTOR DEPARTMENT

More information

Enabling Healthcare in Out-Patient Settings and The Patient Centered Medical Home of the Future

Enabling Healthcare in Out-Patient Settings and The Patient Centered Medical Home of the Future Enabling Healthcare in Out-Patient Settings and The Patient Centered Medical Home of the Future Gregory J. Raglow, MD, FAAFP Group Health Informatics Officer Abu Dhabi Health Services SEHA Objectives List

More information

ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION)

ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION) ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION) Hello and welcome. Thank you for taking part in this presentation entitled "Essentia Health as an ACO or Accountable Care Organization -- What

More information

Kaiser Permanente of Ohio

Kaiser Permanente of Ohio Kaiser Permanente of Ohio Chronic Disease Management Program March 11, 2011 Presenters: Amy Kramer and Audrey L. Callahan 1 Objectives 1. Define the roles and responsibilities of the Care Managers in the

More information

Optimizing HIT for Medical Home Workflows

Optimizing HIT for Medical Home Workflows Summit 2011 LEARN SHARE TRANSFORM Optimizing HIT for Medical Home Workflows Greater Lawrence Family Health Center Shirin Madjzoub, MD, MPH Family Physician Michael Kimball, IS Applications Supervisor Session

More information

Hypertension Best Practices Symposium

Hypertension Best Practices Symposium essentia health: east region 1 Hypertension Best Practices Symposium RN Hypertension Management Pilot Essentia Health: East Region Duluth, MN ORGANIZATION PROFILE Essentia Health is an integrated health

More information

Affinity s Medical Home Journey Operational, Clinical and Financial Perspectives

Affinity s Medical Home Journey Operational, Clinical and Financial Perspectives Affinity s Medical Home Journey Operational, Clinical and Financial Perspectives Dr. Christine Griger - President Timothy Loch - COO Jane Curran-Meuli Regional Director Affinity Health System Top 100 Integrated

More information

Kelly Goode, PharmD, BCPS, FAPhA, FCCP and Lisa Price Stevens, MD, MPH, FACP

Kelly Goode, PharmD, BCPS, FAPhA, FCCP and Lisa Price Stevens, MD, MPH, FACP Kelly Goode, PharmD, BCPS, FAPhA, FCCP and Lisa Price Stevens, MD, MPH, FACP Objec&ves Describe Diabetes Awareness Program Provide Tools for Program Implementation at Other Sites Describe Shared Care Model

More information

Meaningful Use of HIT by RHCs NOSORH Region A Meeting Providence, RI June 18, 2013

Meaningful Use of HIT by RHCs NOSORH Region A Meeting Providence, RI June 18, 2013 Meaningful Use of HIT by RHCs NOSORH Region A Meeting Providence, RI June 8, Learning Objectives Understand the status of adoption of HIT and EHRs by RHCs Discuss how RHCs with EHRs perform on Stage meaningful

More information

Objectives. Disclosures. Nurse Practitioners: Defining Our Role in ACO s and Other Quality-Based, Cost-Effective Initiatives 11/8/2014

Objectives. Disclosures. Nurse Practitioners: Defining Our Role in ACO s and Other Quality-Based, Cost-Effective Initiatives 11/8/2014 Nurse Practitioners: Defining Our Role in ACO s and Other Quality-Based, Cost-Effective Initiatives Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAAN Adult/Family Nurse Practitioner Owner Wright & Associates

More information

The analytics race: how fast are you going?

The analytics race: how fast are you going? Optimizing Data and Analytics in an Accountable Care Environment Western Clinicians Network April 29, 2014 Janice Nicholson, CEO 2i Systems The analytics race: how fast are you going? 1 Applying Technology

More information

Patient Centered Medical Home first adopters: Lessons from three Connecticut practices

Patient Centered Medical Home first adopters: Lessons from three Connecticut practices 703 Whitney Avenue, New Haven, CT 06511 Phone (203) 562-1636 Fax (203) 562-1637 www.cthealthpolicy.org Patient Centered Medical Home first adopters: Lessons from three Connecticut practices On average,

More information

PAYMENT INNOVATIONS SUPPORTING BEHAVIORAL HEALTHCARE DELIVERY IMPROVEMENT. NGA July 2015

PAYMENT INNOVATIONS SUPPORTING BEHAVIORAL HEALTHCARE DELIVERY IMPROVEMENT. NGA July 2015 PAYMENT INNOVATIONS SUPPORTING BEHAVIORAL HEALTHCARE DELIVERY IMPROVEMENT NGA July 2015 My Background Medicaid Director Previously DMH Medical Director 20 years Practicing Psychiatrist CMHCs 10 years FQHC

More information

Burns & McDonnell On-Site Clinic

Burns & McDonnell On-Site Clinic Burns & McDonnell On-Site Clinic A Prescription for Financial and Productivity Success Fall 2013 Lockton Companies C OMPAN Y P R OFI L E Engineering, architecture, construction, environmental and consulting

More information

Humana Physician Quality Rewards Program 2014

Humana Physician Quality Rewards Program 2014 Humana Physician Quality Rewards Program 2014 Medicare Name Date External Presentation 1430ALL0114 B Humana s Accountable Care Continuum Provider Quality Rewards HEDIS based quality metrics Clinical +

More information

Electronic Health Records and Quality Metrics Using the right expertise to make full and meaningful use of your EHR investment

Electronic Health Records and Quality Metrics Using the right expertise to make full and meaningful use of your EHR investment Electronic Health Records and Quality Metrics Using the right expertise to make full and meaningful use of your EHR investment October 2014 402 Lippincott Drive Marlton, NJ 08053 856.782.3300 www.challc.net

More information

Using Health Information Technology to Improve Quality of Care: Clinical Decision Support

Using Health Information Technology to Improve Quality of Care: Clinical Decision Support Using Health Information Technology to Improve Quality of Care: Clinical Decision Support Vince Fonseca, MD, MPH Director of Medical Informatics Intellica Corporation Objectives Describe the 5 health priorities

More information

Open Cities Health Center Expands Tobacco Dependence Treatment

Open Cities Health Center Expands Tobacco Dependence Treatment Open Cities Health Center Expands Tobacco Dependence Treatment Between October 2010 and June 2012, ClearWay Minnesota SM provided Open Cities Health Center (OCHC) with funding and technical assistance

More information

Primary Care Quality Care Indicators - Accuro EMR Prevention

Primary Care Quality Care Indicators - Accuro EMR Prevention Quality Indicators Primary Care Quality Care Indicators - Accuro EMR Prevention Data needs to be entered as indicated in order to auto populate the worksheet Date of colon cancer screening Exemption from

More information

Improving Colon Cancer Screening Rates

Improving Colon Cancer Screening Rates Improving Colon Cancer Screening Rates March 19, 2014 Presenters Matt Flory Health Care Partnerships Director Midwest Division American Cancer Society (ACS) Beverly Annis, RN Professional Resource for

More information

08/04/2014. Tim Hogan, RRT, PhD Primary Care Home Health Director. University of Missouri Health Care Department of Family and Community Medicine

08/04/2014. Tim Hogan, RRT, PhD Primary Care Home Health Director. University of Missouri Health Care Department of Family and Community Medicine Tim Hogan, RRT, PhD, Primary Care Home Health Director Joan Asbee, RN, BSN, CWOCN, Nurse Care Manager Karli Urban, MD, Assistant Professor of Clinical Family and Community Medicine University of Missouri

More information

Using Onsite Health Centers to Integrate Worksite Activities. Larry S. Boress Executive Director National Association of Worksite Health Centers

Using Onsite Health Centers to Integrate Worksite Activities. Larry S. Boress Executive Director National Association of Worksite Health Centers Using Onsite Health Centers to Integrate Worksite Activities Larry S. Boress Executive Director National Association of Worksite Health Centers Copyright NAWHC2013 National Association of Worksite Health

More information

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs)

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health

More information

Own Your Data. Own Your Future. SHOW ME THE DATA: THE MISSOURI JOURNEY. Reform Ready 2/9/2015

Own Your Data. Own Your Future. SHOW ME THE DATA: THE MISSOURI JOURNEY. Reform Ready 2/9/2015 SHOW ME THE DATA: THE MISSOURI JOURNEY California Primary Care Association Quality and Technology Conference San Ramon, California February 19, 2015 Own Your Data. Own Your Future. (shamelessly stolen

More information

TESTIMONY TO THE HEALTH IT POLICY COMMITTEE. Advanced Health Models and Meaningful Use Workgroup

TESTIMONY TO THE HEALTH IT POLICY COMMITTEE. Advanced Health Models and Meaningful Use Workgroup TESTIMONY TO THE HEALTH IT POLICY COMMITTEE Advanced Health Models and Meaningful Use Workgroup Nancy Rockett Eldridge, CEO, Cathedral Square Corporation June 2, 2015 Support And Services at Home (SASH)

More information

Electronic Health Records

Electronic Health Records What Do Electronic Health Records Mean for Our Practice? What are Electronic Health Records? Electronic Health Records (EHRs) are computer systems that medical practices use instead of paper charts. All

More information

3.b.i Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only)

3.b.i Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) 3.b.i Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) Objective: To support implementation of evidence-based best practices for disease management in medical

More information

Creating Team Based Proactive Office Encounters

Creating Team Based Proactive Office Encounters Better Health Greater Cleveland relies on the presenter to obtain all rights to use and display copyright-protected information. Anyone claiming a right or interest in or to any posted information should

More information

The Power of PopIQ and Big Data. i2i Systems West Coast Regional User Conference September 5, 2014

The Power of PopIQ and Big Data. i2i Systems West Coast Regional User Conference September 5, 2014 The Power of PopIQ and Big Data i2i Systems West Coast Regional User Conference September 5, 2014 Statewide Collaboration & Data Analytics Community Clinics Health Network Founded in 1993 Current Initiatives/Areas

More information

Patient Centered Health Home and Data Analytics. Amanda Stangis, Director of Programs, CPCA Andrew Principe, VP Strategy, Arcadia Solutions

Patient Centered Health Home and Data Analytics. Amanda Stangis, Director of Programs, CPCA Andrew Principe, VP Strategy, Arcadia Solutions Patient Centered Health Home and Data Analytics Amanda Stangis, Director of Programs, CPCA Andrew Principe, VP Strategy, Arcadia Solutions Agenda What is a Health Home? What is the connection between Health

More information

Turning on the Care Coordination Switch in Rural Primary Care Practices

Turning on the Care Coordination Switch in Rural Primary Care Practices Turning on the Care Coordination Switch in Rural Primary Care Practices AHRQ Master Contract Task Order #5 HHSA2902007100016I (9/07-11/09) Care Management Plus research at OHSU is supported by funding

More information

Population Health Management In A Value-Based Market: Using Pharmacy Analytics To Increase Consumer Engagement & Improve Outcomes

Population Health Management In A Value-Based Market: Using Pharmacy Analytics To Increase Consumer Engagement & Improve Outcomes Population Health Management In A Value-Based Market: Using Pharmacy Analytics To Increase Consumer Engagement & Improve Outcomes Sponsored By Care Management Technologies February 11, 2016 www.cmthealthcare.com

More information

North Shore Physicians Group Primary Care Redesign

North Shore Physicians Group Primary Care Redesign North Shore Physicians Group Primary Care Redesign Christine Sinsky, MD 12.23.11 The physician cannot do this work alone, notes Lindsay Gainer, Director of Clinical Services and Innovations at North Shore

More information

The IOM Report(s) Albert W. Wu, MD, MPH Johns Hopkins University

The IOM Report(s) Albert W. Wu, MD, MPH Johns Hopkins University This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this

More information

DELIVERING VALUE THROUGH TECHNOLOGY

DELIVERING VALUE THROUGH TECHNOLOGY DELIVERING VALUE THROUGH TECHNOLOGY Mark Nelson, MD - EMR Physician Champion Krishna Ramachandran - Chief Information and Transformation Officer Karen Adamson - Director, Epic Clinical Applications DuPage

More information

Examples of Quality Improvement Projects in Adult Immunization

Examples of Quality Improvement Projects in Adult Immunization Examples of Quality Improvement Projects in Adult Immunization The following activities are provided to prompt your thinking about what works best for your practice. When designing a project, consider

More information

Integrating Self Management Supports in Primary Care

Integrating Self Management Supports in Primary Care Integrating Self Management Supports in Primary Care Support for this product was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, 2009 Objectives: To describe key

More information

HealthCare Partners of Nevada. Heart Failure

HealthCare Partners of Nevada. Heart Failure HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with

More information

Office of Rural Health Policy MEDICARE BENEFICIARY QUALITY IMPROVEMENT PROJECT

Office of Rural Health Policy MEDICARE BENEFICIARY QUALITY IMPROVEMENT PROJECT Office of Rural Health Policy MEDICARE BENEFICIARY QUALITY IMPROVEMENT PROJECT Paul Moore, DPh Senior Health Policy Advisor Office of Rural Health Policy Health Resources and Services Administration Department

More information

The Promise of Regional Data Aggregation

The Promise of Regional Data Aggregation The Promise of Regional Data Aggregation Lessons Learned by the Robert Wood Johnson Foundation s National Program Office for Aligning Forces for Quality 1 Background Measuring and reporting the quality

More information

Norton Healthcare. Faith-Based Integrated Delivery Network of Five Not-for-Profit Hospitals 15 Out-patient Centers 130+ Physician Practices

Norton Healthcare. Faith-Based Integrated Delivery Network of Five Not-for-Profit Hospitals 15 Out-patient Centers 130+ Physician Practices Norton Healthcare Faith-Based Integrated Delivery Network of Five Not-for-Profit Hospitals 15 Out-patient Centers 130+ Physician Practices 2.2 Million yearly patient encounters $1.6 Billion yearly revenue

More information

Health Information Technology: Introduction to One Key Part - the EHR

Health Information Technology: Introduction to One Key Part - the EHR Health Information Technology: Introduction to One Key Part - the EHR Donald P. Connelly, MD, PhD Director, Health Informatics Division University of Minnesota Medical School February 21, 2006 Minnesota

More information

Outline. Vision for Delivering Quality Care Do the Right Thing. Lessons from Quality

Outline. Vision for Delivering Quality Care Do the Right Thing. Lessons from Quality Outline Effectiveness Research Using EHRs: Gold Mine or Tower of Babel? Paul Tang, MD VP, Chief Medical Information Officer Palo Alto Medical Foundation Consulting Associate Professor Stanford University

More information

Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County.

Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County. Winding Waters Clinic Enterprise Oregon Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County. Renee Grandi, MD, Owner Keli Christman, Practice Administrator

More information

PCMH : A WINDOW TO 2014

PCMH : A WINDOW TO 2014 Colorado Community Health Network Spring Conference PCMH : A WINDOW TO 2014 Presented by: Bonni Brownlee, MHA CPHQ CPEHR NCQA PCMH Certified Content Expert Senior Clinical Consultant Audience Poll: Where

More information

DATA DRIVEN HEALTH CARE TRANSFORMATION

DATA DRIVEN HEALTH CARE TRANSFORMATION DATA DRIVEN HEALTH CARE TRANSFORMATION Population Health Analytics as the Foundation for Primary Care Redesign Sylvia Meltzer, MD, LSSGBC Laura Spurr, MPS, PMP Learning Objectives Organization description

More information