Community Access Network

Transcription

1 Community Access Network P O S I T I V E L Y I M P A C T I N G P O P L U L A T I O N H E A L T H U S I N G T H E P A T I E N T C E N T E R E D M E D I C A L / H E A L T H H O M E M O D E L

2 Partners SERVICE AREA (FQHC) (Regional Hospital) (Free Clinic Buchanan County )

3 Partners Social Welfare Board Established in 1913 by Missouri State Statute to provide emergency, medical and dental services to the uninsured residents of Buchanan County Heartland Health Integrated health delivery system that seeks to improve the health of area individuals and communities and to provide the right care, at the right time, in the right place, at the right cost with outcomes second to none. Northwest Health Services Federally Qualified Health Center (FQHC). As a FQHC, NHS provides access to quality, cost-effective, affordable primary and preventive health care to all people who need it, regardless of ability to pay

4 How we started Siloed systems Need in the ER Contracted facilitator Preparation for Health Reform Committed Leadership

5 Goals of the Partnership N C Q A R E C O G N I T I O N F O R A L L 3 O R G A N I Z A T I O N S I M P R O V E D A C C E S S T O P R I M A R Y C A R E S E R V I C E S / R E S O U R C E S S T R E N G T H E N E D L O C A L C A P A C I T Y T O S E R V E F A M I L I E S A S P C H H I M P R O V E D H E A L T H S T A T U S O F F A M I L I E S S U S T A I N A B L E P C H H N E T W O R K I N C R E A S E D C O L L A B O R A T I O N P R E P A R A T I O N F O R H E A L T H R E F O R M

6 Goal Attainment Standardization across environments High level care coordination & communication Reduce barriers to care Reduce inappropriate utilization of the ER Enhanced delivery system based on community needs Accountability for Quality Address social determinants of health Comprehensive care Optimized health/ improved quality of life Improved standardized Chronic Care

7 NCQA For NHS Engaged MPCA Angela, Janice & Kathy Developed an information team 3 nurse managers, 1 nurse, 1 HIT manager, 1 Data Analyst Selected a team lead Treasa Riley Create a gap analysis based on NCQA standards Action plan to fill gaps Benefit grant to pay for application Multi-Site Application Buchanan County locations first Total of 6 locations to be submitted Identify Physician/Provider, Manager & Staff Champions Develop an internal/external communication plan Submit application no later than Dec. 1, 2010

8 Impact of NCQA Recognition for NHS Potential grant funding opportunities Increased emphasis on quality Improved patient involvement in care Increased focus on access & referral processes Gearing up for the future

9 NCQA For Heartland Approached and engaged physician Dr. Holda Developed team Practice Manager, 2 nurses, 1 Health Services Manager, PRN Data Analyst, Quality Manager, Interpreted elements/identified gaps based on NCQA standards Action plan to fill gaps Made decision of individual vs. multisite application Working on Individual-Site Application Create stepped plan for other system clinics Submit application no later than Dec. 1, 2010

10 Impact of NCQA Recognition for Heartland Forces practice change Embeds the Patient Navigator role Provides extra level of quality Creates practice system for planned care Pushes extra level of quality to the outpatient arena Provides template for ideal state Connects the dots

11 NCQA process for Social Welfare Board Completed baseline PCHH self assessment for organization Identified SWB-NCQA team Training Created a gap analysis and action plan utilizing expertise of PCA staff Arranged for funding of application fee Executive Director periodically meets with SWB NCQA team to discuss progress and challenges Engaging additional assistance from nursing student and Vista worker to pull application together by December 1, 2010 Develop internal and external messaging Working with local FQHC and hospital system to launch an EMR January 6, 2011

12 Impact of NCQA recognition for SWB All processes are reviewed, evaluated and enhanced Serves as reliable seal to consumers & health care organizations that Clinic provides quality medical care continuity of patient care enhanced Standardizes care according to best practices Clinic well managed Increase credibility with potential funders

13 Patient Centered Health Home 5 Areas of focus for the partnership & individual locations Wellness IQ Health Health Coaching Health Risk Assessment Smoking Cession Mind/Body Chronic Care Asthma Diabetes Heart Failure CAD COPD Chronic Pain Depression Wellness Care Management Chronic Care Telephonic Support Physician Led Care Management Complex Care Intensive Care Specialized Teams (CHF, COPD) Behavioral Health Hospitalization Emergency Room Physician Led Patient Centered Health Home NCQA: Recognition Physician Quality Reporting Initiative Telephonic Support Telephonic Intake Stratification Predictive Modeling Preventative Care Reminders Appointment Scheduling

14 Patient Assessed for CM triggers (same assessment at any point of contact, including self assessment through PHR) Referral to Call center (phone or automatic) notification through EMR) Call Center assesses per algorithm and refers to appropriate team Healthy; no risk Healthy; >5 risk factors Disease; self managed Disease; new diagnosis Disease; out of control Complex Issues Health Coach Team Disease Management Team Prevention/Wellness Complex CM Team

15 Care Management Triage Process Connecting Patients with Community Resources Assigning Patients to appropriate PCHH Self-Management Goals Referral Tracking & Coordination Quality & Safety focus Community Oriented Primary Care & Chronic Care Models Education, Activism, Empowerment Evidence based teams Data reporting transparency

16 Expected Outcomes of Partnership I N C R E A S E D : A c c e s s T o P r i m a r y / P r e v e n t i v e C a r e U t i l i z a t i o n O f C o m m u n i t y - b a s e d P r o v i d e r s U t i l i z a t i o n O f A p p r o p r i a t e R e s o u r c e s I M P R O V E D : R e i m b u r s e m e n t s P o p u l a t i o n H e a l t h C o m m u n i t y P a r t n e r s h i p s R E D U C E D : U t i l i z a t i o n O f E m e r g e n c y D e p a r t m e n t F o r N o n - e m e r g e n t C a r e P r e v e n t a b l e H e a l t h I s s u e s C o s t O f H e a l t h c a r e S e r v i c e s

17 Contact Information Nichole Wright Northwest Health Services Phone: Fiona Hummer Heartland Health Phone: (816) Linda Judah Social Welfare Board Phone: (816)