1. Yakima Neighborhood Health Services YNHS 2012 5 sites -- 64,580 encounters Health Coverage 33% uninsured 53% Medicaid Ethnicity 66% Hispanic Living in Poverty= 74% ************************ Yakima County Profile Health Coverage 15% uninsured 13% Medicaid Ethnicity 40.8% Hispanic/Latino Living in Poverty = 16.1%

2. Southeast Community CenterCentral WA Comp Mental Health Neighborhood Connections @Triumph Treatment Services Homeless Resource Center- Partnership w/ Homeless Network YNHS – Sunnyside Campus Supportive Housing Programs – Private Landlords, YWCA, Triumph, Housing Authority YNHS Satellites

3. 5 years ago … Successfully passed 3 Joint Commission surveys All reporting was EPM driven – diagnoses and procedure codes Diabetes Collaborative (PECS !) Evidence Based clinical outcomes and population management Health Care for the Homeless expanded “patient centered care” to include recuperative respite and housing EHR was fully implemented for medical services, but learning curve was still steep;

4. Journey to PCMH PCMH work group established -- COO, CMO, QI Coordinator and Medical Assistant Supervisors Goal -- showcase current integration and patient-centered care to obtain Level 3 Recognition. “Play on our Strengths”. MA’s “lead the horse to water” in DM templates and medication reconciliation (open the templates as part of patient intake). Strengthen EHR report-writing, and ability to know what matters.

5. 5 years later… NCQA- Level 3 Recognized (2008 Standards) for 2 sites in June 2011. Applying in June 2013 for 4 sites ((2011 Standards) Open templates, Sharing across programs— dental, behavioral health, outreach, public health allergy lists, medication lists, histories, chronic problems, vitals QI Projects: Meaningful Use, Immunization Rates, Cervical Cancer Screening No noticeable changes in overall patient satisfaction ratings. New questions added related to self-management support and safety practices with high ratings received. (4.86 and 4.96, respectively, out of 5) Staff satisfaction higher than average CHC’s (Staff Pulse) 68 % of medical/dental patients leave with an individualized Patient Plan

6. MA Vitals Report SSRS report that allows us to monitor completion of vitals by medical assistants.

7. Pre-visit Summary Our “virtual” huddle – automatically emailed to provider and team for next day’s appointments.

9. Challenges & Obstacles We’ve Overcome Challenges Balance between population management and individual care (resources) Creating maximum access AND connection to one PCP Lessons Learned Providers will use the template if it is there for them A team approach to care is better for the patient and better for the team