Radical Rosewood A Roadmap to APM Transformation we are family we are family
The Framework • Setting the stage • Transformation at Rosewood • Investment • Measures of Success • Informatics & Reporting • Next steps we are family
Current State of Health Care Suboptimal Failure to quality address what truly impacts the health of our patients Dissatisfied providers & staff Dissatisfied patients High cost of total care in Increased the healthcare demand for care system with dwindling number of PCPs we are family
Encounters! Encounters! Encounters! • Basis for payment: Face-to-face visit with a medical provider • Churning encounters in the same old model just yields the same old results we are family
Oregon Alternate Payment Methodology & Value Based Care An opportunity to challenge our assumptions & transform how we provide care. Is the focus on Do patients need physical health to come to the improving our clinic to have Can we design patients’ overall their needs met? our system to well being? address the factors that truly influence outcomes? Is the medical Is a physical provider the best exam always professional to necessary? meet their needs? we are family
we are family
Core Components Building multi-disciplinary, co-located care teams True team-based care. Transforming the day-to-day model of care • PCPs engaged in population health, panel management & complex care management • Redefined roles for RNs, MAs & Clinical Support Staff • Improved coordination with integrated providers (RD, BHC, SW, CHW, PMHNP) Increasing staff to support the new model Protected time for PCPs! • Integrated Providers: PMHNP, MSW, BHC, RD • RNs for new patient enrollment, triage, and nursing visits • Community Health Workers for patient outreach, social work support, and case management • MAs to support primary care teams and population management Expanding access to care & developing new ways to connect with patients • Nursing visits for acute & chronic controlled issues Leverage existing • Telephone & video visits with providers technology for more • Electronic communication (email via MyChart) • E-consults with specialists convenient care! Address the Screening for and address social determinants of health real barriers to health. Demonstrate Developing robust analytics & reporting value! we are family
Teams CARE TEAM 2 PCPs, CARE 3 MAs, TEAM RN, Clinical Support Staff SUPPORT TEAM RD, BHC, MSW, CHWs, Patient PMHNP + MA & Family EXPANDED TEAM Intake RN + MA, SUPPORT EXPANDED Triage RN + Call Center TEAM TEAM Patient Benefit Coordinators, Receptionists we are family
“Team Time” Population Care Alternative Health Coordination Patient Visits Management Review and manage Telephone visits complex patient care Chronic disease registry management Consult specialty Secure patient email providers Cancer screening registry management Manage care transitions Telemedicine Psychiatry from hospital admissions Panel Management Group Visits & Video e-Consult (2017) Visits (2017-2018) we are family
Protocol-based RN Visits Acute Issues (e.g. Pharyngitis, Dysuria, Conjunctivitis) Controlled Chronic Issues (e.g. DM, HTN) New Patient Intake Visits we are family
New Patient Intake Workflow • Best Practice Advisories (e.g. SBIRT, OneKeyQuestion) • Reason for visit • Recent visits with other care providers (ER, urgent care, previous PCP) MA • Vital signs • Reconciliation with Care Everywhere (outside records, verify pharmacy) • Social history • Reconciliation with Care Everywhere (medications & problem list) • History (medical, surgical, family) • Notes (use Smart Phrase) • Plan (Problem List) RN • Agenda-setting & shared decision making • Labs • Referrals (internal & to community agencies) • Warm handoffs • Return to provide vaccines, mammogram orders, FIT test, AVS and schedule necessary follow up appointments MA we are family
RN Intake Lessons • Paradigm shift with role of nurses • RN working at top of licensure • Agenda setting for successful first visit with PCP • Higher show rate for first appointment with PCP • Complete picture of the patient’s needs, including social determinants • Time to really listen to patients, to get a detailed history, come up with a plan that is a collaboration between the patient and the RN, so that the intervention does not need to be determined in a quick visit with a provider we are family
Screening for Social Determinants of Health • Review of national models (including PRAPARE) • 13 questions that address employment, housing, food insecurity, stress, trauma & social isolation • Focus on questions that are actionable and relevant to our community • Version 3.0 in production (revisions based on data analysis & feedback) • Development in EMR pending information from Epic and further study of our tool we are family
Rosewood’s Social Determinants Screening Tool 10. Stress is when someone feels tense, nervous, anxious, or can’t 1. What is your current work situation? sleep at night because their mind is troubled. a. Unemployed and seeking work How stressed do you feel now? b. Part time work (Circle one: 1 being the least stressed and 10 being the most stressed) c. Full time work 12 3 4 5 6 7 8 9 10 d. Otherwise not employed & not seeking work (select from the following list): □Student □Retired □Disabled □Unpaid primary care giver □Not listed 11. Emotional trauma occurs when there is extreme stress that was 2. Is your current work situation affecting your ability to take care of your unexpected, unavoidable and overwhelmed your ability to cope. health or your family’s health? Have you experienced an event in your life that has led to emotional a. Yes trauma? b. No a. Yes 5. What is your housing situation today? b. No a. I have housing of my own and am NOT worried about losing it c. Unsure b. I have housing of my own, but I am worried about losing it c. I do not have housing of my own (staying with others, in a hotel, on the street, in 12. How often do you see or talk to people that you care about and feel a shelter) close to? 6. Within the past 12 months we worried whether our food would run out (For example: talking to friends on the phone, visiting friends or family, going before we got money. to church or club meetings) a. Often true a. Less than once per week b. Sometimes true b. 1 or 2 times per week c. Never true c. 3 to 5 times per week d. Don’t know d. More than 5 times per week 7. Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more. 13. Today or in the past year, have you or someone in your household a. Often true had to go without any of the following? b. Sometimes true • Food c. Never true d. Don’t know • Clothing • Utilities (electricity/heat) 8. In your daily life, do you feel physically and emotionally safe? • Rent/Mortgage Payment a. Yes • Transportation b. No • Child care c. Unsure • Medicine/Prescriptions 9. In the past year, have you been afraid of your partner or ex-partner? • Medical, Dental, Mental Health or Substance Abuse Care a. Yes • Phone b. No we are family • Legal help c. Unsure • Other: __________________
Social Determinants of Health Snapshot of Findings* * n = 125 (New Patients in August) 36% were worried about 33% lack housing of their own or worried whether food would run about losing it out before they got money 18% unemployed & seeking work we are family
Social Determinants of Health Snapshot of Findings* * n = 125 (New Patients in August) Today or in the past year, have you or someone in your household had to go without any of the following? 30% Food Clothing 25% Utilities (electricity/heat) 20% Rent/Mortgage Payment Transportation 15% Child care 10% Medicine/Prescriptions Medical, Dental, Mental Health, or Substance Abuse Care 5% Phone Legal Help 0% % Yes we are family
Measures of Success Improved Health Outcomes Decreased Utilization Increased Satisfaction Increased Access we are family
Improved Health Outcomes we are family
Improved Health Outcomes Children 2 months-18 years up to date with appropriate well child exam we are family Source: Epic Report: Clinic Panel Metrics: Well Child Check
Improved Health Outcomes Adult patients 65 years old+ up to date with pneumonia vaccination we are family Source: Epic Report: Clinic Panel Metrics: Adult Pneumonia Vaccination Status
Improved Health Outcomes Screening for Clinical Depression & Follow Up Plan Source: Epic Report: Preventive Care and Screening: Screening for Clinical we are family Depression and Follow-Up Plan
Improved Health Outcomes Adult patients with diabetes mellitus who are up to date with A1c testing based off of control status we are family Source: Epic Report: Clinic Panel Metrics: Hemoglobin A1c Testing
Improved Health Outcomes Adult patients with diabetes mellitus up to date on neuropathy screening we are family Source: Epic Report: Clinic Panel Metrics: Foot Exam
Improved Health Outcomes Adult patients with diabetes mellitus up to date on nephropathy screening we are family Source: Epic Report: Clinic Panel Metrics: Diabetes: Urine Protein Screening
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