1. PCMH Curriculum: Keeping the Finger on the Pulse (Evaluating and Reevaluating the Outcomes) InSung Min, MD; Katherine Murphy, DO; Rahima Alani, MD; Justin Conway, MD; Sophia Small-Warner, MPA; Andreas Cohrssen, MD

2. Disclosures No disclosures We placed explanations for the slides in the “Note section” of the Power point for this FMDRL upload of our presentation

4. Background We were an 8/8/8 program 36 weeks of Family Medicine Inpatient We had an audit...

5. More Background We were a 10-8-8 Program 32 weeks of Inpatient Family Medicine 4 weeks of PCMH We had a merger... We were a 9-10-8 Program 2 weeks of PCMH

6. Goals and Objectives Share a curriculum of PCMH Discuss 4 wk vs. 2 wk rotation Report on outcomes Understand successes and challenges

7. PCMH Curriculum

8. Home/ Community Patient Hospital Specialists & Studies Clinic Referrals Nutrition, Mental health Med requests Appointments Transport Clinic Referrals Nutrition, Mental health Med requests Appointments Transport PCMH in the FQHC

9. Care Navigation: Transitional Care Coordinator

10. Home/ Community Transitional Care Coordinator Home/ Community Transitional Care Coordinator Patient Hospital Transitional Care Coordinator Hospital Transitional Care Coordinator Clinic Transitional Care Coordinator Clinic Transitional Care Coordinator Specialists & Studies Transitional Care Coordinator

11. Home/ Community Transitional Care Coordinator Care Navigator Home/ Community Transitional Care Coordinator Care Navigator Patient Hospital Specialists & Studies Care Navigator Specialists & Studies Care Navigator Clinic Transitional Care Coordinator Care Navigator Clinic Transitional Care Coordinator Care Navigator

12. PCMH Curriculum Morning rounds

13. PCMH Curriculum Morning rounds Care Team

14. PCMH Curriculum Morning rounds Pharmacy Student Care Team Literature Review

15. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Literature Review

16. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Home visits Literature Review

17. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Home visits Literature Review Homeless site

18. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Homeless Home visits Literature Review Diabetes Group HIV Compass

19. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Homeless Home visits Literature Review Diabetes Group HIV Compass

20. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Homeless Home visits Literature Review SAMs Diabetes Group HIV Compass

21. PCMH Curriculum Morning rounds Pharmacy Student Care Team Community HC Homeless Home visits Literature Review SAMs Diabetes Group HIV Compass Procedure Clinic

22. Literature Reviews Care Coordination Medication Reconciliation Telephone care and f/u Home Health Services Homelessness Food insecurity Population Management Durable Medical Equipment Access – sliding fees, free clinic, insurance

23. MonTueWedThurFri 7-9amHospital with PGY2 rounding 9- 11:30am Patient follow up Procedure clinic Patient follow up Lit Review Telephone Care and f/u -----Care Coordination Food Insecurity Medication reconciliation 12-5Homeless Site Community Partner rotation Teaching Afternoon Diabetic Group/ shared visit Work with HIV team HOME Visit COMPASS/ HIV ------

24. Morning rounds Pharmacy Student Care Team Community HC Homeless site Home visits Literature Review SAMs Diabetes Group HIV Compass Procedure Clinic

25. Contact with Patient Pre-discharge Telephone Possible Home visit Appointment at FQHC

26. Patient Visit at FQHC

27. Resident Outcomes Data from resident survey, EMR and chart reviews –Schedule adherence –Patients seen outpatient –Impact of interaction with PCMH team –Resident Feedback

28. Resident outcomes

29. Resident outcomes Patient Follow up Visits in FQHC 2 Week4 Week # Weeks1432 # Patients in clinic 532 # Pts/ 2 Wk block 0.72

30. Resident outcomes

31. Patient Care Team at FQHC Patient PCMH Resident Care Management Staff Compass Team Diabetes Group Care Management Supervisors

32. Resident outcomes Resident Feedback 35% of residents: Rotation was very helpful in their development as a physician within the PCMH model 100% of residents: Rotation was helpful

33. Patient Outcomes Outpatient f/u in 7 days D/c summaries into outpatient EMR in 2 days 30 day readmissions

34. Patient outcomes

37. Shortcomings Difficulty in scheduling Difficulty for patients to show Crucial PCMH staff changed

38. Program Benefits for PCMH Completes the Inpatient experience Medication reconciliation Connection to the community Stronger bond of interns to FQHC Readmissions impact Resident satisfaction “Cutting edge” (applicants)

39. Questions – Best Practices „I`ll have an ounce of prevention“