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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