1. Our Patient-Centered Medical Home Journey DHK Family Medicine & Pediatrics 2009-2010

2. The Production Model (The “Medical Widget” Model) P ATIENT P ROBLEM P ROVIDER P ILLS P ROCEDURE $ Profit $

3. Welcome to our medical home! We are a Family Medicine team which is part of a large Family Medicine Department. Our pilot team includes 3 physicians and 2 nurse practitioners We have 7300 patients in our panels on this team. Today we would like to show you what we have done over the last year on our journey. CMHI - for CHI Pilot, Dec 2009

4. On team B, we have two “teamlets” which consist of 1 or two MDs, 1 ARNP, 2 telephone nurses, 2 cmas’ for flow and 1 care coordinator split between two teamlets. Our patients can reach us through our patient portal (POL) or by calling. CMHI - for CHI Pilot, Dec 2009

5. Our telephone nurses deal with avg of100 calls per day. We provide our new patients with a brochure which gives the patient a direct line to their PCP’s nurse.

6. Our flow staff monitor the task lists and work the lab results, notifying the patients regarding their normal labs. We have been participating in the CMS PGP pilot for three years which has helped in the development of the processes for our Diabetic Population, CHF, COPD and CAD population as well. Shoes and socks

7. Patient & Family-Centered Care – Family Advisory Council Patient Reps on Teams

8. Steps towards the Medical Home Pre 2008 Personal Provider: MD practices open (but over- capacity) Team Care: Behavioral Health Integration, DM Educator, RN Clinic Whole Person: ? Care Coordinated: Chronic Pain Guidelines, Discharge Phone Calls Quality: EMR, NCQA DM Recognition Award Advanced Access: ? Payment Reform: PGPDP

9. Medical Home Building 2007-2009 Developed Medical Home Vision Registry and Care Coordinators NCQA Medical Home Designation Multi-stakeholder MH pilot Medical Home Task Force

10. Our story 1 year later… Personal Provider: MD & APRN PCPs with capacity Team Care: BH & Psych integration, DM Educator, RN Clinic, Patient Care Coordination Whole Person: Rounding Team, CC Hospital Visits, Welcome to FM brochure, Parent Advisory Council, Patient Reps, Wellness Care Coordinated: Anticoagulation, Chronic Pain Guidelines, Care Plans, Childhood Obesity, Post Discharge Calls Quality: DM, HTN, COPD, Asthma, Epilepsy, Preventive Care Registries Advanced Access: New Patient Touches, Group Visits, RN BP Visits, Home Visits Payment Reform: PGPDP, Multi-stakeholder MH Pilot

11. Care Coordination The heartbeat of the Medical Home team

12. Role of Care Coordinators Listening to and assessing patient’s needs Building relationships through collaboration and teamwork Facilitating access and advocating for appropriate care Developing care plans in partnership with patient and family

13. Hospital Visits “Touching” our patients Demonstrating Medical Home Building the bridge back to Primary Care

14. Post Discharge Calls Continuity Coordination Trouble shooting

15. Pre-Visit Work New Patients Intake calls Pre-visit testing Increasing access Patient and provider satisfaction

16. Pre-Visit Work Weekly Asthma Registry

17. Pre-visit phone call Asthma Control Test Follow Up phone call (as necessary) Asthma Action Plan Pre-Visit Work Asthma

18. Pre-Visit Work Monthly Epilepsy Registry

19. Care Plans Patient centered partnership Comprehensive Portable “Living”

20. Initiatives Prevention Colonoscopy Registry Mammography Registry Pap smear Registry Wellness Smoking cessation Exercise Weight Management Vision 2020 Registries for Population Management

21. Principles in Use 1) Evidence based guidelines. 2) Use of registry data to improve chronic disease management. 3) Use of registry data for improved preventive care. 4) New concepts in patient management.

22. COPD A Team Approach

23. Spirometry in approx. 85% of patients. Pneumovax/Flu vaccine given in approx 95% of patients. Smoking documentation in EMR 100% of patients. Smoking Cessation counseling in 75% of patients.

24. Anti-Coagulation in Nurse Clinic: Collaboration with DHMC Hospital Protocols and Clinic Crossover. New Start Protocol Completed. In range values for the last 9 months. What’s next? Bridging Protocol.

25. Hypertension: Organizational Goal Improvement Process Rooming Procedure Medication Protocols Patient Education Group Visits

26. Diabetes Mellitus Improvement Process Use of Registry. Pre-work Concept. Improvement in documentation process using EMR. Improvement in data gathering for Eye Exams.