01 Section name goes here Addressing Population Health within the Patient-Centered Medical Home...

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Addressing Population Health within the Patient-Centered

Medical Home (PCMH) Coco Lukas, MPH – Quality Coordinator Rick Reifenberg, MD – Associate Medical Director

Sheila Allen, MPH – Chief Compliance and Quality Officer

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HealthNet is a Federally Qualified Health Center (FQHC)

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Health Centers

School-Based Clinics

HIP Clinic/Shelters

HIP Housing Sites

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Providers• ~70 MD/DOs – IM/Peds, Peds, FP, ObGyn, Psych

• ~45 Advanced Practice Nurses – Certified Nurse Midwives, Ped NP, FNP, Women's Health NP, Psych NP

Staff • 630 Full-Time Employees

HealthNet is a Federally Qualified Health Center (FQHC)

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Joint Commission Accredited for:

HealthNet is a Federally Qualified Health Center (FQHC)

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• Health Center

• Laboratory Services

• Patient Centered Medical Home (PCMH)

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Services Provided

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• Primary and Preventive Health Care

• Dental Services

• Behavioral Health Care

• Homeless Programs

• Support Services (e.g., WIC, social work)

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2014 By the Numbers

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• 59,286 patients

‒ Serves 20% of all Hoosiers covered by Federally Qualified Health Centers

• 263,167 family visits

‒ More outpatient visits than Riley Hospital for Children, which serves patients statewide

• 3,748 women obtained prenatal care

• 2,216 OB deliveries

• 3,092 homeless clients served

• 7,857 patients received dental care

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Payor Mix

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Patient-Centered Medical Home

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Patient-Centered Medical Home

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1. Pre-visit identification and scheduling

2. During patient care visits

3. Post-visit reporting

Population Health Implementation in 3 Phases

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• PHASE 1: Identification and scheduling

Population Health Implementation in 3 Phases

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‒ Reports to identify children due for well child care and those with chronic diseases (diabetes, asthma) that were overdue for visits.

‒ Data used to schedule patients during week and also on special Saturday Clinics.

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The report is emailed monthly to clinic managers. The patients have had the majority of their WCC at that clinic. Patients who are in the system who haven’t had a WCC go to ALL clinic managers

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• PHASE 2: During patient care visits

Population Health Implementation in 3 Phases

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‒ Templates

‒ Standing Orders

‒ Flowsheets

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• Well child assessment, nutrition/exercise counseling, and billing codes

• Mandatory question on pediatric templates re: vaccine status

• Required age-specific standard templates that include tobacco use and referral questions

• Asthma and Diabetes templates

• Nurse visits (e.g. Depo-Provera) with billing

Templates

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Templates

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• Standardized nursing based Standing Orders that mirrored new EHR work flows put in place HealthNet-wide.

• Staff are able to enter labs and vaccines on office visits prior to the Provider seeing the patient.

• Depression (PHQ2, PHQ9) and Anxiety (GAD7) done automatically when patient checks in.

Standing Orders

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Standing Orders

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Standing Orders

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• Helpful for documenting Cancer Screening (Colon and Cervical).

• Diabetic Flow Sheet tracks LDL and

Aspirin use.

• Health Maintenance Flow Sheet tracks

Cancer Screening and Aspirin use.

Flow Sheets

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Flow Sheets

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• PHASE 3: Post-visit reporting

Population Health Implementation in 3 Phases

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‒ Gathering and Reviewing the Data from the Outcomes from Phase 1 and 2 as noted on the prior slides.

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Pediatric Measures

• Well Child Checks 0-15 months

• Well Child Checks 3-6 years

• Adolescent Well Care 12-21 years

• Weight Assessment and Counseling

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Well Child Checks

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Weight Assessment and Counseling – Peds

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OB Measures

• First Trimester Entry

• Low Birth Weight Deliveries

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First Trimester Entry - OB

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Low Birth Weight Deliveries

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Adult and Chronic Disease Measures

• Weight Screening and Follow Up

• Tobacco Assessment and Counseling

• Asthma Pharmacologic Therapy

• Hypertension – Blood Pressure Control

• Diabetes – A1c Control

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Weight Screening and Follow-Up – Adults

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Adult Tobacco Assessment and Counseling

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Asthma Pharmacologic Therapy

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Hypertension Blood Pressure Control

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Diabetes A1c Control

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Questions?

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Contact Information

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Coco Lukas, MPH Quality Coordinator clukas@iuhealth.org

Rick Reifenberg, MDAssociate Medical Director rreifenb@iuhealth.org

Sheila Allen, MPH Chief Compliance and Quality Officer sallen6@iuhealth.org