2. The Long and Winding Road to PCMH

3. Presenters Laurel Domanski Diaz, MNO, Director of Business Operations Dan Gauntner, CNP, Director of Clinical Operations Marianella Napolitano, RN, MBA, Clinical Quality Coordinator

4. Objectives Identify all of the workflows needed to implement PCMH Deep dive into NFP PCMH application Identify the challenge areas within the application Describe how to overcome the challenges presented due to limited ability to produce needed data

5. NFP Background A Federally Qualified Community Health Center founded in 1980 Last year served 13,400 patients on the near west side of Cleveland NCQA recognized as PCMH Level 3 under 2011 standards 17 Providers on staff--7 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives Focus on the medically underserved Serve a large Hispanic population

6. What is a Care Team? A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

7. Our Care Team Composition Three Providers—combination of Family MDs, Family CNPs, one team’s providers consists of 3 Certified Nurse Midwives One to two RNs One to two Patient Advocates Medical Assistant for each Provider Front Office representative at each team meeting

8. Care Team Implementation Activities Developing new procedures around scheduling, registering patients & directing phone calls to teams. Conducting activities around team formation, structure and ongoing activities. Organizing providers and support staff into integrated care teams Redesigning of Nursing staff structure to provide individual nurses to care teams. Adding a Patient Advocate to each team, vital role in the PCMH model Extended Team Support includes:  On-site Clinical Pharmacist  CareSource RN  Wellness Coordinator  Refugee Health Services  Medication Assistance Program  Diabetes Education

9. The PCMH Team & Application Plan Identify the PCMH Application Team Identify Key Application Facilitators Delegation of different areas of application to relevant person Need to have a variety of people on team, clinical and non- clinical Organization of application and documents Tackle each section, utilizing organization’s resources as needed Weekly working sessions, day long sessions as submission time approached

10. Survey & Intake – What we needed to create Inventory of Policies and Procedures, update the manual with EMR implementation, focused on PCMH relevant documents Inventory of reports that existed, what needed to be created, etc. Surveyed current workflows and determined how they needed to change to meet the requirements:  Patient Advocate role and new responsibilities to meet requirements  Front Office no-show work  Clinical Teams work flow around self management goals and patient education  Referral follow up process

11. Deep Dive Into the PCMH Application

12. Element 1: Enhanced Access & Continuity A—Access During Office Hours: Phone reporting system was used to demonstrate volume of incoming calls that RNs used to triage patient calls B—After Hours Access: Reports from our Answering Service that shows when the patients called NFP and at what time NFP providers returned the call.

13. After Hours Documentation

14. Element 1: Enhanced Access & Continuity E—Medical Home Responsibilities CareEverywhere capabilities allowed us to demonstrate care coordination/communication across different settings. G—The Practice Team Standing Orders Protocol Development Pre-Orders Workflow Implementation (insert workflow)

15. Pre-Orders Workflow PA identifies patients with Chronic Conditions PA scrubs the chart and enters routine labs/immunizations per protocol PA calls all DM, HTN patients to remind them of visit and to bring blood sugar readings and medications Documentation of pre-visit / pre-order preparation Team Huddles From documentation in EPIC, team is aware of pre-orders MA releases pre- orders during the patient’s visit Prior to the VisitDay of the Visit

16. Pre-Order Protocol

17. Element 2- Identify and Manage Populations A—Patient Information Primary Caregiver is defined as the name of the Emergency contact for patients under 18 NFP did not identify a legal guardian/health care proxy D—Use Data for Population Management Solutions (Chronic Care, Well Child Care, Coumadin report) Managed Care Plans registries Patient Schedule for pre-natal care outreach & chronic disease management No Show report within EPIC Televox report for daily reminders

18. Element 3 – Plan and Managed Care and Element 4 – Provides Self-Care Support and Community Resources 3A—Implement Evidence-Based Guidelines Defined guidelines used and inserted screenshots of patient charts where they were used Health maintenance and best practice alerts 3B–-Identify High Risk Patients High Risk Definition (Solutions) Rosters – Ability to analyze data using excel 3C, 3D, 4A NFP Patient Examples NCQA Manual Chart Audit option

19. Element 5 – Track and Coordinate Care 5B—Referral Tracking and Follow-up Access to portals for other Epic providers in the region to obtain reports Item 7 - Providing an electronic summary of the care record to another provider for more than 50 percent of referrals NFP provides electronic access to outside providers through Care Everywhere – which is used by majority of healthcare providers in region.

20. Element 6 – Measure and Improve Performance Leadership commitment to Quality FQHCs: used your Quality Management Plan from your HRSA grant UDS reports and trends Solutions reports Utilization measures (preventative care measures) Reinforcement of workflows/training Immunization Registries Make mention of any Quality Collaborative that you are currently participating

21. Questions?