Patient Centered Medical Home Presented by Marjorie Young, - - PowerPoint PPT Presentation

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Patient Centered Medical Home Presented by Marjorie Young, - - PowerPoint PPT Presentation

Mar 30, 2024 47 likes •187 views

Patient Centered Medical Home Presented by Marjorie Young, Executive Director Inez Hawes, Clinical Director Pine Medical Group, P.C. www.pinemed.com First Program: Diabetes Champion of program in practice is our Medical Director

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SLIDE 1

Patient Centered Medical Home

Presented by Marjorie Young, Executive Director Inez Hawes, Clinical Director Pine Medical Group, P.C. www.pinemed.com

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SLIDE 2

First Program: Diabetes

  • Champion of program in practice

is our Medical Director

  • Independent RHC
  • Hospital Benefit G-codes
  • Stark issues
  • Beginning the program
  • Decreased HbA1c
  • Hospital achieved a 200% increase in patients in their

diabetic program

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SLIDE 3

(Diabetic Program continued…)

  • Lab interface
  • Registry reports—gaps in care
  • Ongoing interaction
  • Results
  • Surveys
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SLIDE 4

Asthma Days

  • In-service nursing staff by physicians
  • Champion of program
  • Nursing teach back COPD
  • Respiratory referral
  • Care plan meetings with

respiratory therapist

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SLIDE 5

Care Management

  • PCMH care management template created

and scanned into charts of patients contracted by the care manager

  • Documentation of her work
  • Action plans
  • Outcomes
  • Action plans—fit patients
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SLIDE 6

Care plan visit

  • Emphasize preventive behaviors
  • Chronic condition survey
  • Follow-up with patients in the hospital and

referrals from PCP

  • Relationship established with Care Manager
  • Relationship allows Care Manager to create

trust—creates action plans and goal-setting

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SLIDE 7

(Care plan visit continued…)

  • Literacy/Care Manager assessment
  • Hospital discharges
  • CHF, COPD, etc.
  • Evaluate follow-up care
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SLIDE 8

PCMH evolved into…

  • Lunch & learns
  • Interviews/radio
  • NCQA Level III
  • Office info
  • Website
  • Quality standings
  • Top 3 each year
  • Financial
  • Strategy/evals
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SLIDE 9

Urgent Care

  • Access
  • Office Extension
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SLIDE 10

Patient Advocate

  • Medicaid apps
  • MI Child
  • Medications
  • FMLA Forms
  • Help at Home
  • Rides for appointments
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SLIDE 11

(Patient Advocate continued…)

Community Resources

  • Food pantry
  • SFS
  • Charity care apps—hosp
  • Pre-pay uninsured for surgery
  • Forms/Physicians
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SLIDE 12

New Product Information

  • WellCentive implemented—identify gaps in care
  • a. Patient Summary Sheet printed for each visit
  • New patients entered
  • Quest Labs portal into WellCentive
  • SureScripts eRx incorporated into EMR
  • Registry used to identify gaps in care—ongoing alerts

in EMR

  • Continue to incorporate registry information for all

chronic conditions

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SLIDE 13

Financial Benefits

  • Priority Health
  • BCBS
  • 10% uptick all E&M codes with BCBS
  • Increase of $3.00 per member/per month

with Priority Health

  • Higher increase due to NCQA Level III
  • T-Codes, Care managers
  • Financial incentive yearly, $265,000.00
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SLIDE 14

(Financial Benefits continued…)

  • Grant--$145,000.00 over two years used for

software-nurses

  • Quality payments increased each year
  • Medicare Demonstration Project begins

January 1, 2012.