Dr. Steven Roth Jennifer Nappi RN NCM Thundermist Health Center

Dr. Steven RothJennifer Nappi RN NCM

Thundermist Health Center

What We Hear Patients WantRelief From What Ails

- Our patients want to be healthy, but…- Easier treatment is better, e.g.

The Silver BulletEpedient ( fewer doses, shorter courses)

Convenience- Right time- Right place- No wait

What We Hear Patients WantInstant Information

- X- Ray- Rapid tests – flu, mono, strep, urine, HbA1C, pregnancy, lipids, etc.- Answers to all their questions

The latest and the greatest:- what they learn from the media (drug ads, doc shows, news reports)- one myth perpetuated by the present healthcare system: the higher the tech the better the care.

What Patient a Patient Centered Medical Home Offers

AccessAffordabilityAppropriate Diagnosis and TreatmentEducation

What Thundermist Has DoneOpen Access – doing today’s work todayExtended hours: three evenings until 8pm,

Saturday hours at all sitesconstruct sliding scalesoffer discounted medication via 430B grant

with CVSComprehensive servicesIncorporate NCMs in each office

For Hospital Inpatients (IP)Collection of daily admission and discharge

data by our NCM’s (South County & Woonsocket)

THC – South County physician does hospital social rounds connecting with our sickest patients and tracking of admissions and discharges

Hospital IP continued

NCM follow up on labs & imaging studies the PCP received which is some cases is the first indication of ED/IP admit

Beginning relationships with SCH discharges case managers

New Work Flow

NCM follow-up on Inpatient visitsRNs follow-up on ER visitsFront line staff follow-up on Urgent careDeveloped Patient education materials to be

mailed to all patients - Appropriate Use Packages for ED/UC visits

Use of template

Tracking patient ER/Hospital visits

Tracking type of follow-up

Produce data for insurance companies

Preliminary data

Tracking NHPRI ER/Urgent care visits for 2

years

ER visits - decrease

Inpatient stays – about the same

Urgent care visits – about the same

Steps takenTHC – South County has established

relationships with hospital care managers THC – South County & Woonsocket

Receive/can access daily ER visits/inpatient admits

THC Quality Management Team - Reassess & develop work flow based on clinical data

ChallengesStrengthen established hospital relationshipsEstablish relationship with Kent County for

WW office (in progress)Continue to assess & revise work flow as

needed to improve patient careWork in concert with insurers to improve

patient education on the patient’s plan of care

Challenges continued

Process to expedite DI & lab tests from the office

Facilitate process to send visit information to specialists

Educate the patient, staff, general community & the medical community on the role of primary care giver as the orchestrator of the patient’s health care