Rural Health Care Leadership Conference. From Cardboard to Concrete and Beyond Medical Home Sweet Home. February 10, 2015

Size: px
Start display at page:

Download "Rural Health Care Leadership Conference. From Cardboard to Concrete and Beyond Medical Home Sweet Home. February 10, 2015"

Transcription

1 Rural Health Care Leadership Conference From Cardboard to Concrete and Beyond Medical Home Sweet Home February 10, 2015

2 PLEASE NOTE: The views expressed by the conference speakers do not necessarily reflect the views of the American Hospital Association and Health Forum. 2

3 Commitment to Community 3

4 Population of 26,948 Demographics: 52% African American 48% Caucasian Community Profile Median income of $29,849 20% of the population is below the poverty line Overall health ranking is 89 th out of 100 counties in North Carolina 4

5 Top Five Causes of Death in Anson County 1. Heart disease 2. Cancer (primarily trachea, bronchus and lungs) 3. Cerebrovascular disease (brain blood clot or hemorrhage) 4. Chronic lower respiratory disease 5. Diabetes 5

6 Obesity and Diabetes Focus 36% of the adults in Anson County are obese Defined as having a Body Mass Index [BMI] of 30 or more Public Health Survey Priorities Obesity and Diabetes 23% have Heart Disease 27% have Hypertension (High Blood Pressure) 26% have High Cholesterol 25% have Diabetes 6

7 Leadership Vision This community is counting on us to help them. We have an opportunity to greatly improve population health with our new model of care where we blend 21 st century analytics with 21 st century innovations. Joe Piemont, Carolinas HealthCare System President and COO 7

8 What is a Patient Centered Medical Home? The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place, but as an approach to primary care whereby patient treatment is team based and coordinated to ensure patients receive the necessary care in the right place, at the right time, and in the manner that best meets their needs 8

9 Features of the Medical Home Patient Centered Comprehensive Coordinated Accessible Committed to Quality and Safety 9

10 Conceptualization and Design of New Facility 10

11 Lean 3P: People - Preparation - Process Objective of 3P event: Create a detail level facility design that best enables the flow of patients, clinicians, medication, supplies, equipment, information, and processes (7 flows) Using Lean principles, subject matter experts who do the work define process flow first; physical layout is then designed to support workflow Over 5 day event, Surgery, Patient Care, ED/Medical Home, Patient Navigation, Imaging, and Overall Layout teams developed and ranked multiple designs based on how well each met core design criteria 11

12 Core Design Criteria 1. Patient travel distance 2. Nurse travel distance 3. Physician travel distance 4. Patient handoffs 5. Floor space (square footage) 6. Staffing requirements 7. Capacity for growth 8. Access 12

13 Day 1 - Developing and Selecting Designs 13

14 Final Overall Layout 14

15 Day 2 - Building the Selected Design

16 Days 3 and 4 - Simulations/Revising Layout 16

17 Days 3 and 4 Flow Simulation Examples Inpatient Where do we store cribs? Family member space: need to locate chairs away from patient care area Operating Room Patient going south! Ambu bag on headboard? Where is crash cart? Where would EMS pick this patient up for transfer? Registration Patient arrives for scheduled surgery need escort; where is pre-op? Wheelchair storage close to front lobby? ED/Medical Home Agitated patient screaming in lobby; where is security? Clinical staff? Safe room and sitter space available? Patient presents with stroke symptoms; where is rapid triage area? 17

18 Day 5 Design Approval and Report Out 18

19 From Cardboard to Concrete and Beyond 19

20 True North To significantly improve the health status of Anson County by offering an innovative, community-focused delivery model. 20

21 Anson Service Mix Patient-Centered Primary Care Practice Emergency Department Inpatient and Observation Unit Surgery Digital Imaging Pharmacy Laboratory Behavioral Health Personal Care Services / CAP / Home Health Community Meeting Space 21

22 Power of the System Committee Structure System-wide collaboration and teamwork to create change Legal and Regulatory Transition Operations Committee Medical Home Committee Anson Executive Committee Construction Committee Teammate Committee Community Relations Committee Increased emphasis on providing value to the customer 22

23 Innovative Care Model Outcomes focused Wellness and prevention Triple Aim: transforming to provide value (cost/quality/access) Virtual Care Health Advocate Coaches Rotating Specialist Providers New Facility Design Improving the Health of Anson County Highly Engaged Community Medical Screening Exam Process Resource and Skill Mix 23

24 Our New Model Patient Flow Patient seeks medical care Community health advocates update primary providers Provider screens for needs Care Team follows up with patient Patient is treated in the most appropriate setting Health Coach coordinates care and connects patient to community services 24

25 Our Commitment Enhance patient and community outcomes through personal, virtual and collaborative connectivity of Carolinas HealthCare System s network of specialized services, supplemented by existing community services provided by local faith-based and other organizations Provide and support a team of healthcare professionals for primary and preventive care, including a family practice residency program Enhance the number and breadth of specialist physicians practicing in Anson County Provide improved access to appropriate services, through telemedicine applications and other services Develop a flexible, cost-effective new facility that encourages collaboration among health professionals and provides an adaptable design for the evolving care needed to service the community 25

26 Care Coordination Team 26 Virtual Care Transport Assistance Wellness Coach Home Health (CAP) Personal Care Acute Care Hospital Clinical Pharmacist Behavioral Health CCNC Mobile Clinic Faith Based Services (Advocate) Dietician Patient Navigators Social Workers Advanced Care Practitioner (ACPs) Family Practice Physicians Tele Monitoring Health Quest Pharmacy Assistance Registered Nurses Care Coordinator

27 21 st Century Analytics with 21 st Century Innovations Community Health Management Identify population and create registry Perform analytics Create segments Top 3% of population with high use and cost (1 st Tier) Next 7% of population with high use and cost (2 nd Tier) Target interventions Measure and monitor Select and Stage Programs to Implement Effects within months Effects within 1 2 years Effects within 3 5 years or more 27

28 Measuring Progress and Success - Leading Short Term Initiatives Increase % of Anson County population utilizing Anson Primary Care Medical Home once every 18 months Baseline Performance 2015 Target 2016 Target State Benchmark National Benchmark 19% 30% 35% N/A N/A Decrease % of inappropriate ED utilization for existing patients Increase # of Wellness Visits for Care Coordination of High Risk/High Cost patients 45% 40% 35% 44.1% 42.8% HSR HSR Increase # of Community Engagement Activities - Screening Events - Pre-D and Diabetes - Mental Health N/A N/A - Educational Offerings - Nutritional Classes - Smoking Cessation N/A N/A 28

29 Measuring Progress and Success - Lagging Long Term Initiatives Baseline Performance 2019 Target 2020 Target State Benchmark National Benchmark Increase % of Anson County population utilizing Anson Primary Care Medical Home once every 18 months 19% 50% 55% N/A N/A Decrease ED Utilization Per Capita % 41% Decrease Adult Diabetes Incidence Rate Decrease Adult Obesity Incidence Rate 14% 9% 8% % 28% 25% 28.6% 27.6% Decrease Heart Disease Hospitalization Rate 72.1 per 1, per 1, per 1, per 1, per 1,000 Decrease Medicare Spend Per Beneficiary (MSPB)

30 Integrated Partnerships Carolinas HealthCare System and the Anson Community 30

31 Community Support

32 73 years old female Lifetime smoker Chronic conditions include hypertension and diabetes Battles depression Elderly patient Myrtle Lives alone with little support from friends or family Historically a non-compliant patient 14 Visits to the Emergency Room last year 32

33 Myrtle s Care Is Now Coordinated Visited Anson s ER in late July for a non- emergent condition After medical screening exam was transitioned to Carolinas Primary Care Hasn t been to the ER in 90 days, and her chronic conditions are being treated by her PCP Has utilized Anson transportation services for her PCP visits Has utilized HealthQuest Pharmacy Assistance program Has a weekly call from a Nurse/Social Worker, and is also being seen by our Psychotherapist 33

34 Improving Outcomes In Summary Access to Care Mobile unit and outreach efforts Medical Home with 3 additional providers and extended hours Specialists rotating to Anson County Transportation assistance Care Coordination Comprehensive Team Defined care plans and goals Data Analytics Disease Registry Risk Stratification of patients Engage patients and families to be part of the Care Team Promotes Health Advocates to help educate the Community 34

35 Improving Outcomes In Summary Lowering the Cost of Care Medical screening process in the ER Virtual Care Care Coordination Predictive data analytics Outreach efforts to drive patients to Medical Home Community Outreach Health screenings Pre D, Cholesterol, Blood Pressure, etc. Community Education Health Advocates Mobile Unit HEALTHWORKS 35

36 Emergency Dept Utilization 36

37 Medical Screening Exams 37

38 Trends in Patient Volume 38

39 Doing Different Things in Different Ways Innovative Mobile/Virtual Collaborative Data Informed Patient Engagement 39

40 Thank You

medicaid commission on a n d t h e uninsured May 2009 Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid SUMMARY

medicaid commission on a n d t h e uninsured May 2009 Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid SUMMARY kaiser commission on medicaid SUMMARY a n d t h e uninsured Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid Why is Community Care of North Carolina (CCNC) of Interest?

More information

Innovative Ways of Achieving The Triple Aim: Lessons from a Rural Community Health System

Innovative Ways of Achieving The Triple Aim: Lessons from a Rural Community Health System Innovative Ways of Achieving The Triple Aim: Lessons from a Rural Community Health System Roxanne Elliott, MS Policy Director FirstHealth of the Carolinas Goals For Today Review scope of project Integrate

More information

2015 DUPLIN COUNTY SOTCH REPORT

2015 DUPLIN COUNTY SOTCH REPORT 2015 DUPLIN COUNTY SOTCH REPORT Reported March 2016 State of the County Health Report The State of the County Health Report provides a review of the current county health statistics and compares them to

More information

Community Health Needs Assessment: St. John Owasso

Community Health Needs Assessment: St. John Owasso Community Health Needs Assessment: St. John Owasso IRC Section 501(r) requires healthcare organizations to assess the health needs of their communities and adopt implementation strategies to address identified

More information

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services

More information

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14

More information

Patient-centered medical homes (PCMH): eligible providers.

Patient-centered medical homes (PCMH): eligible providers. ACTION: Final DATE: 09/21/2018 3:40 PM 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary

More information

Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015

Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015 Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015 I. Executive Summary The vision of Nevada County Behavioral Health (NCBH)

More information

Community Counseling Centers, Inc. & North Country Health Care

Community Counseling Centers, Inc. & North Country Health Care Community Counseling Centers, Inc. & North Country Health Care Holbrook & Show Low Navajo County Communities 9/28/11 The CCC multi-faceted approach to an integrated health program with North Country Health

More information

VHA Transformation to a Patient Centered Medical Home Model of Care

VHA Transformation to a Patient Centered Medical Home Model of Care VHA Transformation to a Patient Centered Medical Home Model of Care Joanne M. Shear MS, FNP-BC VHA Primary Care Clinical Program Manager Office of Primary Care Operations & Policy Washington, DC Joanne.shear@va.gov

More information

Treating sinusitis? Managing obesity? Preventing heart disease? Preventing lung cancer? Managing individuals with multiple chronic diseases?

Treating sinusitis? Managing obesity? Preventing heart disease? Preventing lung cancer? Managing individuals with multiple chronic diseases? Treating sinusitis? Managing obesity? Preventing heart disease? Preventing lung cancer? Managing individuals with multiple chronic diseases? Providing care for long-term cancer survivors? Managing depression?

More information

FirstHealth Moore Regional Hospital. Implementation Plan

FirstHealth Moore Regional Hospital. Implementation Plan FirstHealth Moore Regional Hospital Implementation Plan FirstHealth Moore Regional Hospital Implementation Plan For 2016 Community Health Needs Assessment Summary of Community Health Needs Assessment Results

More information

Community Health Needs Assessment for Corning Hospital: Schuyler, NY and Steuben, NY:

Community Health Needs Assessment for Corning Hospital: Schuyler, NY and Steuben, NY: Community Health Needs Assessment for Corning Hospital: Schuyler, NY and Steuben, NY: November 2012 Approved February 20, 2013 One Guthrie Square Sayre, PA 18840 www.guthrie.org Page 1 of 18 Table of Contents

More information

2015 Annual Convention

2015 Annual Convention 2015 Annual Convention Date: Tuesday, October 13, 2015 Time: 8:00 am 9:30 am Location: Gaylord National Harbor Resort and Convention Center, National Harbor 10 Title: Activity Type: Speaker: Opportunities

More information

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program: QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care

More information

Jumpstarting population health management

Jumpstarting population health management Jumpstarting population health management Issue Brief April 2016 kpmg.com Table of contents Taking small, tangible steps towards PHM for scalable achievements 2 The power of PHM: Five steps 3 Case study

More information

Durham and Duke - From a City of Medicine to a Community of Health

Durham and Duke - From a City of Medicine to a Community of Health Durham and Duke - From a City of Medicine to a Community of Health J. Lloyd Michener, MD - Professor and Chair Department of Community and Family Medicine Duke Medicine Public Health Workforce - Atlanta,

More information

Managing Patients with Multiple Chronic Conditions

Managing Patients with Multiple Chronic Conditions Best Practices Managing Patients with Multiple Chronic Conditions Fletcher Allen Health Care Case Study Organization Profile Located in Burlington, Fletcher Allen Health Care (FAHC) is Vermont s university

More information

Cardiovascular Disease Prevention and Control: Interventions Engaging Community Health Workers

Cardiovascular Disease Prevention and Control: Interventions Engaging Community Health Workers Cardiovascular Disease Prevention and Control: Interventions Engaging Community Health Workers Community Preventive Services Task Force Finding and Rationale Statement Ratified March 2015 Table of Contents

More information

Accountable Care and the Laboratory Value Proposition. Les Duncan Director of Operations Highmark Health - Home and Community Services

Accountable Care and the Laboratory Value Proposition. Les Duncan Director of Operations Highmark Health - Home and Community Services Accountable Care and the Laboratory Value Proposition Les Duncan Director of Operations Highmark Health - Home and Community Services Agenda The Goals and Status of Delivery System Reform and Alternative

More information

South Dakota Health Homes Care Coordination Innovation

South Dakota Health Homes Care Coordination Innovation South Dakota Health Homes Care Coordination Innovation Senator Deb Soholt NCSL Health Innovation Task Force December 6, 2016 South Dakota Health Homes Health Homes (HH)- provide enhanced health care services

More information

Union County Governance Public Health Partnership

Union County Governance Public Health Partnership Union County Governance Public Health Partnership Community Health Improvement Plan 2013 Revisions CHIP PRIORITIES Contents Table of contents Table of contents.1 The Union County Governmental Public Health

More information

Using Data for Quality Improvement in a Clinical Setting. Wadia Wade Hanna MD, MPH Technical Assistance Consultant Georgia Health Policy Center

Using Data for Quality Improvement in a Clinical Setting. Wadia Wade Hanna MD, MPH Technical Assistance Consultant Georgia Health Policy Center Using Data for Quality Improvement in a Clinical Setting Wadia Wade Hanna MD, MPH Technical Assistance Consultant Georgia Health Policy Center Dr. W. Hanna, PLS, November 2015 Quality An organizational

More information

The TeleHealth Model THE TELEHEALTH SOLUTION

The TeleHealth Model THE TELEHEALTH SOLUTION The Model 1 CareCycle Solutions The Solution Calendar Year 2011 Data Company Overview CareCycle Solutions (CCS) specializes in managing the needs of chronically ill patients through the use of Interventional

More information

Value-based Care Report. February How Value-based Care is improving quality and health.

Value-based Care Report. February How Value-based Care is improving quality and health. Value-based Care Report February 2018 How Value-based Care is improving quality and health. 1 Value-based Care means better health, better care and lower costs. Placing greater emphasis on value in health

More information

TO BE RESCINDED Patient-centered medical homes (PCMH): eligible providers.

TO BE RESCINDED Patient-centered medical homes (PCMH): eligible providers. ACTION: Final DATE: 09/21/2018 3:40 PM TO BE RESCINDED 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model

More information

Slide 1. Slide 2 Rural Princeton. Slide 3 Agenda Rural ACO RURAL ACOS CAN WORK AND LEAD THE WAY

Slide 1. Slide 2 Rural Princeton. Slide 3 Agenda Rural ACO RURAL ACOS CAN WORK AND LEAD THE WAY Slide 1 RURAL ACOS CAN WORK AND LEAD THE WAY Nebraska Rural Health Association September 20, 2017 Slide 2 Rural Princeton Slide 3 Agenda Rural ACO Illinois Rural Community Care Organization (IRCCO)/Statewide

More information

6/3/ National Wellness Conference. Developing Strategic Partnerships to improve the Health and Wellness of the Community. Session Objectives

6/3/ National Wellness Conference. Developing Strategic Partnerships to improve the Health and Wellness of the Community. Session Objectives 2015 National Wellness Conference Developing Strategic Partnerships to improve the Health and Wellness of the Community. Kimberly Sbardella, R.N. Manager, Community Health & Wellness Carolinas HealthCare

More information

ACOs: California Style

ACOs: California Style ACOs: California Style ACO Congress John E. Jenrette, M.D. Chief Executive Officer Sharp Community Medical Group November 2, 2011 California Style California Style A CO California Style California Style

More information

Managing Risk Through Population Health Initiatives

Managing Risk Through Population Health Initiatives Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty

More information

Stanford Coordinated Care

Stanford Coordinated Care Stanford Coordinated Care Support the patients, manage their care Ann Lindsay MD Alan Glaseroff MD IHI Innovation Network Webinar April 12, 2013 Where s the Leverage on Trend? Registries Gaps in Care Planned

More information

Session 097 PD - Population Management for Managed Medicaid. Moderator: Jeremy Adam Cunningham, FSA, MAAA

Session 097 PD - Population Management for Managed Medicaid. Moderator: Jeremy Adam Cunningham, FSA, MAAA Session 097 PD - Population Management for Managed Medicaid Moderator: Jeremy Adam Cunningham, FSA, MAAA Presenters: Jason Jeffrey Altieri, ASA, MAAA Jordan Paulus, FSA, MAAA Mary Kindel Van der Heidje,

More information

Managing Patients with Multiple Chronic Conditions

Managing Patients with Multiple Chronic Conditions Managing Patients with Multiple Chronic Conditions Sponsored by AMGA and Merck & Co., Inc. 1 Group Pre-work Affinity Medical Group Heart, Lung & Vascular Center COURAGE Clinic 2 Medical Group Profile Affinity

More information

Low Income Pool (LIP) Tier One Milestone (STC-61) Application for Enhancement Projects. Submitted by:

Low Income Pool (LIP) Tier One Milestone (STC-61) Application for Enhancement Projects. Submitted by: 2012-2013 Low Income Pool (LIP) Tier One Milestone (STC-61) Application for Enhancement Projects Submitted by: Florida Health Sciences Center, Inc. d/b/a Tampa General Hospital July 31, 2012 1 1. Applicant:

More information

Telehealth in the Veterans Health Administration. Mary C. Foster, DNP, Telehealth Program Manager Mid-Atlantic Health Care Network January 27, 2016

Telehealth in the Veterans Health Administration. Mary C. Foster, DNP, Telehealth Program Manager Mid-Atlantic Health Care Network January 27, 2016 Telehealth in the Veterans Health Administration Mary C. Foster, DNP, Telehealth Program Manager Mid-Atlantic Health Care Network January 27, 2016 The Vision For Telehealth In VA Patient Focused Makes

More information

Community Health Needs Assessment Supplement

Community Health Needs Assessment Supplement 2016 Community Health Needs Assessment Supplement June 30, 2016 Mission Statement, Core Values, and Guiding Social Teachings We, St. Francis Medical Center and Trinity Health, serve together in the spirit

More information

Organized, Evidence-based Care

Organized, Evidence-based Care Organized, Evidence-based Care Planning Care for Individual Patients and Whole Populations MODERATOR: Nicole Van Borkulo, MEd, Practice Improvement Specialist, SNMHI, Qualis Health SPEAKERS: Ed Wagner,

More information

COMMUNITY HEALTH NEEDS ASSESSMENT HINDS, RANKIN, MADISON COUNTIES STATE OF MISSISSIPPI

COMMUNITY HEALTH NEEDS ASSESSMENT HINDS, RANKIN, MADISON COUNTIES STATE OF MISSISSIPPI COMMUNITY HEALTH NEEDS ASSESSMENT HINDS, RANKIN, MADISON COUNTIES STATE OF MISSISSIPPI Sample CHNA. This document is intended to be used as a reference only. Some information and data has been altered

More information

L8: Care Management for Complex Patients: Strategies, Tools and Outcomes

L8: Care Management for Complex Patients: Strategies, Tools and Outcomes The Triple Aim 16 th Annual Summit: Institutes for Healthcare Improvement - Improving Patient Care in the Office Practice and the Community March 16, 2015 Dallas, Texas L8: Care Management for Complex

More information

Patient Centered Medical Home The next generation in patient care

Patient Centered Medical Home The next generation in patient care Patient Centered Medical Home The next generation in patient care Provider Training Module I OBJECTIVE To explain... What Patient Centered Medical Home is How it works Why it s important Where to begin

More information

Patient-centered medical homes (PCMH): Eligible providers.

Patient-centered medical homes (PCMH): Eligible providers. ACTION: Final DATE: 09/20/2016 8:11 AM 5160-1-71 Patient-centered medical homes (PCMH): Eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary

More information

Partner with Health Services Advisory Group

Partner with Health Services Advisory Group Partner with Health Services Advisory Group Bonnie Hollopeter, LPN, CPHQ, CPEHR Health Services Advisory Group (HSAG) Quality Improvement Lead Rosalie McGinnis, MS, RN HSAG Quality Improvement Lead November

More information

Hendrick Center for Extended Care. Community Health Needs Assessment Implementation Plan

Hendrick Center for Extended Care. Community Health Needs Assessment Implementation Plan Hendrick Center for Extended Care Community Health Needs Assessment Implementation Plan - 2014-2016 Overview: Hendrick Center for Extended Care ( HCEC ) is a Long Term Acute Care Hospital, within Hendrick

More information

Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator

Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator Janet Tomcavage, RN, MSN VP Health Services, Geisinger Health Plan Danville, PA February 3, 2012 Patient-centered primary care

More information

Issue Brief. Maine s Health Care Workforce. January Maine s Unique Challenge. Current State of Maine s Health Care Workforce

Issue Brief. Maine s Health Care Workforce. January Maine s Unique Challenge. Current State of Maine s Health Care Workforce January 2009 Issue Brief Maine s Health Care Workforce Affordable, quality health care is critical to Maine s continued economic development and quality of life. Yet substantial shortages exist at almost

More information

Using Data for Proactive Patient Population Management

Using Data for Proactive Patient Population Management Using Data for Proactive Patient Population Management Kate Lichtenberg, DO, MPH, FAAFP October 16, 2013 Topics Review population based care Understand the use of registries Harnessing the power of EHRs

More information

Shana Scott, JD, MPH, Health Systems Team Lead Tuesday, October 3, 2017

Shana Scott, JD, MPH, Health Systems Team Lead Tuesday, October 3, 2017 Health Systems Transformation & Health System Interventions: Innovative Public Health Approaches to Improve Quality of Care for Georgians with Chronic Conditions Presentation at 2017 Southern Obesity Summit

More information

IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE. Tennessee Primary Care Association Annual Conference October 25 26, 2012.

IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE. Tennessee Primary Care Association Annual Conference October 25 26, 2012. IMPLEMENTATION OF INTEGRATED CARE FROM A LEADERSHIP PERSPECTIVE Tennessee Primary Care Association Annual Conference October 25 26, 2012 Outline I. Brief Overview of Cherokee (Who are we?) II. The Integrated

More information

Requirements Document for the Blue Quality Physician Program sm Criteria Effective 08/03/2015

Requirements Document for the Blue Quality Physician Program sm Criteria Effective 08/03/2015 All practices must reapply to the BQPP every 18 months Criteria Definition Validation Source(s) 7 Practice Elements 3 Provider Elements Practice level points: 1. PCMH/PPC/PCSP Recognition *Mandatory 2.

More information

Virtual Care Solutions Moving Care from the Hospital to the Home

Virtual Care Solutions Moving Care from the Hospital to the Home Virtual Care Solutions Moving Care from the Hospital to the Home Access Strategy Revenue Strategy Primary Care Strategy Building onto existing infrastructure to move to the next paradigm of healthcare

More information

Designing Reliable Value-based Systems of Care for Chronic Disease and Prevention

Designing Reliable Value-based Systems of Care for Chronic Disease and Prevention Designing Reliable Value-based Systems of Care for Chronic Disease and Prevention Frederick J. Bloom, Jr. MD MMM President, Guthrie Medical Group 1/23/15 Where We Want to Be 1. Affordable coverage for

More information

Community Health Needs Assessment (CHNA) Implementation Plan. October 2016 Believe. Inspire. Do

Community Health Needs Assessment (CHNA) Implementation Plan. October 2016 Believe. Inspire. Do Community Health Needs Assessment (CHNA) Implementation Plan Believe. Inspire. Do Great Plains Health FY 2017 - FY 2019 Implementation Plan A comprehensive, six-step community health needs assessment (

More information

Value-based Care Report. February How Value-based Care is improving quality and health.

Value-based Care Report. February How Value-based Care is improving quality and health. Value-based Care Report February 2018 How Value-based Care is improving quality and health. Value-based Care delivers: Value-based Care means better health, better care and lower costs. Placing greater

More information

Integrated Health System

Integrated Health System Integrated Health System Please note that the views expressed are those of the conference speakers and do not necessarily reflect the views of the American Hospital Association and Health Forum. Page 2

More information

MONROE COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017

MONROE COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017 MONROE COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Monroe County. Where possible, benchmarks

More information

Complex Care Coordination A new line of business

Complex Care Coordination A new line of business Ho okele Health Navigators Complex Care Coordination A new line of business 2013 NAHC Annual Meeting and Exposition 10/31/13 "Medicine used to be simple, ineffective, and relatively safe. It is now complex,

More information

The Drive Towards Value Based Care

The Drive Towards Value Based Care The Drive Towards Value Based Care Thursday, March 3, 2016 Michael Aratow, MD, FACEP Chief Medical Information Officer, San Mateo Medical Center Gaurav Nagrath, MBA, Sr. Strategist, Population Health Research

More information

Measuring Comprehensiveness of Primary Care: Past, Present, and Future

Measuring Comprehensiveness of Primary Care: Past, Present, and Future Measuring Comprehensiveness of Primary Care: Past, Present, and Future Mathematica Policy Research Washington, DC June 27, 2014 Welcome Moderator Eugene Rich, M.D. Mathematica Policy Research 2 About CHCE

More information

ONTARIO COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017

ONTARIO COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017 ONTARIO COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Ontario County. Where possible, benchmarks

More information

UTILIZING HEALTH CLINICS TO MANAGE AND REDUCE HEALTHCARE COSTS

UTILIZING HEALTH CLINICS TO MANAGE AND REDUCE HEALTHCARE COSTS UTILIZING HEALTH CLINICS TO MANAGE AND REDUCE HEALTHCARE COSTS PRESENTED BY: Mardi Burns, CHC Senior Vice President, Senior Benefits Consultant Al Jaeger, CEBS Senior Vice President, Senior Benefits Consultant

More information

How to Register and Setup Your Practice with HowsYourHealth. Go to the main start page of HowsYourHealth:

How to Register and Setup Your Practice with HowsYourHealth. Go to the main start page of HowsYourHealth: How to Register and Setup Your Practice with HowsYourHealth Go to the main start page of HowsYourHealth: After you have registered you will receive a practice code and password. Save this information!

More information

Strategy Guide Specialty Care Practice Assessment

Strategy Guide Specialty Care Practice Assessment Practice Transformation Network Strategy Guide Specialty Care Practice Assessment 1/20/2017 1 Strategy Guide: Specialty Care PAT 2.2 Contents: Demographics Tab: 3 Question 1: Aims... 3 Question 2: Aims...

More information

Catholic Health Community Health Inventory Related to Physical Activity and Nutrition

Catholic Health Community Health Inventory Related to Physical Activity and Nutrition & Priority Areas: Partnerships Name & Description of Program Area Served Targeted Population Served Eligible Persons Reimbursement for services = those educational & other efforts that are geared towards

More information

Hendrick Medical Center. Community Health Needs Assessment Implementation Plan

Hendrick Medical Center. Community Health Needs Assessment Implementation Plan Hendrick Medical Center Community Health Needs Assessment Implementation Plan - 2014-2016 Hendrick Medical Center Community Health Needs Assessment Implementation Plan - 2014-2016 Overview: Hendrick Medical

More information

New Models for Rural Post-Acute Care. Mark Lindsay MD Assistant Professor Mayo Clinic College of Medicine

New Models for Rural Post-Acute Care. Mark Lindsay MD Assistant Professor Mayo Clinic College of Medicine New Models for Rural Post-Acute Care Mark Lindsay MD Assistant Professor Mayo Clinic College of Medicine Objectives Understand Post-acute Transitional Care as a tremendous opportunity for critical access

More information

Payment Reforms to Improve Care for Patients with Serious Illness

Payment Reforms to Improve Care for Patients with Serious Illness Payment Reforms to Improve Care for Patients with Serious Illness Discussion Draft March 2017 Payment Reforms to Improve Care for Patients with Serious Illness Page 2 PAYMENT REFORMS TO IMPROVE CARE FOR

More information

Managing Patients with Multiple Chronic Conditions

Managing Patients with Multiple Chronic Conditions Best Practices Managing Patients with Multiple Chronic Conditions Dartmouth-Hitchcock Physicians Case Study Organization Profile Headquartered in Bedford, New Hampshire, Dartmouth-Hitchcock is a large

More information

Overview of Six Texas Demonstrations

Overview of Six Texas Demonstrations Texas Case Study: Document 2 Overview of Six Texas Demonstrations The chart below provides an overview of six Texas demonstrations. Where possible, the chart indicates the purpose of the demonstration,

More information

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred 1

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred   1 POPULATION HEALTH PLAYBOOK Mark Wendling, MD Executive Director LVPHO/Valley Preferred www.populytics.com 1 Today s Agenda Outline LVHN, LVPHO and Populytics Overview Population Health Approach Population

More information

Russell B Leftwich, MD

Russell B Leftwich, MD Russell B Leftwich, MD Chief Medical Informatics Officer Office of ehealth Initiatives, State of Tennessee 1 Eligible providers and hospitals can receive incentives for meaningful use of certified EHR

More information

SWAN Alerts and Best Practices for Improved Care Coordination

SWAN Alerts and Best Practices for Improved Care Coordination SWAN Alerts and Best Practices for Improved Care Coordination IHIN and SWAN Course Overview Our Goal: To educate healthcare providers in how to manage SWAN alerts for meaningful impact at the point of

More information

Coastal Medical, Inc.

Coastal Medical, Inc. A Culture of Collaboration The Organization Physician-owned group Currently 19 offices across the state of Rhode Island and growing 85 physicians, 101 care providers The Challenge Implement a single, unified

More information

Highmark Lifestyle Returns SM Enjoy the many rewards of a healthy lifestyle!

Highmark Lifestyle Returns SM Enjoy the many rewards of a healthy lifestyle! SM Enjoy the many rewards of a healthy lifestyle! Page 1 of 11 Take charge of your health and enjoy the benefits! We know that the way we live has a real impact on the way we feel. When we take care of

More information

HEALTHY EMPLOYEES HEALTHY EMPLOYEE BENEFIT PLAN

HEALTHY EMPLOYEES HEALTHY EMPLOYEE BENEFIT PLAN HEALTHY EMPLOYEES HEALTHY EMPLOYEE BENEFIT PLAN At a point in time when many employers are forced to cut benefits healthcare costs are increasing at 3 to 4 times the rate of inflation access to quality

More information

Foreign Service Benefit Plan

Foreign Service Benefit Plan Simple Steps to Living Well Together Foreign Service Benefit Plan 2018 Wellness Benefits and Incentive Rewards Health Plan Accredited by The FOREIGN SERVICE BENEFIT PLAN has Health Plan Accreditation from

More information

Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director

Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director AMGA Pre-conference Workshop 1 April 14, 2011 Washington, D.C. Disclosure Nothing in Today

More information

CHEMUNG COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017

CHEMUNG COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017 CHEMUNG COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Chemung County. Where possible, benchmarks

More information

Decreasing Medical. Costs. Are your members listening to you? PRESENTED BY: September 22, 2016

Decreasing Medical. Costs. Are your members listening to you? PRESENTED BY: September 22, 2016 Decreasing Medical Costs Are your members listening to you? PRESENTED BY: Aaron Crowell, Executive Vice President, MTM, Inc. Gary Jacobs, Executive Vice President, CareCentrix Dan Masciopinto, SVP of Product,

More information

What is Mental Health Integration?

What is Mental Health Integration? What is Mental Health Integration? Quality Experience Cost A standardized clinical and operational team process that incorporates mental health as a complementary component of wellness & healing * Mental

More information

Quality: Finish Strong in Get Ready for October 28, 2016

Quality: Finish Strong in Get Ready for October 28, 2016 Quality: Finish Strong in 2016. Get Ready for 2017 October 28, 2016 Agenda Stars: Medicare Advantage Quality Changes for 2017 Pay for Quality and PCMH Programs Important Announcements! 7 Stars: Medicare

More information

Goals & Challenges for Outpatient Quality Directors. Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE

Goals & Challenges for Outpatient Quality Directors. Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE Goals & Challenges for Outpatient Quality Directors Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE Objectives Learn a practical way for Quality Directors to align Quality Measures

More information

Leveraging Wellness Visit with Medicare: Improving Income and Patient Outcomes

Leveraging Wellness Visit with Medicare: Improving Income and Patient Outcomes Leveraging Wellness Visit with Medicare: Improving Income and Patient Outcomes Overview Why Medicare Wellness Exams What are the Medicare Wellness Exams Annual Wellness Exam Components What is covered

More information

Advancing Primary Care Delivery

Advancing Primary Care Delivery Advancing Primary Care Delivery Tenth National Pay for Performance Summit March 3, 2015 Simeon Schwartz, MD CEO, WESTMED Medical Group, P.C. WESTMED Medical Group Established 1996 by 16 physicians 300

More information

Transforming Clinical Practices Initiative

Transforming Clinical Practices Initiative Transforming Clinical Practices Initiative Overview CMS through its Center for Medicare & Medicaid Innovation is launching its Transforming Clinical Practices Initiative (TCPI), which over a four-year

More information

CMS Oncology Care Model s Standards for Patient Navigation

CMS Oncology Care Model s Standards for Patient Navigation CMS Oncology Care Model s Standards for Patient Navigation Nikolas Buescher Executive Director of Cancer Services Penn Medicine, Lancaster November 13, 2017 Ann B Barshinger Health Cancer Institute scale

More information

Sanford Medical Center Mayville Community Health Needs Assessment Implementation Strategy

Sanford Medical Center Mayville Community Health Needs Assessment Implementation Strategy Sanford Medical Center Mayville Community Health Needs Assessment Implementation Strategy 2017-2019 dba Sanford Mayville Medical Center EIN # 45-0228899 Dear Community Members, Sanford Mayville is pleased

More information

Building the Universal Roadmap to Population Health Management

Building the Universal Roadmap to Population Health Management Building the Universal Roadmap to Population Health Management Executive Webinar January 21, 2016 Karen Handmaker, MPP, PCMH CCE IBM Watson Health House Keeping 1. Using the control panel Use the control

More information

PPS Performance and Outcome Measures: Additional Resources

PPS Performance and Outcome Measures: Additional Resources PPS Performance and Outcome Measures: PPS Performance and Outcome Measures: This document includes supplemental resources to the content on PPS Performance and Outcome Measures presented at the December

More information

Medical Management Program

Medical Management Program Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina

More information

Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc.

Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc. Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc. October 13-15, 15, 2010 Scottsdale, AZ Kaiser Permanente of the Mid-Atlantic States (KPMAS) 1 KPMAS Medical Group Profile

More information

St. Johns River Rural Health Network

St. Johns River Rural Health Network St. Johns River Rural Health Network Comprehensive Diabetes Management Presented to: Florida LIP Council January 22, 2009 Nikole Helvey, MS HSA, Network Manager Rural Health Networks In Florida Established

More information

Payment Transformation: Essentials of Patient Attribution An Introduction for Internal Staff

Payment Transformation: Essentials of Patient Attribution An Introduction for Internal Staff Payment Transformation: Essentials of Patient Attribution An Introduction for Internal Staff May 6, 2016 Payment Transformation Will Address Key Goals In Pursuit of Māhie 2020 - Maximize Value to Members,

More information

Integration Workgroup: Bi-Directional Integration Behavioral Health Settings

Integration Workgroup: Bi-Directional Integration Behavioral Health Settings The Accountable Community for Health of King County Integration Workgroup: Bi-Directional Integration Behavioral Health Settings May 7, 2018 1 Integrated Whole Person Care in Community Behavioral Health

More information

Sunflower Health Plan

Sunflower Health Plan Key Components for Successful LTSS Integration: Case Studies of Ten Exemplar Programs Sunflower Health Plan Jennifer Windh September 2016 Long- term services and supports (LTSS) integration is the integration

More information

STEUBEN COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017

STEUBEN COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017 STEUBEN COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Steuben County. Where possible, benchmarks

More information

Getting Ready for the Maryland Primary Care Program

Getting Ready for the Maryland Primary Care Program Getting Ready for the Maryland Primary Care Program Presentation to Maryland Academy of Nutrition and Dietetics March 19, 2018 Maryland Department of Health All-Payer Model: Performance to Date Performance

More information

PRESCRIPTION FOR HEALTH A COMPREHENSIVE WEB SITE TO HELP YOU IMPROVE PATIENTS MEDICATION ADHERENCE

PRESCRIPTION FOR HEALTH A COMPREHENSIVE WEB SITE TO HELP YOU IMPROVE PATIENTS MEDICATION ADHERENCE PRESCRIPTION FOR HEALTH A COMPREHENSIVE WEB SITE TO HELP YOU IMPROVE PATIENTS MEDICATION ADHERENCE MEDICATION ADHERENCE Medication adherence can be defined as how well a patient s* medication behavior

More information

BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN

BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN 1 TABLE OF CONTENTS Executive Summary... 3 Community Description... 4 Geography... 4 Population Trends... 5 Income...

More information

Quality Measurement and Reporting Kickoff

Quality Measurement and Reporting Kickoff Quality Measurement and Reporting Kickoff All Shared Savings Program ACOs April 11, 2017 Sandra Adams, RN; Rabia Khan, MPH Division of Shared Savings Program Medicare Shared Savings Program DISCLAIMER

More information

Distinctive features of HPH in Taiwan: what made this network successful?

Distinctive features of HPH in Taiwan: what made this network successful? Distinctive features of HPH in Taiwan: what made this network successful? Dr. Ying-Wei Wang, Director General, Health Promotion Administration, Taiwan HPH Taiwan Network Representative 1 Where is Taiwan?

More information