1. 1 Michaela Frazier, LMSW Director of Community Benefit Programs Institute for Family Health Care Coordination and Technology to Support Physical and Behavioral Health

2. The Institute for Family Health Large FQHC network Primary care, behavioral health, dental and community programs 100,000 patients with over 500,000 visits Rural and urban centers 2

3. Our Service Area

4. Behavioral Health and EMR EMR implementation in 2002 All behavioral health and community programs on EMR since implementation 4

5. Collaborative Documentation Helping consumers embrace use of computer and technology in session Changing room set up Using tools and graphs in session Quoting patients 5

6. Use of the EMR in Care Coordination 6

7. Review progress with patients 7

8. Shared Care Plan

9. Safety Planning

10. Care Team Management Patient Documentation Management o Assessments due o Care plans o Upcoming appointments Gaps Lists o Annual wellness visits o Eye exams etc. Emergency Visit Notifications o Information pushed into the record through the RHIO o Supports Transitions of Care 10

11. It Takes a Village….. Community or physician portal Ability to improve intake and expedite referral services Ability to get information on patients In an emergency Longitudinal care planning Continuity Real time provider communication Agencies no longer keeping health records Institute Link!!! 11

12. DIRECT SCHEDULING

13. Patient Snap Shot

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15. Chart Review

16. MEDICATIONS (Current/Past)

17. Document Upload

18. Patient Portal Classes 18

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20. 20 My Goals and Plans You have a diagnosis of DIABETES. Here are your personal treatment goals: High A1C (average sugar level). Your goal is less than 7%.

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22. Contact Information: Michaela Frazier, LMSW email: mifrazier@institute.org cell: 917-831-0334 Contact Information: Michaela Frazier, LMSW email: mifrazier@institute.org cell: 917-831-0334 mifrazier@institute.org

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