ECH Health Care Home

Why is Health Care Home important to Mayo? The needs of the patient come first. The way we define and address our patient’s needs is changing. We use a team approach, with all team members working to the full extent of their licensure. We assess and address our patient’s needs beyond their chief complaint. We address the needs of our patient population whether they are seeing us in the office or not. We work more closely to coordinate care with the ED, hospital, care facilities and community partners. Our goal is to provide the right care, at the right time, in the right location, with the right provider. Don’t we do this already in Primary Care? Sometimes, but we don’t accomplish these tasks consistently. When we are at work, with openings on our schedule, and our patients come in to see us, we do a decent job of this. When we are away, we don’t do this as well. When our patients aren’t in the office, we don’t do as well. When the office visit is focused on the acute complaint, we often don’t attend to their other health needs. Why are we doing this now? The traditional paradigm we use to care for our patients is unsustainable. We are responsible for ever increasing numbers of patients. Advances in medicine and public health have resulted in a much older and medically complex patient population. We are expected to effectively deliver a broad range of preventive and chronic care services to our patients who were not part of the traditional practice of medicine. A physician does not have time, resources or energy during a face-to-face office visit to accomplish this work. A new approach is needed.

The Adult Health Care Home Patient Chronic issues expected to last a lifetime. Medical equipment needed for daily living. Receiving outside resources related to medical issues. Patient/family unable to self-coordinate. Two or more co-morbid conditions.

Health Care Home Team Patient Patient appointment Coordinators (PAC) Clinical Assistants (CA) Medical Secretary Nurses: Triage, Care Teams Transition Program Social Workers & Discharge Planners Provider RN Care Manager/Care Coordinator Language Department review the role descriptions and the flow diagram

Who is the Health Care Home Team? Communication with School District Transition from the Hospital Subspecialty Consult Patient and Primary Care Healthcare Team Patient-Centered Care Communication with Public Health Nurse Transition to a Nursing Home

Patient Stories Patient-centered Care 81 year-old male 50 year-old female

Services Provided Coordinating Specialty appointments Home advice for the home health agency Acute calls from the family Medication renewals Follow up calls after hospitalization Care Conference Coordination Home Health Agency coordination Arranged medical equipment Language, literacy, & cultural adaptations

Lead Local Community Resources for Seniors with Disabilities Olmsted Co. Public Health Services: Long Term Care Consultation Personal Care Assessments (PCA) Case Management Community Alternatives for Disabled Individuals (CADI) Elderly Waiver 507-328-6400 Workforce Center: Counseling (Vocational Rehab. Specialist) Training Finding & Keeping a Job Assistive Technology Follow-up Services 507-285-7315

Community Resources Southeastern MN Center for Independent Living (Rochester SEMCIL): Senior Companion Program Disability Linkage Line (888-460-1815) Transition Service Assistive Technology Nursing Relocation Independent Living Skills Peer Mentor Services Ramp Project & Accessibility Services 507-285-1815

Community Resources Extended Employment Long Term Support Ability Building Center (ABC) 507-281-6262 Additional resources: Senior Linkage Line: 800-333-2433 United Way 211 (800-543-7709) Intercultural Mutual Assistance Association (IMAA):507-289-5960 Elder Network: 507-285-5272 Rochester Senior Center: 507-287-1404

Final Thoughts