Making CCO’ s work: Leveraging Patient-Centered PRIMARY CARE HOMES

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MAKING CCO’S WORK: LEVERAGING PATIENT-CENTERED PRIMARY CARE HOMES Dr. Elizabeth Powers Winding Waters Clinic Enterprise, Oregon Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County.

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Making CCO’ s work: Leveraging Patient-Centered PRIMARY CARE HOMES. Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents and Visitors of Wallowa County. Dr. Elizabeth Powers Winding Waters Clinic Enterprise, Oregon. What do we do differently as a PCPCH?. - PowerPoint PPT Presentation

Transcript of Making CCO’ s work: Leveraging Patient-Centered PRIMARY CARE HOMES

Page 1: Making CCO’ s  work: Leveraging Patient-Centered  PRIMARY CARE HOMES

MAKING CCO’S WORK:LEVERAGING PATIENT-CENTERED

PRIMARY CARE HOMESDr. Elizabeth Powers

Winding Waters ClinicEnterprise, Oregon

Our Mission is to Provide Excellent, Comprehensive Healthcare to the Residents

and Visitors of Wallowa County.

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What do we do differently as a PCPCH?

Proactive (vs. Reactive) Team-Based Care Chart Scrubs Daily Huddle Chronic Care Model – ACTIVE management of ongoing

conditions. Outreach for Preventive Care

Patient Education Shared Decision Making (utilizing decision aids) Community Outreach:

Marketing and Patient Education regarding PCPCH/Access Diabetes and Asthma Education Living Well with Chronic Conditions (Stanford Curriculum)

Patient Engagement via Patient Advisory Council Staff Engagement via QI Committee and Project

Champions

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PCPCH – How to get there: Lay the foundation

Engaged Leadership Quality Improvement Strategy

Build Relationships Empanelment Continuous, Team-Based Healing Relationships

Change Care Delivery Patient-Centered Interactions Organized, Evidence-Based Care

Reduce Barriers to Care Enhanced Access Care Coordination

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PCPCH – Care Coordination: Goals:

Keep our patients as healthy as possible. Get them involved in making decisions regarding their own health. Help them utilize the services offered throughout the community.

How we make this happen: Build Trust Care Touches over Time Community Linkages

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Creating non-traditional alliances and community linkages:

Wallowa County Network of Care: Our Vision: 100% ACCESS, 0% DISPARITY Our Mission: Better Health and Better Living…

…Through Community Collaboration and Education

Our Values: Communication, Collaboration, and Creativity

Initial goals: Develop an integrated network that includes ALL

community providers. Provide access for ALL clients to ALL services when they

walk through the door of any WCNC location.

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PCPCH – Enhanced Access Access Improvements in 2010:

Open access scheduling Walk-in urgent care Expanded hours Care teams 24 hour telephone access to MD On-line access to care team (patient portal)

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Winding Waters Clinic Annual Outpatient Visits

ER Visits for Wallowa County

Winding Waters Clinic Annual Inpatient Visits

Ongoing trend of decreasing ER visits.

Shift to increased number of Outpatient Visits 12 months after EHR adoption (median of 901).

Improved WWC access

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ER/Readmissions Data Don’t have any “before” data. 410 visits to ER/hospital in 6 months 23 pts (5.6%) with more than 2 ER visits/hosp.

admissions 6 with psychiatric comorbidity 5 with substance abuse comorbidity 3 deceased (end of life) 11 >65, 7 >80

# Repeat ER visits since tracking – 7 (Same patient, same issue)

# Hospital readmissions since tracking – 3 (Same patient, same issue, within 6 months)

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Barriers to PCPCH transformation

Knowledge Time Culture Change Financial Resources Staff Shortages

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What do we need from a CCO to continue as a highly functioning PCPCH?

Reliable Payment Structure PMPM Payments (stratified based on PCPCH

functionality) Additional payments for quality outcomes.

Data Standardization Standard Monthly Scorecard with Universal

Benchmarks Community-Specific Scorecard Based on local QI

Projects

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What do we need from a CCO continued… Technical Assistance

Quality Improvement Training Team Training starting with Communication Skills:

motivational interviewing, Team STEPPS, etc. Educational Assistance

Financial support for community education. Outside resources to train local people (ex. Living Well

Classes). Ongoing training for behavioral health specialists and

community health workers. Survey Assistance

Cover cost of CAHPS survey. Work with communities to measure patient and care team

engagement.

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We are proud to be a PATIENT CENTERED Primary Care Home!

In our little corner of Oregon, we are taking it one patient at a time and we are positively impacting those patients’ lives.

We can’t yet prove that our impact is community-wide, but we are improving patient engagement and education.

The only way we can stem the tide of health care spending AND improve the health of our communities is to be champions for all patients, one patient at a time.

HOWEVER, we can’t keep doing this work without a system that supports us. If we build the system around what each patient needs, we will move in the right direction.

We need a liaison present as part of our care team and network to gain an understanding of our community, our practice, and most importantly, our patients.

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A Transformative Innovation for CCO’s:

Practice Enhancement Coordinator: Like a member of a CCT from the insurance

company! Know and understand each community. Know the individual practices within each

community. Help practices move along the continuum of

PCPCH. Ensure that CCO policies support PCPCH

success. Help build trust among providers in each

community. Focus CCO attention and resources on key

areas to truly improve community health.

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Winding Waters ClinicElizabeth Powers, MD – Managing

[email protected]

Keli Christman – Practice [email protected]

Wallowa Valley Network of CareChantay Jet – Secretary

[email protected] Slope Family MedicineAlpine ChiropracticBoard of County CommissionersBuilding Healthy FamiliesCommunity ConnectionsDepartment of Public HealthOlive Branch Family Health Inc.Olive Branch PharmacySafeway PharmacyWallowa Memorial HospitalWallowa Mountain AcupunctureWallowa Mountain MedicalWallowa Valley Center for WellnessWinding Waters ClinicWindspirit Medicine