What Can the Primary Care Clinical Program Do to Help Our Clinic?
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1 What Can the Primary Care Clinical Program Do to Help Our Clinic? Central Region October 1, 2015 PPC Annual Meeting
2 What is the purpose of the PCCP? 1. Create reports on ADHD, care manager turnover and physician satisfaction for clinics to work on 2. Mapping algorithms to treatment for each chronic condition in the ICD 10 manual 3. To make it easier to follow best practices for teams and patients in PCP clinics 4. Be the shining example of living our healthiest lives possible for the entire system
3 Our ultimate goal is to help people live the healthiest lives possible. Together, we have the opportunity and the responsibility to make a better healthcare system. Charles Sorenson, MD President and CEO Intermountain Healthcare
4 Objective of the Primary Care Clinical Program Identify and develop support for patients served by Intermountain in Primary Care areas for helping people live the healthiest lives possible.
5 Primary Care Clinical Program and Intermountain Hospitals Medical Group SelectHealth Primary Care Clinical Program Population Health Affiliated Practices
6 Clinical Program Organizational Structure Clinical Program Leadership Medical and Operations Director Support Staff Development Guidance Councils Medical Directors Regional Clinical Manager SelectHealth, other support staff Implementation and Development Development Teams Specific Disease Process Development Physician Leadership Councils Implementation and Development 6
7 Intermountain Clinical Programs Behavioral Health Cardiovascular Intensive Medicine Musculoskeletal Neurosciences Oncology Pediatric Specialty Primary Care Surgery Women and Newborn 7
8
9 Primary Care Clinical Program Development Teams Choosing Wisely Diabetes Pre-diabetes High Blood pressure Asthma Anticoagulation Mental Health Integration Depression Anxiety Attention Deficit Disorder Chronic Pain Sleep disorders and Obstructive Sleep Apnea Antibiotic Stewardship Sinusitis Otitis Media Strep Bronchitis Community Acquired Pneumonia Lifestyle and Weight Management Chronic Obstructive Pulmonary Disease Chronic Kidney Disease Lipid Management 9
10 Concerning Population Health and the PCCP 1. The best cohort is the smallest cohort 2. The only patients that matter are our employees 3. By working to take care of all patients with best practices, every report looks better 4. Medicare patients take precedent as we are all getting older and deserve great care
11 The goal of Population Health and Clinical Programs is to improve health and decrease waste Cost Per Health Process X Processes Per Health Episode X Health Episodes Per Person Healthcare Cost Per Person = Cost per day, cost per MRI, Lab Test, etc. Number of tests per visit e.g. MRI for back pain How many patients have diabetes Efficiency Intracase Utilization Population Utilization
12 The balance between two worlds Fee for Service and Pay for Value 12
13 How does the PCCP help? Patient Education Provider Education and Support Supporting all Patients in the Practice Supporting Patients Coming into the Offices
14 How does the PCCP help? Patient Education Fact Sheets & Booklets Diabetes Prevention Program Health Hub Provider Education and Support Supporting all Patients in the Practice Supporting Patients Coming into the Offices
15 Concerning Patient Education, the best Fact Sheet is A long fact sheet after all more information is better 2. One that is translated into 6 languages 3. One that is handed out and reviewed with the patient for understanding 4. Colorful! And has at least 2 pictures of the PPC team
16 Patient Fact Sheets
17 Patient Fact Sheets How to Monitor Your Blood Pressure Understanding Chronic Kidney Disease (CKD) Low Back Pain Colds and Coughs in Adults: Managing Viral Infections (also for Pediatrics) Cervical cancer screening Borderline BP what to do Should I take med or LWM for elevated BP Statin shared decision making Preventive Care Women and Men Diabetes Prevention Act now to protect your health And more!
18 Patient Education Booklets Diabetes High Blood Pressure MAWDS CKD (in development) Lifestyle Weight Management Clinic Implementation Kit
19 How to get Patient Handouts Go to: iprintstore.org
20
21 Patients At-risk for T2DM Prediabetic, (Confirmed) 17,000 patients Based on FPG or HbA1c results Prediabetic, (Unconfirmed) Patients at risk for DM Adult patients > 18 yrs 35,000 patients Unconfirmed They have an abnormal glucose drawn at the same time as a fasting lipid panel 80,000 patients have risk factors for pre diabetes but have not been tested
22 Type PCCP in your IE8 browser
23 Linking Classes to Rural Regions
24 Patient Education on the Health Hub
25 Provider Education is important to the PCCP because The best doctors know it all too 2. Best outcomes happen when providers know the best practices and their patients needs 3. Creating educational opportunities is a wonderful chance to hear ourselves talk about how great we are 4. Changes happen so infrequently with medicine, nothing needs to be updated
26 How does the PCCP help? Patient Education Provider Education and Support Grand rounds for the PCP Creation of CPMs Flash cards and flash card app Web and EMR enhancements Our team to yours Research and evaluation of outcomes in our system that can guide recommended practices Supporting all Patients in the Practice Supporting Patients Coming into the Offices
27 Grand Rounds for the Primary Care Provider Link: Care-Grand-Rounds.aspx
28 Grand Rounds for the Primary Care Provider- ECME
29
30 Monthly Education for Staff Link: Education-Videos.aspx
31 Monthly Education for Staff Link: Education-Videos.aspx
32 Care Process Models High Blood Pressure Chronic Kidney Disease Diabetes Asthma Sinusitis Cervical Cancer Screening And More
33 CPM Documents and Flash Cards
34 Flash Cards- Condensed CPMs
35 Apple Device Flash card app /flashcard/install.html
36
37 Our Team to Yours
38 Research and Guidance for Best Practices Diabetes education paper Team based care study Diabetes prevention Anticoagulation
39 How does the PCCP help? Patient Education Provider Education and Support Supporting all Patients in the Practice EMR Support Process improvement Advocate for Resources Supporting Patients Coming into the Offices
40 The PCCP is delighted when patients come in to see their provider because The PCCP gets kickbacks for each patient that comes in for an annual wellness visit 2. Data is generated to create new and different reports 3. Providers and staff get to use the tools and information that the PCCP provides 4. It gives something for the doctors to do
41 HELP2 Forms
42
43
44 icentra Development Advisories Care Process Models Anticoagulation Alerts Care Pathways mpages Tablet Pilot
45 Taking Best Practices to the System
46 Best Practices for Clinic Process: Collaboration with Pharmacy Collaborative Pharmacy Management Allows providers to partner with a pharmacist for support in selecting, titrating, and monitoring medications
47 MHI support and implementation
48 How does the PCCP help? Patient Education Provider Education and Support Supporting patients when they are in the office Supporting patients when they are not in the office Reports that identify patients with gaps in care Feedback loop to improve efficiencies
49 What does the PCCP think about tools? 1. We love tools! All you need is a hammer, right? 2. Power or manual? 3. Anything to create efficiency and effectiveness in excellent care is a great plan 4. Tools are just for those with weak minds who can t track everything they need to remember
50 Quality Reporting One Report Registries for HBP, Diabetes, & Asthma Customizable Patient Lists
51 PCCP Dashboard
52 Master Patient Watch List Helps to see the patient as a whole person with potentially several conditions, not just one
53 High Blood Pressure
54 HBP Report with Patient List
55 HBP Patient Management Report
56 Correction Tool for Report Feedback loop is important
57 What could the PCCP do without the Medical Group? 1. Nothing 2. Nothing 3. Nothing 4. Nothing 5. All of the above
58 WHAT HAPPENS WHEN WE WORK TOGETHER?
59 Utah, Summit and Wasatch Counties High blood pressure not in control
60 How to we maintain the gain
61 How to we maintain the gain
62 The PCCP Touches lives through the hard work of you in the clinics 2. Is a valuable member of the care team 3. Cares about patients outcomes and overall health 4. Knows that excellent healthcare takes a team 5. All of the above
63 Questions? Contact information: Phone: Phone: Phone:
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