W hat Can the Prim ary Care Clinical Program Do to Help Our Clinic? - - PowerPoint PPT Presentation

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W hat Can the Prim ary Care Clinical Program Do to Help Our Clinic? - - PowerPoint PPT Presentation

Feb 06, 2023 277 likes •920 views

W hat Can the Prim ary Care Clinical Program Do to Help Our Clinic? Central Region October 1, 2015 PPC Annual Meeting Wha hat is the he pur urpose e of the he PCCP? 1. Create reports on ADHD, care manager turnover and physician

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W hat Can the Prim ary Care Clinical Program Do to Help Our Clinic?

Central Region October 1, 2015 PPC Annual Meeting

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Wha hat is the he pur urpose e of the he 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

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“Our ultimate goal is to help people live the healthiest lives possible. Together, we have the

  • pportunity — and the

responsibility — to make a better healthcare system.”

—Charles Sorenson, MD President and CEO Intermountain Healthcare

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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”.

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Primary Care Clinical Program and Intermountain

Hospitals Medical Group SelectHealth Primary Care Clinical Program Population Health Affiliated Practices

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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

Clinical Program Organizational Structure

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Intermountain Clinical Programs

Behavioral Health Cardiovascular Intensive Medicine Musculoskeletal Neurosciences Oncology Pediatric Specialty Primary Care Surgery Women and Newborn

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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

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Concer ncerni ning ng P Popul ulation Hea ealth h and nd t the he PCCP CCP…

  • 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

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X X Population Utilization Health Episodes Per Person How many

patients have diabetes

Intracase Utilization Processes Per Health Episode

Number of tests per visit e.g. MRI for back pain

Efficiency Cost Per Health Process Cost per day, cost per MRI, Lab Test, etc.

The goal of “Population Health” and Clinical Programs is to im prove health and decrease w aste

Healthcare Cost Per Person =

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The balance between two worlds Fee for Service and Pay for Value

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How does the PCCP help?

  • Patient Education
  • Provider Education and Support
  • Supporting all Patients in the Practice
  • Supporting Patients Coming into the Offices
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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
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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
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Patient Fact Sheets

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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 m ore!

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Patient Education Booklets

Diabetes High Blood Pressure MAWDS CKD (in development) Lifestyle Weight Management Clinic Implementation Kit

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How to get Patient Handouts

Go to: iprintstore.org

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Patients At-risk for T2DM

Adult patients > 18 yrs Patients “at risk” for DM Prediabetic, (Unconfirmed) Prediabetic, (Confirmed)

Based on FPG

  • r HbA1c results

Unconfirmed – They have an abnormal glucose drawn at the same time as a “fasting lipid panel”

17,000 patients 35,000 patients

80,000 patients have risk factors for pre diabetes but have not been tested

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Type PCCP in your IE8 browser

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Linking Classes to Rural Regions

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Patient Education on the Health Hub

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Provider Ed Education is s important to the he PCCP beca ecaus use. e...

  • 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

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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
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Grand Rounds for the Primary Care Provider

Link: https: / / intermountainphysician.org/ intermountaincme/ Pages/ Primary- Care-Grand-Rounds.aspx

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Grand Rounds for the Primary Care Provider- ECME

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Monthly Education for Staff

Link: https: / / intermountainphysician.org/ intermountaincme/ Pages/ Monthly- Education-Videos.aspx

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Monthly Education for Staff

Link: https: / / intermountainphysician.org/ intermountaincme/ Pages/ Monthly- Education-Videos.aspx

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Care Process Models

  • High Blood Pressure
  • Chronic Kidney Disease
  • Diabetes
  • Asthma
  • Sinusitis
  • Cervical Cancer Screening
  • …And More
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CPM Documents and Flash Cards

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Flash Cards- Condensed CPMs

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Apple Device “Flash card” app

http: / / ebu.intermountainhealthcare.org/ physician / flashcard/ install.html

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https: / / physician.intermountain.net/ medicalgroup/ pages/ default.aspx

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Our Team to Yours

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Research and Guidance for Best Practices

  • Diabetes education paper
  • Team based care study
  • Diabetes prevention
  • Anticoagulation
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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
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The he PCCP is del elight hted ed when hen patient ents co come e in t n to see t ee thei heir provider er b beca ecaus use. e...

  • 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
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HELP2 Forms

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iCentra Development

  • Advisories
  • Care Process Models
  • Anticoagulation
  • Alerts
  • Care Pathways
  • mPages
  • Tablet Pilot
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Taking Best Practices to the System

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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

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MHI support and implementation

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How does the PCCP help?

  • Patient Education
  • Provider Education and Support
  • Supporting patients when they are in the
  • ffice
  • Supporting patients when they are not in the
  • ffice
  • Reports that identify patients with gaps in care
  • Feedback loop to improve efficiencies
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What t does th the PCCP th think about t to 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

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Quality Reporting

  • One Report
  • Registries for HBP, Diabetes, & Asthma
  • Customizable Patient Lists
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PCCP Dashboard

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Master Patient Watch List

Helps to see the patient as a whole person with potentially several conditions, not just one

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High Blood Pressure

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HBP Report with Patient List

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HBP Patient Management Report

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Correction Tool for Report

Feedback loop is important

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What could the PCCP do without the Medical Group?

  • 1. Nothing
  • 2. Nothing
  • 3. Nothing
  • 4. Nothing
  • 5. All of the above
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W HAT HAPPENS W HEN W E W ORK TOGETHER?

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Utah, Summit and Wasatch Counties High blood pressure not in control

325 37

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How to we “maintain the gain”

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How to we “maintain the gain”

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The PCCP CCP... ...

  • 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
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Questions?

Contact inform ation:

  • W ayne.Cannon@im ail.org
  • Phone: 8 0 1 -4 4 2 -3 1 3 1
  • Sharon.Ham ilton@im ail.org
  • Phone: 8 0 1 -4 4 2 -2 8 2 3
  • Tonya.Schaffer@im ail.org
  • Phone: 8 0 1 -4 4 2 -3 2 3 5