What Can the Primary Care Clinical Program Do to Help Our Clinic? Central Region October 1, 2015 PPC Annual Meeting
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
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
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.
Primary Care Clinical Program and Intermountain Hospitals Medical Group SelectHealth Primary Care Clinical Program Population Health Affiliated Practices
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
Intermountain Clinical Programs Behavioral Health Cardiovascular Intensive Medicine Musculoskeletal Neurosciences Oncology Pediatric Specialty Primary Care Surgery Women and Newborn 7
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
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
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
The balance between two worlds Fee for Service and Pay for Value 12
How does the PCCP help? Patient Education Provider Education and Support Supporting all Patients in the Practice Supporting Patients Coming into the Offices
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
Concerning Patient Education, the best Fact Sheet is... 1. 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
Patient Fact Sheets
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!
Patient Education Booklets Diabetes High Blood Pressure MAWDS CKD (in development) Lifestyle Weight Management Clinic Implementation Kit
How to get Patient Handouts Go to: iprintstore.org
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
Type PCCP in your IE8 browser
Linking Classes to Rural Regions
Patient Education on the Health Hub
Provider Education is important to the PCCP because... 1. 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
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
Grand Rounds for the Primary Care Provider Link: https://intermountainphysician.org/intermountaincme/pages/primary- Care-Grand-Rounds.aspx
Grand Rounds for the Primary Care Provider- ECME
Monthly Education for Staff Link: https://intermountainphysician.org/intermountaincme/pages/monthly- Education-Videos.aspx
Monthly Education for Staff Link: https://intermountainphysician.org/intermountaincme/pages/monthly- Education-Videos.aspx
Care Process Models High Blood Pressure Chronic Kidney Disease Diabetes Asthma Sinusitis Cervical Cancer Screening And More
CPM Documents and Flash Cards
Flash Cards- Condensed CPMs
Apple Device Flash card app http://ebu.intermountainhealthcare.org/physician /flashcard/install.html
https://physician.intermountain.net/medicalgroup/pages/default.aspx
Our Team to Yours
Research and Guidance for Best Practices Diabetes education paper Team based care study Diabetes prevention Anticoagulation
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
The PCCP is delighted when patients come in to see their provider because... 1. 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
HELP2 Forms
icentra Development Advisories Care Process Models Anticoagulation Alerts Care Pathways mpages Tablet Pilot
Taking Best Practices to the System
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
MHI support and implementation
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
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
Quality Reporting One Report Registries for HBP, Diabetes, & Asthma Customizable Patient Lists
PCCP Dashboard
Master Patient Watch List Helps to see the patient as a whole person with potentially several conditions, not just one
High Blood Pressure
HBP Report with Patient List
HBP Patient Management Report
Correction Tool for Report Feedback loop is important
What could the PCCP do without the Medical Group? 1. Nothing 2. Nothing 3. Nothing 4. Nothing 5. All of the above
WHAT HAPPENS WHEN WE WORK TOGETHER?
Utah, Summit and Wasatch Counties High blood pressure not in control 325 37
How to we maintain the gain
How to we maintain the gain
The PCCP... 1. 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
Questions? Contact information: Wayne.Cannon@imail.org Phone: 801-442-3131 Sharon.Hamilton@imail.org Phone: 801-442-2823 Tonya.Schaffer@imail.org Phone: 801-442-3235