Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg

Counties of rural South Western Kentucky

Cohort 1Learning Community Region 4

Hopkinsville, KYKecia Fulcher – Project Director

kfulcher@pennyroyalcenter.org

Lisa Bridges – Nurse Care Managerlbridges@pennyroyalcenter.org

1-877-473-7766

Statistics are good sometimes in evaluating programs, but the most important number we see each and every day is ONE. One represents each

person whose life has been changed, or even saved as a result of Integrated Health. The 24-year old male

client with early onset Diabetes and Hypertension doesn’t care about statistics, but he does care about

ONE, and how his life has been improved because we also cared about ONE.

Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of Western Kentucky

Who We Are• University of Kentucky

– Primary Evaluator – Tina Studts, PhD.

• Collaborative Agreements– Dentists, Labs, Health Departments, Hospitals

• Our Own Primary Care Staff– Dr. Stephen Thore / Dual Licensed

Psychiatric Addictionist / OB/GYN– Dr. David Gray – Dual Licensed

Psychiatrist / Family Practice– Linda Dillard, APRN– Lisa Bridges, RN Nurse Care Manager

Program Goals275 clients per year / 1,100 in 4 years

To improve access to primary care services.

To improve prevention, early identification and intervention as well as

treating chronic diseases.

To enhance the program’s capacity to holistically serve individuals

through screening techniques and service delivery.

To improve the overall health status of the Hopkinsville community.

Individual GrantProgram Measures

Our Typical ClientFemale – 59%Mid 40s – Early 50s – 27%Stable place to live in community – 78%Non-Drinker – 76%Obese – (Based on BMI) – 71%Tobacco User – 65%

DAST, Audit, SPO2 – O2 saturation

Successful Strategy : Evaluation/Reassessment

We have a subcontract with the University of Kentucky for data collection along with help from our IT Department. Two research assistants complete reassessment interviews.

Reassessment Rates : Year 1 - 96% Year 2 - 89%

Successful Strategy: HITBefore HIT

Using EHR since April 2009 – Certified Vendor is NetSmart

Since HIT Obtained 1st Meaningful Use payments Installed and have begun using OrderConnect Will install ConsumerConnect – Client portal to access PHI Will install CareConnect – HIE Portal Kentucky GOEHI obtained a National Council Grant – We are working with KHIE and KYREC. Working toward Year 2 Meaningful Use Criteria

Health and Wellness TopicsDisease ManagementDiabetes / Pre-DiabetesOral health for diabetesHyperlipidemiaHypertensionHepatitis CTobacco CessationOral healthChronic Fatigue / Fibromyalgia

Plans for The Future• Sustainability

• Clinical – Contracts with other primary care providers• Administrative – Commitment to long term plans for integration • Financial – Developing fiscal services for primary care

• Next six months:• Hire CNA for improved patient flow• Add two more exam rooms• Become a provider for Medicaid, TriCare, and other third party payors• Explore Medical Health Home and ACO activity