1. Clinical Redesign Approach Centric to the LPN Coordinated Care Model
Best Practice:
Clinical Redesign Approach Centric to the LPN Coordinated Care Model
Laura Nicosia, MD
Chair – Primary Care – Ochsner WB
October 29, 2015

2. Agenda Purpose of program Program overview
Short and long term program goals
Preliminary results

3. -Steven Lefar, Sg2 President and CEO
Purpose of Program
“Today we are primarily in the business of delivering care one patient at a time. By contrast, a population health practitioner is concerned with achieving healthy outcomes for an entire population.”
-Steven Lefar, Sg2 President and CEO

4. Purpose of Program
Use Epic to maximize population health management through the use of a registry
A registry is a group of patients who match a specified criteria and, based on that population, have relevant clinical and miscellaneous metrics.

5. Purpose of Program
A diabetes registry could include an Epic inclusion rule that looks at patients who have a diabetes-related diagnosis on their problem list and/or have had an encounter with a diabetes diagnosis documented within the last five (5) years – regardless of age, insurance, etc.
Based on this criteria we may want to see for a specific provider all of their patients with diabetes and:
Patient’s Last Office Visit Date
Patient’s blood pressure (BP) - goal less than 140/90
Patient’s Last LDL result
Patient’s Last Positive Urine Protein Result
Patient’s Last Foot Exam Date
Patient’s Last Eye Exam Date

6. CCC LPN Program - Overview
Piloted in Baton Rouge in April 2015
Expanded system wide to all of Primary Care (including the WB) in June 2015
Currently have 23+ CCCs in place system wide – 3 on the WB (ratio is about 1 CCC per 7-8 physicians) for the Ochsner Primary Care employed providers

7. CCC LPN Program - Overview

8. CCC LPN Program – Goals short term
#1 Goal is to close primary care gaps
Place bulk orders based on the diabetes registry (Hgb A1c, urine for microalbumin, lipid panel)
Call patients that have not been seen in a year to schedule an appointment
Pre-visit planning – look at patients that will be coming in next 2 weeks to close care gaps

9. CCC LPN Program – Goals short term

10. CCC LPN Program – Goals short term

11. CCC LPN Program – Goals long term
Referrals to outpatient case management
Attend QBPC meetings on Fridays to address barriers with patients scheduled to see PCP in 2 weeks
Teach providers about the metrics – roll out just beginning
Meet with providers at least once every 2 weeks to review patient needs with scheduled appointments – align with HEDIS and STAR goals
Support Population Health: understand the programs and navigate patients to the support needed (i.e., DM patients that may need a health coach, or empowerment program, or a visit with a nutritionist)

12. Population Health: Care TOuch
CCC LPN Program - Goals
Other registries to come:
HTN
in progress
COPD
role out spirometry to satellite clinics
Wellness
Immunization
Population Health: Care TOuch

13. CCC LPN Program - Goals Other considerations:
Once orders are fulfilled the orders and gap disappear from the registry
Orders remain good for 1 year
Will recontact patients with open gaps quarterly
Patient Groups can be prioritized:
Humana Gold
MSSP (Medicare)
Employee Group
Blue Cross: Quality Blue Primary Care

14. CCC LPN Program - Goals Other considerations:
We are working with Registration on capturing the patient’s PCP in Epic
We are working with lab to create a walk up mechanism for several selected sites (other sites will need an appointment)
At this time bulk notifications will be sent as follows:
Portal Patients will be notified via the portal
Non-portal patients will be notified by phone or letter based on preference

15. CCC LPN Program - Results
West Bank
(~ inception through August 2015)
Total # of patients in registry:
Outreach: # pts who received a notification:
Total # of labs/tests completed:
Unique # pts that completed labs:
Avg # of labs/tests completed by patient:
Percent of patients reached out to that completed labs: 24%
(In line with the total system result which is ~ 24%)