1. Pawtucket Medical Central Falls Medical Pawtucket Dental Blackstone Valley Community Health Care FQHC serving 15,000 patients 30 providers, including 18 medical providers (12 MDs and 6 mid-levels), behavioral health and dental 2 medical locations, 1 dental Integrated behavioral health, including psychiatrist Eye exams, pharmacy services, lab on site About BVCHC

2. Accredited by The Joint Commission since 1999 Recognized as a NCQA Level 3 PCMH since May 2011 The three Blackstone sites have been recognized by HIMSS Analytics as Stage 6 sites on the A-EMRAM in August 2013. (A-EMRAM Ambulatory EMR Adoption Model) Recognized as an “Analytic Company” by the International Institute of Analytics and HIMSS Analytics on the DELTA Powered Analytics Assessment in February 2014 2

3. Care Team Re-Design Original Model Pod Model BLUE POD Provider Care Manager MA AMA RN

4. HUDDLE ! 4

5. Green Pod Huddle 5

6. How it works at BVCHC? AMA – Huddle leader 15 mins every day Attended by Clinicians, MAs, AMA, RN, NCM Distribution of next day census by AMA 6

7. A Typical Next Day Census Pre-Visit Planning F DMADOC Provider Appt. TimeNameAgeVisit TypeReason Pt. Portal Glucose A1c Microalbumin Eye Exam Foot Exam Dental DM LDL Tob. Status Tob. Cessation PHQ2 Fall Risk BMI Care Plan Immunizations Colonoscpy Pap Smear Chlamydia Mammogram LDL Off-Site Self Mgmt. Goals NCM Referral Appointments Listing Beg TmPat Name Pat AgeEventDetails Auger, Emily PA 8:15 A24 yrs.Newnew cpe, flu shot 9:15 A47 yrs.Preventativecpe 1:30 P28 yrs.Newnew cpe, flu shot 2:00 P36 yrs.Office Visitto discuss persistant headaches 2:15 P18 yrs.Preventativecpe/flu shot 3:45 P62 yrs.Newcpe,flu shot gyn care, colonoscopy? Total Appointments for Auger, Emily PA (7) Hussain, Nausheen MD 9:15 A54 yrs.Office Visit2wk htn f/u 190/99 12/6/13. on 3 diff meds for BP 9:30 A24 yrs.Newcpe, flu shot, pap? BMI 43 in 2009 10:15 A36 yrs.Newdeaf pt..cpe 11:15 A51 yrs.Open Accesson dialysis, DM, er fu from MHRI-hypoglycemia 11:30 A50 yrs.Office Visitarthritis 1:30 P73 yrs.Office VisitDM,HTN(pt claims is taking htn meds) 1:45 P38 yrs.Preventativecpe.htn 2:15 P41 yrs.Preventativecpe 3:30 P11 yrs.PreventativeWCV-shots? None in kidsnet 4:00 P49 yrs.Office Visit6wk htn f/u 4:15 P43 yrs.Newnew cpe,flu shot Total Appointments for Hussain, Nausheen MD (11) Polanco, Jose MD 10:00 A47 yrs.Office Visitvertigo 3 month f/u and mammo due/flu shot 10:15 A41 yrs.Office Visit3 month f/u DM, HTN, WT, HLd 10:30 A66 yrs.Office Visit3 month f/u hypertension/mammo order 10:45 A82 yrs.Open Accesswill call for oncology notes,insomnia,DM 11:00 A25 yrs.Office Visit elevated liver,depression-called pt to come in for labwork 11:15 A39 yrs.Office Visithyperlipedmia,htn. TRG 779. repeat lipid panel? 11:30 A71 yrs.Office VisitDM,htn-notes from urologist-hypertropy 11:30 A27 yrs.Office Visitweight check and flu shot-BMI 39 Total Appointments for Polanco, Jose MD (8) Total Appointments (26) 7

8. Pre-Visit Planning ER records Immunization records Consults Labs results and POCT for DM Preventive tests ( pap, colonoscopy, mammogram ) Charts requiring update ( tobacco cessation, diabetic foot exams, diabetic eye exam, PHQ2, Fall Risk ) 8

9. Pre-Visit Planning continued Challenging patients ( uncontrolled diabetics/ hypertensives, mental health issues, social issues, patients requiring interpreters, family conference ) Mid level provider concerns Other issues ( does the pt need to be seen, is the correct provider seeing pt, “chronic no show pts- what can be done ”) 9

10. Huddle Lesson 10

11. 11 Benefits and Challenges Benefits Effective and efficient visits - cuts frustration Improved patient and clinician satisfaction with visit Improves morale – provides help to those who need it Identifies deficiencies Challenges Frequent training and ‘refreshers’ are required for pre-visit planning and reports Time constraints Should RN’s be doing Huddles ?

12. 12 Any questions? Christine Grey Chief Operating Officer Blackstone Valley Community Health Care cgrey@bvchc.org Nausheen Hussain Medical Director Blackstone Valley Community Health Care nhussain@bvchc.org