December 5th Learning Session Slides - PCMH Care Coordination
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Transcript of December 5th Learning Session Slides - PCMH Care Coordination
Patient-Centered Medical Home Transformation
www.hcgc.org
Improving patient engagement by sharing provider notes Nationwide Children’s Hospital Aarti Chandawarkar, MD Cheryl Pippin, MD
Improving care coordination in patient-centered medical homes Central Ohio Primary Care Larry Blosser, MD, Medical Director Judy Minaudo, RN, Quality Improvement Manager
Patient Centered Medical Home
•One of the first 9 Medical Homes in the Columbus area
•Since 2013 all COPC primary care practices have received – 44 total
Level 3 NCQA Patient Centered Medical Home accreditation
5% of patients
Typically have complex disease(s) and comorbidities
15-35% of patients
May have uncontrolled conditions and risk factors
60-80% of patients
Typically have minor conditions that are easily managed
High- Risk
Patients _____________
Rising-Risk Patients
______________
Low-Risk Patients
Source: The Advisory Board Company, 2013
CHF, DM, MI, COPD, PNEUMONIA
DM with A1c >9, DM Smokers, COPD
CAMPAIGNS using PATIENT PORTAL
Hospital Discharge
(Aetna MA, Humana MA, Anthem MA and MediGold only)
Home
Automatic referral to Care
Coordinator: CHF, DM, MI, COPD, or
PNEUMONIA
TCN will refer to Care Coordinator if TCN feels patient is
eligible with an explanation of
current concerns
SNF
TCN will message PCP; TCN will message CC if
currently enrolled
TCN will follow in SNF if FALL RISK, diagnosis of
WEAKNESS or CHF, DM, MI, COPD, PNEUMONIA
Automatic referral to Care Coordinator at time
of Discharge for above reasons
Care Coordination Roles
Assessment of Risk Factors
Help Patient with Setting
Goals
Disease Education
and Prevention
Assessment of Patient and Family
Needs
Connection to
Community Resources
Home Health &
DME Referrals
Patient Centered Medical Home
• “PCMH is just a building permit to do Population Health Management”
• - Bill Wulf, CEO
• Provide long-term patient centered multidisciplinary team approach= PCMH techniques
• Team consists of: – Physician Champion
– Site Rep
– Clinical lead
• Conditions: – Diabetes with A1c >9
– Diabetic Smokers
– COPD for 2015
Rising Risk & PCMH Initiative
Healthcare Transformation Learning Session December 5, 2014
Thank you for joining us today…
We need each of you to complete the brief evaluation and leave on your chair!
Happy Holidays!
Upcoming Regional Learning Sessions
Please save these dates from 8:30-11:30am: May 15, 2015
August 21, 2015
December 4, 2015