1. A Pilot Study of a Care Coordination Model in a Community Health Center Peak Vista Community Health Centers September 16, 2015 Public Health in the Rockies

2. Peak Vista Community Health Centers  Federally Qualified Health Center  History/Current  43 Years In Colorado Springs  82,000 patients  700 staff  26 locations  Patients  Low income, underserved  No patient denied care  Substantial Medicaid population (68%)  Medicare (10%)  Uninsured (15%) Private Insurance (5%)

3. Current Challenges  Payment Reform  Very little specific information (no clear timeline/model) but it’s coming!  Move from Fee for Service to Pay for Performance  Team Based, Coordinated Care  Better Outcomes  Greater Patient Satisfaction  Reduction of Cost of Care

4. Current Challenges  Paradigm Shift  Public Health Aspects  Population Health  Research, Data Analysis (Epis)  Identifying Risk Factors/Upstream (Determinants)  Prevention  Improved Collaboration (Programs, Services)  Especially with local Health Departments

5. Planning & Implementation  Create a Pilot Program in One Clinical Setting  Coordinated Care Teams  Care Group approach to improving outcomes  Less Reliance on Provider (Physician, Mid-Level)  Larger role for Nurses  Inclusion of Resource Navigator, Pharmacist  Less Emphasis on Encounter Rate, More on Outcomes  Population Health Focus  Population Health Study  Ultimately will Inform Upstreaming Initiatives

6. Purpose/Goals  Test the feasibility of care coordination in our clinics  Improve the health outcomes of our patients  Create effective collaboration among the care team  Increase efficiency in the clinic  Reduce the number of unnecessary appointments  Encourage patients to be actively engaged in their healthcare  Improve the patient experience

7. Study Design  Longitudinal  Observational  Combined retrospective/prospective approach  Retrospective chart review  Used previous 1-year period to define our study population and establish baseline measures  Follow group for 6 months to 1 year

8. Setting  Union clinic  Location  Near downtown Colorado Springs  Providers  3 physicians/2 mid-levels  Patients  Panel of 5106 patients  714 Diabetics

9. Sample Selection  Inclusion/Exclusion criteria  Patients assigned to a Union provider  Appointment within last year  <80 years old  Diabetic patients (ICD-9 code 250.0-250.93)  Total patients in study- 5051  Total diabetics in study- 691

10. Program/Intervention  Implementation of care coordination model  Pre-visit planning  Communication/sharing knowledge  Medication management  Assessing patient needs and goals  Monitoring and follow-up  Helping with transitions of care  Linking to community resources  Population health management

11. Data Collection  Data collected from routine office visits  Entered into EHR system by care team  Baseline data  Most recent clinical measures of patients seen within 1 year prior to start of study  Follow-up data  Collect data at 6 months, 1 year

12. Clinical Quality Measures  Diabetics  A1c  Weight/BMI  Adherence to medications (Statins, ACE Inhibitors, ARB)  Microalbumin  Fasting lipid profile/LDL  Foot exam/Eye exam  All patients  Screenings (Mammogram, colonoscopy, pap smear)  Vaccinations (Flu, Pneumonia, Tetanus)  Smoking status/tobacco counseling  Number of office visits

13. Data Analysis  Compare clinical measures from baseline and end of study  All patients- preventive services  Diabetics  Compare patient outcomes among diabetic risk groups  Uncontrolled vs controlled

14. Anticipated Use of Study Results  Identify successes as well as opportunities for improvement  Streamline the care team daily workflow  Evaluate population health management capabilities  Identify additional clinical measures of interest  Expand care coordination to other clinics

15. Challenges  Identifying and Selecting Leadership  Understanding of the Goal  Trust  Of Leadership  In Each Other’s Abilities

16. Challenges  Culture Change  Provider/Team Training – Let it Go  Patient Centered  Patient Needs  Be where the patient is  Motivational Interviewing  Everyone’s Opinion is Important  Top of License  Prevention vs. Current Condition (Upstream)  Understanding Population Health  Willingness to Try – Failure or Success Acceptable