Primary Care Practice supports in the Community Integrated Medical - - PowerPoint PPT Presentation

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Primary Care Practice supports in the Community Integrated Medical - - PowerPoint PPT Presentation

Dec 12, 2022 326 likes •466 views

Primary Care Practice supports in the Community Integrated Medical Home Niharika Khanna, MBBS, MD, DGO Associate Professor Family and Community Medicine University of Maryland School of Medicine Director Maryland Health Care Innovations

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Niharika Khanna, MBBS, MD, DGO Associate Professor Family and Community Medicine University of Maryland School of Medicine Director Maryland Health Care Innovations Collaborative

Primary Care Practice supports in the Community Integrated Medical Home

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Ackn knowled wledgeme gements nts

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  • Department of Health and Mental Hygiene

Medicaid

Community Health Resources Commission – Initial Funder of the Maryland Learning Collaborative

Maryland Health Care Commission

DHMH Center for Chronic Disease Prevention

Howard County Local Health Improvement Coalition

  • Commercial Carriers – Aetna, CareFirst, CIGNA, Coventry, United Health Care, Maryland MCOs
  • Tricare
  • Plan Sponsors

State of Maryland Employee Health Plan

Federal Employee Health Program

Maryland Health Insurance Program

  • Maryland Learning Collaborative- Practice Transformation Leaders and Advisors

Dept of Family and Community Medicine , University of Maryland School of Medicine

University of Maryland School of Nursing

Johns Hopkins Community Physicians and Guided Care at Johns Hopkins

  • Health IT Adoption and Optimization – CRISPHEALTH
  • Pharmaceutical Sponsors

Abbott

Teva Respiratory

Novo Nodisk

  • Outreach

Societies of Family Medicine, Pediatrics and Hospital Medicine, Maryland Chapter ACP, MedChi

Mid-Atlantic Business Group on Health

Merck & Co., Inc.

Pfizer Inc.

Sanofi-Aventis

  • Consultants

Remedy Health Care Consulting – Practice Transformation

IMPAQ International, LLC – Evaluation Consultant

NCQA – Recognition

Discern Consulting LLC – Payment Development

Social and Scientific Systems – Data Aggregation and Attribution

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IMPROVING CARE

Within settings Between settings Across numerous settings, over time Within disciplines Among disciplines Across clinical and

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Patient Centered Medical Homes

Reducing readmissions and improving care across settings

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Core tenets of the new model of care

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 Greater Access

 Advanced access scheduling systems  Availability by email and phone

 Coordination of care  Management of information

 Secure patient portals  Working with structured data  Performance reporting and improvement  Health Information Technology optimization

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Popul pulation ation Hea ealt lth h Improvement ment at at All All Levels els

  • f Heal

alth th Ne Need

5 Slide Courtesy Howard County LHIC

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Primary Care Team Structure

6 Slide Courtesy AHRQ TeamSTEPPS

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Change Concepts for Advanced Primary Care

Engaged Leadership Team based care Patient centered interactions Care Coordination Quality Improvement

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Hospital

identifies high utilizers

PCMH practice CCT determines need Follows patient for 90 days Notifies CCT

  • Identify patient as eligible for

program

  • Place flag in EMR
  • Pre-visit planning, reviews

data, labs and ENS

  • Determine patient plan of

care

  • include CHW team in visit, as

appropriate

  • send visit summary to CHW

team

Flagging Patient visit

Communication

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Practice

identifies high utilizers

PCMH practice

  • Identify patient as eligible for

program

  • Place flag in EMR
  • Pre-visit planning, reviews

data, labs and ENS

  • Determine patient plan of

care

  • Include CCT at visit, as

appropriate

  • Send visit summary to CCT

CCT determines need, communicates with practice, & sends care plan Follows patient for ≈90 days Notifies CCT with referral, CHN completes final determination of patient’s program eligibility.

Identify patients – All of the following:

  • 2 or more chronic conditions
  • 2 or more hospital admissions in 12 months
  • Howard County Resident

Flagging Patient visit

Communication

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SHARED CARE PLAN

Critica tical l in Linking nking Pa Patients, ents, CHW, , Clinical cal Team with h complement ntar ary y roles

From Edwin Fisher,MD AAFP Together on Diabetes

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Healthy Howard Community Care Team

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Supported by Community Health Workers Results in Patient Centered Care for the Patient

Patient-Physician(Clinician) Partnership

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Q&A

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