1. Patient Centered Medical Home at a CHD Okaloosa County Health Department Opportunity Health Clinic

2. Opportunity Health Clinic- Patient Centered Primary Care at the Okaloosa County Health Department The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults in a setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults in a setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association have agreed on joint principles of the PCMH and programs to assure quality care within this model is available The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association have agreed on joint principles of the PCMH and programs to assure quality care within this model is available

3. Joint Principles of the Patient Centered Medical Home Personal Physician -each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Personal Physician -each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice - the personal physician leads a team who collectively take responsibility for the ongoing care of patients Physician directed medical practice - the personal physician leads a team who collectively take responsibility for the ongoing care of patients Whole person orientation - responsible for all health care needs personally or by arrangement through all life stages and for acute, preventive, chronic, and end-of-life care Whole person orientation - responsible for all health care needs personally or by arrangement through all life stages and for acute, preventive, chronic, and end-of-life care Coordinated and integrated care - across complex health system elements Coordinated and integrated care - across complex health system elements Quality and safety - Evidence-based medicine, use of IT, voluntary recognition process, patient participation in QI Quality and safety - Evidence-based medicine, use of IT, voluntary recognition process, patient participation in QI Enhanced Access - through open scheduling, expanded hours and new communication options Enhanced Access - through open scheduling, expanded hours and new communication options Payment recognizes the added value of the medical home concept Payment recognizes the added value of the medical home concept

4. Okaloosa CHD - PCMH PCMH PCMH For persons living with HIV/AIDS for 9 years For persons living with HIV/AIDS for 9 years For uninsured individuals for 1 year For uninsured individuals for 1 year Linkage to a PCMH for Medicaid and uninsured has the potential to reduce ambulatory care sensitive hospital admissions and readmissions Linkage to a PCMH for Medicaid and uninsured has the potential to reduce ambulatory care sensitive hospital admissions and readmissions

5. HIV/AIDS PCMH- Examples of Long term success – 4 patients Enrolled in program for 8-9 years Enrolled in program for 8-9 years Male/Female ages 38-54 yrs Male/Female ages 38-54 yrs Besides HIV have 7-13 other serious diagnoses Besides HIV have 7-13 other serious diagnoses Average number of medications: 13 (7-19) Average number of medications: 13 (7-19) 3 employed, 1 disability due to stroke 3 employed, 1 disability due to stroke 1 uninsured small business owner, 2 TPI, 1 Medicaid/Medicare 1 uninsured small business owner, 2 TPI, 1 Medicaid/Medicare ALL CD4 >200; VL undetectable; no hospitalizations in at least the last 2 years ALL CD4 >200; VL undetectable; no hospitalizations in at least the last 2 years

6. Michael: IDDM since age 9 yrs; lost Medicaid, now age 21 yrs Prior to enrollment in OH clinic Prior to enrollment in OH clinic Repeated hospital admissions for DKA Repeated hospital admissions for DKA Inability to obtain Levamir brand insulin- using 70/30 because of cost Inability to obtain Levamir brand insulin- using 70/30 because of cost No diabetic test strips or nutritional counseling No diabetic test strips or nutritional counseling No access to physician care No access to physician care No lab testing access No lab testing access Fasting glucose 589 mg/dl Fasting glucose 589 mg/dl Wt 116 lbs Ht 5’ 10’’ Wt 116 lbs Ht 5’ 10’’ Couldn’t hold a job due to illness Couldn’t hold a job due to illness Enrolled in OH clinic for 2 months No admission since enrollment On Levamir insulin with much improvement in glucose control Completed diabetes education class on Day 1 of enrollment Tests sugars daily Seen frequently by OH provider and has phone contact with nurse HgbA1c = 8% and average glucose now 120 mg/dl Wt gain of 13 lbs in one month Now holds full-time job

7. The POWER of Patient –Centered Primary Care to Reduce Hospital Readmissions Excellent primary physician care Excellent primary physician care Compassionate nurse case management Compassionate nurse case management Access to medication & assistance with medication adherence Access to medication & assistance with medication adherence Nutrition counseling Nutrition counseling Behavioral health care Behavioral health care Coordination of specialty care & other care Coordination of specialty care & other care Continuity between inpatient & outpatient care Continuity between inpatient & outpatient care

8. Other resources in Okaloosa County to decrease hospital readmission Hospital-based coumadin clinics post discharge Hospital-based coumadin clinics post discharge Referral to FQHC or CHD clinics Referral to FQHC or CHD clinics Medicaid providers for children Medicaid providers for children Hospital-based urgent care clinics Hospital-based urgent care clinics Non-hospital based urgent care clinics Non-hospital based urgent care clinics

9. Other ideas to reduce readmissions Assure there is communication between inpatient and outpatient providers especially when inpatient care is provided by hospital employed physicians Assure there is communication between inpatient and outpatient providers especially when inpatient care is provided by hospital employed physicians Hospitals provide means for patients/families to have questions answered following discharge with goal of early intervention to prevent readmission Hospitals provide means for patients/families to have questions answered following discharge with goal of early intervention to prevent readmission Hospitals consider routine immediate post-discharge calls (24-72 hrs) to check on status of patient Hospitals consider routine immediate post-discharge calls (24-72 hrs) to check on status of patient

10. Opportunities Hospitals working with CHDs providing primary care Hospitals working with CHDs providing primary care Targeted use of laboratory, radiology services, and other hospital resources to support patients in care in medical homes Targeted use of laboratory, radiology services, and other hospital resources to support patients in care in medical homes Enhanced communication as care networks are stabilized and providers become known to hospital staff Enhanced communication as care networks are stabilized and providers become known to hospital staff