The Small Rural Health Care Home Clinic: Unique Designs to Meet the Standards

The Small Rural Health Care Home Clinic: Unique Designs to Meet the Standards

The Small Rural Health Care Home Clinic: Unique Designs to Meet the Standards Objectives: The rural health clinic has a unique culture The practice design aligns with the HCH legislative rule subparts Clinics identify strategies to face challenges and achieve success in meeting the standards.

The Rural Health Clinic Located in a non-urban area (population <50,000), A designated health professional shortage area (HPSA)or a medically under-served area (MUA) Capable of delivering outpatient primary care services furnished by a licensed professional provider. If it employs one mid-level provider onsite 50 percent of the time the clinic is open. Rural Health Clinics CAN become certified HCH and also may bill under the specified payment mythology.

MDH HCH Rule Standard Categories: Access / Communication Patient Tracking and Registry Functions Care Coordination Care Planning Performance Reporting & Quality Improvement

Introductions: Johnson Memorial Health Services A rural health clinic serving approximately 3,500 patients, early in the process of seeking HCH certification. Kathy Johnson, CEO of Johnson Memorial will dialog with us about the reasons Johnson Memorial is seeking certification, the culture change that is required and some strategies they will employ to do that.

1282 Walnut Street Dawson, MN 56232 320-769-4323 www.jmhsmn.org Kathy Johnson, ADN, BA, CHCE CEO / Administrator

Panel Discussion: Johnson Memorial Why are you interested in HCH Certification?

Panel Discussion: Johnson Memorial What are the aspects of culture change that Johnson Memorial is working on and what are the strategies to do that? Culture of Excellence LEAN Baldrige Criteria Quarterly Leadership Development

HCH Rule Subpart/s Access / Communication Patient Tracking and Registry Functions

Panel Discussion: Johnson Memorial What have you learned in the process that you could share with other clinics that may be considering HCH Certification? Communicate, Communicate, Communicate!! Don t Rush Use Available Resources

Introductions: Lakewood Health System Dr John Halfen, Lakewood Clinic Medical Director Nicole Worden, Care Coordinator Initially certified 5 clinics July 2010 The clinics were of the first clinics to become certified in the state of MN. At the time of the initial certification, 500 patients were receiving care coordination services; the clinics are currently process for HCH Recertification Year Three.

Panel Discussion: Lakewood Health System What has been the greatest benefit to your patients and clinics as a Certified HCH?

1. PATIENT INVOLVEMENT a) Care-individual Inclusion Subpart 9A - (Advisory Committee) Administration b) Comprehensive Care Subpart 5B (Coordination, Collaboration and Communication for optimal care) i. Appointments address all problems coordination of all providers ii. Review of Redesigning

ii. Review of Redesigning Care for Patients 5% - Most ill RN Care Coordination 95% - Searches for Best Practices e.g. asthma action plans, dietetic D5 s Total Population Education Community/Collaborative Screenings Encouragement (Exercise, Nutrition)

2. WORKING AT THE TOP OF LICENSES Subpart 6C - HCH team works at the top of his/her license Teams working together Urgent Care Development treatment according to need RN Enable early treatment Access own PCP Other HCH physicians or extenders

TEAMS MEMBERS Patients Primary Care Physicians Registered Nurses Physician Assistants and Nurse Practitioners Doctor of Pharmacy Licensed Practical Nurses Registered Dieticians

2. WORKING AT THE TOP OF LICENSES Teams working together Urgent Care Development treatment according to need RN Enable early treatment Access own PCP Other HCH physicians or extenders

3. BEST PRACTICES ASSURED Subpart 7A HCH adopts and implements EB Guidelines for medical services. Directives LHS Preventative Guidelines

LIST OF DIRECTIVES 1. DM without urine microalbumin within last year 2. Chronic renal disease stages I & II not on ARB or ACE inhibitor 3. Chronic renal disease without creatinine, calcium and lipid profile within one year 4. Chronic renal disease without BP in last year 5. Prescribed use of NSAIDS daily w/out DX of R.A. 6. BMI >40 without dietary consult 7. Chronic use of antipsychotics without psychiatric consult 8. Chronic use of Estrogens 9. Chronic Aspirin use in men < 45 y.o. 10. Chronic Aspirin use in women < 55 y.o. 11. Diabetes w/out HGB A1C > 9 (run every 6 months) 12. Chronic NSAID use in patients with heart failure 13. On Plavix and taking PPI 14. Hypertension or hyperlipidemia without blood glucose in past year 15. No lipid profile within 5 years and > 45 or < 75 years old 16. CAD not on ASA

LIST OF DIRECTIVES (cont d) 17. Age 50-80 and no colonoscopy within 10 years 18. Women with uterus < 65 without pap smear within last 2 years 19. Women between 50 75 y.o. without mammogram within last 2 years 20. Psychotropics without psychosis diagnosis and no dosage reduction in past year 21. Males 50-70 y.o. with no PSA within last 2 years 22. Women > 65 without bone densitometry 23. Women > 50 on PPI/H2 blocker, without bone densitometry within 2 years 24. Diabetes with thiazide 25. COPD without Pneumovax 26. CAD without HMG Co-A reductase inhibitor < 80 years old 27. Diabetes with LDL > 100 age < 80 28. CAD with LDL > 100 29. CHF without ARB or ACE inhibitor 30. Previous MI without beta blocker 31. CVA/TIA without ASA or Plavix 32. CVA/TIA without carotid Doppler

LIST OF DIRECTIVES (cont d) 33. Osteoporosis without bone resorption inhibitor 34. Hip/Spine fracture without bone densitometry 35. Diabetes without Hgb A1C within 6 months 36. Breast cancer without Selective Estrogen Receptor Modulators (SERM) 37. PPI/H2 block without GERD/PUD DX 38. PPI/H2 block with osteoporosis 39. Hepatitis C without viral studies 40. >65 y.o. without Pneumovax 41. CAD with DM without ARB or Ace inhibitor 42. CAD and blood pressure > 140/90 43. Chronic Kidney Disease Stage 4/5 and no renal consult in 1 year 44. COPD and no PFT in 2 years 45. Patient with DX of Asthma, Emphysema without PFT Testing 46. Ischemic Vascular Disease and no ASA/Plavix

3. BEST PRACTICES ASSURED Directives LHS Preventative Guidelines

Periodic Screenings Subpart 3A -The HCH reviews the HCH population to manage health care services, provide appropriate follow-up, and identify any gaps in care. Monthly: Patients with 10 or more medications without MTM in past year Patients not seen within past 6 months Patients turning 65 (Welcome to Medicare Exam) Males turning 65 with history of any smoking and no abdominal ultrasound Diabetic patients with birthdays reminded of shoe availability and documented in the chart Annually: Medical Home Patient Screening Protocol Medical Home Screening Calendar

LAKEWOOD HEALTH SYSTEM PREVENTIVE SERVICES GUIDELINES Based upon the recommendations of the U.S. Preventive Services Task Force, as well as the judgment of the Lakewood physicians, the following are guidelines which Lakewood Health System endorses. These are meant to be general guidelines only. Specific recommendations for specific patients must be made by their own physicians taking into consideration their own clinical situations as well as individual preferences. The guidelines are NOT correct for patients with specific factors which increase their risk compared to the general population. 1. Screening mammography every 1-2 years for women aged 50 to 74. 2. Screening by Pap smear for cervical cancer in women less than 65 who have been sexually active and have a cervix and every 1-3 years depending upon previous history and age. 3. PSA every 2 years for men ages 50-70.(Not a USPSTF recommendation) 4. One time screening for abdominal aortic aneurysm in men ages 65-75 who have ever smoked. 5. Aspirin use in men aged 45 to 79 and women aged 55 to 79, unless significantly contraindicated by other conditions in adults with increased risk of coronary heart disease.

LAKEWOOD HEALTH SYSTEM PREVENTIVE SERVICES GUIDELINES (cont d) 6. Blood pressure screening for adults over 18 every two years if normal. 7. Lipid screening for men over age 35 and women over age 45 at 5 years intervals if normal, but start at age 20 if history of diabetes, coronary artery disease or family history of coronary artery disease. 8. Urine cultures in pregnant women at 12-16 weeks gestation. 9. Depression screening during routine visits. 10. Weight and height measurements along with waist circumferences when applicable to find BMI >35, or male waist>40 or female waist >35. 11. Promote physical activity with a minimum of 3X weekly with heart rate >100 for 20 minutes or more. 12. Screening for diabetes every 3 years in adults with hypertension or hyperlipidemia. 13. Bone densitometry in women starting at least by age 65 but younger with higher risk factors and repeated according to findings no sooner than every 2 years when abnormal.

LAKEWOOD HEALTH SYSTEM PREVENTIVE SERVICES GUIDELINES (cont d) 14. Rh (D) blood typing and testing for all pregnant women during the first visit for prenatal care. Repeated at 24-28 weeks for Rh (D) negative women prior to receiving Rh(D) immunoglobulin. 15. Screening of children less than 5 years old for evidence of defects in vision. 16. Screening for chemical misuse such as alcohol and tobacco during routine visits. 17. Colonoscopy every 10 years starting at age 50 to 75 unless increased risk factors. 18. Chlamydia testing in all sexually active women < 24 years old at least annually and other women is any increased risk. 19. HIV screening for all adults and adolescents at increased risk due to being in correctional facilities, or homeless shelters, or being male homosexuals or parenteral drug abusers.

LAKEWOOD HEALTH SYSTEM PREVENTIVE SERVICES GUIDELINES (cont d) Physical examinations and immunizations are encouraged for children and adults according to the following schedule: Children and adolescents: Immunizations according to the established schedule of the American Academy of Family Physicians, American Academy of Pediatrics and the Center for Disease Control. Annual visits for routine physical screenings Male adults: Annually until finished with college, every 5 years until 50, then every 2 years. Consider meningococcal and hepatitis vaccinations when starting college. Diphtheria/tetanus boosters every 10 years. Influenza annually starting at age 50 but anytime earlier if desired. Pneumococcal vaccine at age 65.

LAKEWOOD HEALTH SYSTEM PREVENTIVE SERVICES GUIDELINES (cont d) Physical examinations and immunizations are encouraged for children and adults according to the following schedule: Female adults: Once sexually active, annually with pap smears, birth control and Chlamydia testing until finished with college, and annual Pap smear has been normal for 3 consecutive years, then every 3 years. Resumption of annual visits at age 50 Consider meningococcal and hepatitis vaccines when starting college Papilloma virus immunization preferable before sexual activity Diphtheria/tetanus boosters every 10 years Influenza annually starting at age 50 but anytime earlier if desired Pneumococcal vaccine at age 65 Self examinations are recommended as follows: Testicular examination for tumors is recommended every 3 months Breast self-examinations are recommended monthly Skin examinations should be done every 6 months Other health care professionals: Dentist annually Optometrist - annually

Panel Discussion: Lakewood Health System What aspects of the HCH rule criteria have been most challenging and what were your strategies to address it?

LIVING CARE PLANS Subpart 7A, 7B. 8 -Care Plan Standard a.what we want Relevancy to patient and providers Adaptable b. What we have c. Future Plans

REGISTRY CARE COORDINATED Subpart 3A, B, 4 - Registry and Tracking, Prevention of Gaps in Care a) EMR (Centricity) b) Workspace Share-point c) Crystal Reports 3. Tracking care coordinated 4. Vitalization Reports 5. MNCM entire clinic population

Panel Discussion: Lakewood Health System What makes the rural HCH clinic unique and how does HCH certification impact that?

UNIQUE VIA HCH Subpart 2 -Access and Communication 1) Access 2) 24/7 RN/MD Availability 3) Patient Ownership 4) Comprehensive Visits 5) Individual Needs based care examples

Panel Discussion: Lakewood Health System What have you learned in your HCH journey that you could share with other clinics that may be in the process of application or recertification

1. FINANCIAL IMPACT a) Cost of development b) Cost of ongoing coordination and training c) Loss of system revenue d) Delay pay-back

2. QUALITY IMPROVEMENT Subpart 9, 10, 11 More than recognized at beginnings

3. TAKE STEPS A. Start Small B. Expect Resistance C. Develop MD Champion D. Expect Contagiousness E. Work on reimbursement

4. REIMBURSEMENT Tiering - Minor Total Cost of Care is the major benefit a) Initial years b) Long-term Shared savings / Shared Risk Attribution Risk Stratification

The Small Rural Health Care Home Clinic: Unique Designs to Meet the Standards Questions?