K A R E N F U N K M D M P P V I C E - P R E S I D E N T O F C L I N I C A L S E R V I C E S

A N N G U Y E N D D S M P H V I C E - P R E S I D E N T O F D E N T A L S E R V I C E S

Patient-Centered System Redesign The Integrated Dental Home

Objectives

To describe Clinicarsquos history with patient-centered care and system redesign

To describe the application of the Planned Care Model to the Clinica health care home

To describe ldquoThe Big 6rdquo and give specific examples of how they have facilitated the development of a patient-centered integrated medical-dental home

Clinica Family Health Services

Demographics gt40000 active pts

Medical Dental Behavioral Health Pharmacy

49 uninusured 56 ltPoverty 98 lt200 Poverty

PCHH Journey 1977 Founded 1998 Joined IHI Chronic Care

Collaborative 2000 Delivery System Redesign 2001-04 Planned Care Approach

to QI 2004-10 Spread amp Sustain

Improvements NCQA Level 3 PCMH

Future Patient Activation

Planned (Chronic) Care Model

Key Redesign Initiatives (The Big 6)

To improve patient-centered population-based management

1 Continuity

2 Access

3 Improved Care Delivery Model

4 Improved Office Efficiency

5 Improved Information System Design

6 Patient Activation amp Self-Management

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

Objectives

To describe Clinicarsquos history with patient-centered care and system redesign

To describe the application of the Planned Care Model to the Clinica health care home

To describe ldquoThe Big 6rdquo and give specific examples of how they have facilitated the development of a patient-centered integrated medical-dental home

Clinica Family Health Services

Demographics gt40000 active pts

Medical Dental Behavioral Health Pharmacy

49 uninusured 56 ltPoverty 98 lt200 Poverty

PCHH Journey 1977 Founded 1998 Joined IHI Chronic Care

Collaborative 2000 Delivery System Redesign 2001-04 Planned Care Approach

to QI 2004-10 Spread amp Sustain

Improvements NCQA Level 3 PCMH

Future Patient Activation

Planned (Chronic) Care Model

Key Redesign Initiatives (The Big 6)

To improve patient-centered population-based management

1 Continuity

2 Access

3 Improved Care Delivery Model

4 Improved Office Efficiency

5 Improved Information System Design

6 Patient Activation amp Self-Management

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

Clinica Family Health Services

Demographics gt40000 active pts

Medical Dental Behavioral Health Pharmacy

49 uninusured 56 ltPoverty 98 lt200 Poverty

PCHH Journey 1977 Founded 1998 Joined IHI Chronic Care

Collaborative 2000 Delivery System Redesign 2001-04 Planned Care Approach

to QI 2004-10 Spread amp Sustain

Improvements NCQA Level 3 PCMH

Future Patient Activation

Planned (Chronic) Care Model

Key Redesign Initiatives (The Big 6)

To improve patient-centered population-based management

1 Continuity

2 Access

3 Improved Care Delivery Model

4 Improved Office Efficiency

5 Improved Information System Design

6 Patient Activation amp Self-Management

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

Planned (Chronic) Care Model

Key Redesign Initiatives (The Big 6)

To improve patient-centered population-based management

1 Continuity

2 Access

3 Improved Care Delivery Model

4 Improved Office Efficiency

5 Improved Information System Design

6 Patient Activation amp Self-Management

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

Key Redesign Initiatives (The Big 6)

To improve patient-centered population-based management

1 Continuity

2 Access

3 Improved Care Delivery Model

4 Improved Office Efficiency

5 Improved Information System Design

6 Patient Activation amp Self-Management

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

1 Continuity

Most important Data shows that improved continuity results in

Fewer visits to the emergency room1

Improved patient satisfaction2

Improved rates of preventive services completion (pap mammograms vaccinations)3

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

1 Continuity

Defined Dental Panels Assigned PDP

Panel Sizes - adjusted by

Patient Age Gender

Care Type

Comprehensive

Acute Care

Dentist FTE

Metrics Continuity w PDP

Continuity w Care Team (site)

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

2 Access

50000 patients who canrsquot get in

High Leverage Changes for Access

Match demand amp supply daily

Decrease appointment types amp times (reduce ldquocarve-outsrdquo)

Develop contingency plans

Reduce demand for visits

Optimize the care team

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

2 Access

The Challenge Medical amp Dental Parity

Medical gt 40000 Patients

Dental lt 9000 Patients

Our Solution Populations of Focus

Routine Care

Diabetics

Pregnant Women

Children

Acute Care Max 20 of Weekly Visits

77 of all dental visits to POF (only 19 of all Clinica POF patients)

Total Dental Visits per Year

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

1 Continuity + 2 Access = Outcomes

0

10

20

30

40

50

60

70

80

90

100

Year

Clinica Trimester of Entry of Prenatal Care

3rd Trimester

2nd Trimester

1st Trimester

2008 Change in data

collection from Prenatal

Database to EMR

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

1 Continuity + 2 Access = Outcomes

Assignment of PDP

POF amp Triaging

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

3 Improved Care Delivery Model

Group Visits

Facilitated group process for patient activation

Care setting in space designed for groups

Patients invited on basis of chronic disease history and utilization patterns

The goal is patient activation

Patients remain in same group for continuity

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

3 Improved Care Delivery Model

Colocation of Dental Clinics

Centralized Processes Financial Screening

Call Center

Scheduling

Integration of Dental Hygienists on the medical

care team

Dental participation in group visits

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

4 Improved Office Efficiency

3 FTEs Medical Provider 3 FTEs Medical Assistant 1 FTE Nurse Team Manager 1 FTE Behavioral Health Professional 2 FTEs Receptionist 1 FTE Medical Records Clerk 05 FTE Referral Case Manager 025 FTE Dental Hygienist

The Care Team

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

4 Improved Office Efficiency

The ldquoDental Podrdquo

Red Team

Blue Team

Yellow Team

ldquoHigh Techrdquo flags used to identify team ops used and phase of patient care

Workstations

Operatories

Color-coded team-based seating

4 Improved Office Efficiency

Providers sit with support staff

Facilitates huddling and communication

Supports working at ldquotop of the licenserdquo

RDH Student DA

EDDA EDDA DDS

Red Team

5 Improved Information System Design

Mobile tablets for easy use of electronic health record at site of care

Monthly review by administrative and care team staff of quality outcomes

Business intelligence tools that help plan care for populations of focus

5 Improved Information System Design ndash Quality Outcomes

UDS Hypertension Control - BP lt14090

2013 Cumulative of Patients in Control

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-

13

Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Lafayette 693565877123690468186872 713472827106

Pecos 701369966923721774967837 769275557536

Peoples 533354706129637764806937 710370716868

Thornton 666770357388653869266944 741276087487

Goal 750075007500750075007500 750075007500750075007500

Jan-13 Feb-13 Mar-13 Apr-13May-

13Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Strategic Plan Goal 75 of HTN Pts with

5 Improved Information System Design

Business Intelligence amp Reporting Tools

Care Planning Tools (Outreach Tool)

5 Improved Information System Design

Org Structure supports collaboration and

clinical quality PresidentCEO

CFOVP of

Clinical Services

Director of

Accounting

Controller

Billing

Specialists

Dir of FPampA

Clinic

Medical Directors

(5)

ECS

Clinical

Manager

Board

of Directors

VP

of

Human Resources

Exec

Services

Manager

Financial

Screeners

HR

Generalists

Clinic

Directors

(5)

Site Billers

Application

Support

Specialist

Mgr

Reimbursements

amp Billing

Analysis

Purchasing

Coord

Onsite

Support

Clinica Family Health Services

Call Center

Attendants

Call Center

Manager

Support

Lead

Sr HR

Generalist

Admin Asst(Pecos)

ClinicalMA

Trainers

Providers

Dir of Patient

Financial

Services

Accounting

Assts

AccountantsCredentialling

Clerk

HR Generalist

Payroll Manager

Pharmacist

Pharmacy

Technicians

VP of

Dental

Services

Dental

Assistants

Nurse Team

Managers

MA Team

Managers

Office

Techs

Clinic

Operations

Managers

Referral

Case

Managers

COT

Exec

Services

Specialists

AMDs

Director

Care

Transitions

Hygienists

Grant

Writer

VP of

Clinical Services

VP of

Operations

Nursing

Services

Managers

Database

Admin

Developer

Clinic

Nurses

Case

Managers

(Lafayette)

Case

Managers

Quality

Coach(iPN)

BHPs

Homeless Prgm

Nurse

(Peoples)

Development

Director

DieticiansMedical

Assts

Dental Ops

Dir

VP of

Strategic Support

Director

Business

Intelligence

Central

Scheduling

Payroll

Benefits

BI Project

Manager

Med Recs

Auditor

Dir of Billing

Projects

amp Compliance

Med Recs

DATMs

Office

TechsAsst Dental

Dir

Dentists

Dir of

Nursing

Care Team

Development

Director

Process

Improvement

Project

Managers

Sr Analytic

Specialist

IT

Director

Clinical

Quality

Manager

ACO

Director

Rounders

Floats

Newborn

Home Visit

Program

TOC

Dir of BH

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

5 Improved Information System Design

Mobile tablets for easy use of electronic health record at site of care

Monthly review by administrative and care team staff of quality outcomes

Business intelligence tools that help plan care for populations of focus

5 Improved Information System Design ndash Quality Outcomes

UDS Hypertension Control - BP lt14090

2013 Cumulative of Patients in Control

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-

13

Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Lafayette 693565877123690468186872 713472827106

Pecos 701369966923721774967837 769275557536

Peoples 533354706129637764806937 710370716868

Thornton 666770357388653869266944 741276087487

Goal 750075007500750075007500 750075007500750075007500

Jan-13 Feb-13 Mar-13 Apr-13May-

13Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Strategic Plan Goal 75 of HTN Pts with

5 Improved Information System Design

Business Intelligence amp Reporting Tools

Care Planning Tools (Outreach Tool)

5 Improved Information System Design

Org Structure supports collaboration and

clinical quality PresidentCEO

CFOVP of

Clinical Services

Director of

Accounting

Controller

Billing

Specialists

Dir of FPampA

Clinic

Medical Directors

(5)

ECS

Clinical

Manager

Board

of Directors

VP

of

Human Resources

Exec

Services

Manager

Financial

Screeners

HR

Generalists

Clinic

Directors

(5)

Site Billers

Application

Support

Specialist

Mgr

Reimbursements

amp Billing

Analysis

Purchasing

Coord

Onsite

Support

Clinica Family Health Services

Call Center

Attendants

Call Center

Manager

Support

Lead

Sr HR

Generalist

Admin Asst(Pecos)

ClinicalMA

Trainers

Providers

Dir of Patient

Financial

Services

Accounting

Assts

AccountantsCredentialling

Clerk

HR Generalist

Payroll Manager

Pharmacist

Pharmacy

Technicians

VP of

Dental

Services

Dental

Assistants

Nurse Team

Managers

MA Team

Managers

Office

Techs

Clinic

Operations

Managers

Referral

Case

Managers

COT

Exec

Services

Specialists

AMDs

Director

Care

Transitions

Hygienists

Grant

Writer

VP of

Clinical Services

VP of

Operations

Nursing

Services

Managers

Database

Admin

Developer

Clinic

Nurses

Case

Managers

(Lafayette)

Case

Managers

Quality

Coach(iPN)

BHPs

Homeless Prgm

Nurse

(Peoples)

Development

Director

DieticiansMedical

Assts

Dental Ops

Dir

VP of

Strategic Support

Director

Business

Intelligence

Central

Scheduling

Payroll

Benefits

BI Project

Manager

Med Recs

Auditor

Dir of Billing

Projects

amp Compliance

Med Recs

DATMs

Office

TechsAsst Dental

Dir

Dentists

Dir of

Nursing

Care Team

Development

Director

Process

Improvement

Project

Managers

Sr Analytic

Specialist

IT

Director

Clinical

Quality

Manager

ACO

Director

Rounders

Floats

Newborn

Home Visit

Program

TOC

Dir of BH

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

5 Improved Information System Design ndash Quality Outcomes

UDS Hypertension Control - BP lt14090

2013 Cumulative of Patients in Control

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-

13

Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Lafayette 693565877123690468186872 713472827106

Pecos 701369966923721774967837 769275557536

Peoples 533354706129637764806937 710370716868

Thornton 666770357388653869266944 741276087487

Goal 750075007500750075007500 750075007500750075007500

Jan-13 Feb-13 Mar-13 Apr-13May-

13Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Strategic Plan Goal 75 of HTN Pts with

5 Improved Information System Design

Business Intelligence amp Reporting Tools

Care Planning Tools (Outreach Tool)

5 Improved Information System Design

Org Structure supports collaboration and

clinical quality PresidentCEO

CFOVP of

Clinical Services

Director of

Accounting

Controller

Billing

Specialists

Dir of FPampA

Clinic

Medical Directors

(5)

ECS

Clinical

Manager

Board

of Directors

VP

of

Human Resources

Exec

Services

Manager

Financial

Screeners

HR

Generalists

Clinic

Directors

(5)

Site Billers

Application

Support

Specialist

Mgr

Reimbursements

amp Billing

Analysis

Purchasing

Coord

Onsite

Support

Clinica Family Health Services

Call Center

Attendants

Call Center

Manager

Support

Lead

Sr HR

Generalist

Admin Asst(Pecos)

ClinicalMA

Trainers

Providers

Dir of Patient

Financial

Services

Accounting

Assts

AccountantsCredentialling

Clerk

HR Generalist

Payroll Manager

Pharmacist

Pharmacy

Technicians

VP of

Dental

Services

Dental

Assistants

Nurse Team

Managers

MA Team

Managers

Office

Techs

Clinic

Operations

Managers

Referral

Case

Managers

COT

Exec

Services

Specialists

AMDs

Director

Care

Transitions

Hygienists

Grant

Writer

VP of

Clinical Services

VP of

Operations

Nursing

Services

Managers

Database

Admin

Developer

Clinic

Nurses

Case

Managers

(Lafayette)

Case

Managers

Quality

Coach(iPN)

BHPs

Homeless Prgm

Nurse

(Peoples)

Development

Director

DieticiansMedical

Assts

Dental Ops

Dir

VP of

Strategic Support

Director

Business

Intelligence

Central

Scheduling

Payroll

Benefits

BI Project

Manager

Med Recs

Auditor

Dir of Billing

Projects

amp Compliance

Med Recs

DATMs

Office

TechsAsst Dental

Dir

Dentists

Dir of

Nursing

Care Team

Development

Director

Process

Improvement

Project

Managers

Sr Analytic

Specialist

IT

Director

Clinical

Quality

Manager

ACO

Director

Rounders

Floats

Newborn

Home Visit

Program

TOC

Dir of BH

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

5 Improved Information System Design

Business Intelligence amp Reporting Tools

Care Planning Tools (Outreach Tool)

5 Improved Information System Design

Org Structure supports collaboration and

clinical quality PresidentCEO

CFOVP of

Clinical Services

Director of

Accounting

Controller

Billing

Specialists

Dir of FPampA

Clinic

Medical Directors

(5)

ECS

Clinical

Manager

Board

of Directors

VP

of

Human Resources

Exec

Services

Manager

Financial

Screeners

HR

Generalists

Clinic

Directors

(5)

Site Billers

Application

Support

Specialist

Mgr

Reimbursements

amp Billing

Analysis

Purchasing

Coord

Onsite

Support

Clinica Family Health Services

Call Center

Attendants

Call Center

Manager

Support

Lead

Sr HR

Generalist

Admin Asst(Pecos)

ClinicalMA

Trainers

Providers

Dir of Patient

Financial

Services

Accounting

Assts

AccountantsCredentialling

Clerk

HR Generalist

Payroll Manager

Pharmacist

Pharmacy

Technicians

VP of

Dental

Services

Dental

Assistants

Nurse Team

Managers

MA Team

Managers

Office

Techs

Clinic

Operations

Managers

Referral

Case

Managers

COT

Exec

Services

Specialists

AMDs

Director

Care

Transitions

Hygienists

Grant

Writer

VP of

Clinical Services

VP of

Operations

Nursing

Services

Managers

Database

Admin

Developer

Clinic

Nurses

Case

Managers

(Lafayette)

Case

Managers

Quality

Coach(iPN)

BHPs

Homeless Prgm

Nurse

(Peoples)

Development

Director

DieticiansMedical

Assts

Dental Ops

Dir

VP of

Strategic Support

Director

Business

Intelligence

Central

Scheduling

Payroll

Benefits

BI Project

Manager

Med Recs

Auditor

Dir of Billing

Projects

amp Compliance

Med Recs

DATMs

Office

TechsAsst Dental

Dir

Dentists

Dir of

Nursing

Care Team

Development

Director

Process

Improvement

Project

Managers

Sr Analytic

Specialist

IT

Director

Clinical

Quality

Manager

ACO

Director

Rounders

Floats

Newborn

Home Visit

Program

TOC

Dir of BH

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

5 Improved Information System Design

Org Structure supports collaboration and

clinical quality PresidentCEO

CFOVP of

Clinical Services

Director of

Accounting

Controller

Billing

Specialists

Dir of FPampA

Clinic

Medical Directors

(5)

ECS

Clinical

Manager

Board

of Directors

VP

of

Human Resources

Exec

Services

Manager

Financial

Screeners

HR

Generalists

Clinic

Directors

(5)

Site Billers

Application

Support

Specialist

Mgr

Reimbursements

amp Billing

Analysis

Purchasing

Coord

Onsite

Support

Clinica Family Health Services

Call Center

Attendants

Call Center

Manager

Support

Lead

Sr HR

Generalist

Admin Asst(Pecos)

ClinicalMA

Trainers

Providers

Dir of Patient

Financial

Services

Accounting

Assts

AccountantsCredentialling

Clerk

HR Generalist

Payroll Manager

Pharmacist

Pharmacy

Technicians

VP of

Dental

Services

Dental

Assistants

Nurse Team

Managers

MA Team

Managers

Office

Techs

Clinic

Operations

Managers

Referral

Case

Managers

COT

Exec

Services

Specialists

AMDs

Director

Care

Transitions

Hygienists

Grant

Writer

VP of

Clinical Services

VP of

Operations

Nursing

Services

Managers

Database

Admin

Developer

Clinic

Nurses

Case

Managers

(Lafayette)

Case

Managers

Quality

Coach(iPN)

BHPs

Homeless Prgm

Nurse

(Peoples)

Development

Director

DieticiansMedical

Assts

Dental Ops

Dir

VP of

Strategic Support

Director

Business

Intelligence

Central

Scheduling

Payroll

Benefits

BI Project

Manager

Med Recs

Auditor

Dir of Billing

Projects

amp Compliance

Med Recs

DATMs

Office

TechsAsst Dental

Dir

Dentists

Dir of

Nursing

Care Team

Development

Director

Process

Improvement

Project

Managers

Sr Analytic

Specialist

IT

Director

Clinical

Quality

Manager

ACO

Director

Rounders

Floats

Newborn

Home Visit

Program

TOC

Dir of BH

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

6 Patient Activation amp Self-Management

We take care of 99995 of our own health care decisions So do our patients

It is our job to find ways to help motivate patients to make the necessary behavioral changeshellipsmoking exercise weight loss hellipflossing

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

6 Patient Activation amp Self-Management

Dental self-management on care planner coming soon

Documentation and routine assessments in the EDR during exams and CRAs

SELF-MANAGEMENT GOALS (select at least one)

Regular Dental Care Brush with F- Toothpaste Keep Germs to Yourself Eat Healthy Foods

Drink Tap Water Less Juice No Bottle at Bedtime Wean off bottlepacifierdigit Only Water in Cup

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

Clinicarsquos Lessons Learned

Put the patient first

Find ways to add the patient voice

Start small but start

Optimize the team

Use the QI tools that work

Make improvement a system characteristic

Free up leaders to innovate and ldquospin the fly wheel fasterrdquo

Measure data over time

Home remodeling starts with a homehellip

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

Prim

ary M

ed

ic

al S

ervic

es Behavioral Health Services

Ora

l H

ea

lth

Se

rvic

es

Well Visits through the Life Cycle

La

bo

rato

ry S

erv

ice

s

Group Visits

Chronic Disease Management

Pe

diatric

s Vaccinations

Nutritional Support

In-P

atie

nt

Ho

spit

al S

ervi

ces

Obstetrics Family Medicine

Thank You

Dr Karen Funk kfunkclinicaorg

Dr An Nguyen anguyenclinicaorg

wwwclinicaorg

Continuity References

1Brousseau DC Meurer JR Isenberg ML Kuhn EM Gorelick MH Association between infant continuity of care and pediatric emergency department utilization Pediatrics 2004 Apr113(4)738-41 2Christakis DA Wright JA Zimmerman FJ Bassett AL Connell FA Continuity of care is associated with high-quality care by parental report Pediatrics 2002 Apr109(4)e54

3 Cabana MD Jee SH Does continuity of care improve patient outcomes J Fam Pract 2004 Dec53(12)974-80