1. Life Long Care Citizen’s Health Initiative –
Multi stakeholder Medical Home Pilot
June 22, 2010

2. Today’s Goals Presentation from Life Long Care
Update on Medicare Advanced Primary Care demonstration
Provider List
Other items
June 22, 2010

3. Welcome to our medical home!
Clinic opened January 2003
Advanced Practice Registered Nurses
Mission
Vision
Values
June 22, 2010

4. Life Long Care Our Mission
To create an environment that is a safe space and that role-models a healthy work place
June 22, 2010

5. Life Long Care Our Vision
The patients we serve will experience high quality care feeling safe and supported through evidenced based care within a nursing model in a medical home.
June 22, 2010

6. Life Long Care Our Values: Safety The experience. Nursing What we do.
Confidentiality Honoring the gift.
Individuality It’s about people.
Time Moments of quality as individuals
and as employees.
June 22, 2010

7. Life Long Care
Payor Distribution 69%Commercial 23%Medicare 2%Medicaid 5%Self Pay 1%Other
June 22, 2010

8. Life Long Care Our Team 3 APRNs 1 RN 2 MA 1 Office Manager
2 Receptionist
June 22, 2010

9. Life Long Care Clinic Location Physical Structure Population Served
Services Offered
June 22, 2010

10. Medical Home Getting There
CMHI’s TAPPP™ Framework
The Gap Analysis and Report
Special thanks to Jeanne McAllister, Lora Council, Carl Cooley, CMHI and the New Hampshire Endowment for Health for guidance and support.
June 22, 2010

11. Medical Home Getting There
Medical Home Improvement Plan
Challenges to change.
The NCQA Model
High Quality Teams: Lea Ayers, Ph.D
Challenges to be true to self.
Documentation without conformity.
June 22, 2010

12. Becoming a Medical Home Learning and Growing or Learning to Dance Backwards
CMHI’s TAPPP™ Framework
Team/teamwork -
Access /communication about access -
Population Approaches -
Planned Coordinated Care -
Patient & Family-Centered Care -
June 22, 2010

13. Teamwork - Teamwork flows from the mission, vision and values.
The lived experience: Lunch!
Humor: No sacred cows.
Anyone can have Reverse Tourettes
Documentation: Put it on the server.
June 22, 2010

14. Access Same Day Appointments Triage to reduce need
Improve phone communications
Move into the internet world.
Document policies.
Alternative communications
24/7
Brochures etc.
June 22, 2010

15. Organization of Clinical Information
Registry: CAD, CHF, NIDDM, Asthma
Referral Tracking: What saves lives and what enables dependent behavior?
Problem list vs Strengths list
Care Plan print out
June 22, 2010

16. Planned, Coordinated Care
Evidenced Based Practice: Documented?
High Risk list: Flexible yet functional
Care Coordination: Nursing 101
Documentation: Nursing 501
June 22, 2010

17. Community Resources How did we make connections?
How did we maintain relationships?
How did we document?
How did we educate about resources?
How did we measure competence?
June 22, 2010

18. Practice Performance What was to be measured?
patient satisfaction, ED visits, HEDIS data review, immunization
data, CAD, NIDDM, CHF
How would we measure?
Surveys and EMR reports
What data was needed?
NCQA requirements and the Medical Home Project
What data did we really want?
ED and hospital visit, behavior change, target area competence
June 22, 2010

19. Patient Engagement Partners in Care. Feedback
Methods to elicit information about the patient experience of care
How we use patient feedback to drive improvement
June 22, 2010

20. Flexible funding
If we had some flexible funding to support innovations, we would attempt to achieve the following medical home activities:
Electronic case management and eligibility
Health care competence software and other training and testing modalities.
Larger space: group meetings.
Co-location with other agencies/providers.
June 22, 2010

21. Q & A
June 22, 2010

22. Summing Up
In the last year we have worked on: Enhancing our communications, website, e-prescribing, referral documentation,
We know there have been real changes because: HEDIS data, Staff and patient responses, billing dept error corrections, immunization rate increases, DM flow charts utilized.
We have been supported by: TAP3 Analysis Report, Payor reports, patient responses, staff meetings, intuition.
We wanted to, but were not able to work on or improve: EMR update, Case management software, automatic lab results down loaded, Asthma Action Plan within EMR,
Significant barriers: Space, regional support, time, technical support, administrative support.
June 22, 2010

23. What’s next for us
Other comments -
June 22, 2010