Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of rural...
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Transcript of Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of rural...
Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg
Counties of rural South Western Kentucky
Cohort 1Learning Community Region 4
Hopkinsville, KYKecia Fulcher – Project Director
Lisa Bridges – Nurse Care [email protected]
1-877-473-7766
Statistics are good sometimes in evaluating programs, but the most important number we see each and every day is ONE. One represents each
person whose life has been changed, or even saved as a result of Integrated Health. The 24-year old male
client with early onset Diabetes and Hypertension doesn’t care about statistics, but he does care about
ONE, and how his life has been improved because we also cared about ONE.
Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of Western Kentucky
Who We Are• University of Kentucky
– Primary Evaluator – Tina Studts, PhD.
• Collaborative Agreements– Dentists, Labs, Health Departments, Hospitals
• Our Own Primary Care Staff– Dr. Stephen Thore / Dual Licensed
Psychiatric Addictionist / OB/GYN– Dr. David Gray – Dual Licensed
Psychiatrist / Family Practice– Linda Dillard, APRN– Lisa Bridges, RN Nurse Care Manager
Program Goals275 clients per year / 1,100 in 4 years
To improve access to primary care services.
To improve prevention, early identification and intervention as well as
treating chronic diseases.
To enhance the program’s capacity to holistically serve individuals
through screening techniques and service delivery.
To improve the overall health status of the Hopkinsville community.
Individual GrantProgram Measures
Our Typical ClientFemale – 59%Mid 40s – Early 50s – 27%Stable place to live in community – 78%Non-Drinker – 76%Obese – (Based on BMI) – 71%Tobacco User – 65%
DAST, Audit, SPO2 – O2 saturation
Successful Strategy : Evaluation/Reassessment
We have a subcontract with the University of Kentucky for data collection along with help from our IT Department. Two research assistants complete reassessment interviews.
Reassessment Rates : Year 1 - 96% Year 2 - 89%
Successful Strategy: HITBefore HIT
Using EHR since April 2009 – Certified Vendor is NetSmart
Since HIT Obtained 1st Meaningful Use payments Installed and have begun using OrderConnect Will install ConsumerConnect – Client portal to access PHI Will install CareConnect – HIE Portal Kentucky GOEHI obtained a National Council Grant – We are working with KHIE and KYREC. Working toward Year 2 Meaningful Use Criteria
Health and Wellness TopicsDisease ManagementDiabetes / Pre-DiabetesOral health for diabetesHyperlipidemiaHypertensionHepatitis CTobacco CessationOral healthChronic Fatigue / Fibromyalgia
Plans for The Future• Sustainability
• Clinical – Contracts with other primary care providers• Administrative – Commitment to long term plans for integration • Financial – Developing fiscal services for primary care
• Next six months:• Hire CNA for improved patient flow• Add two more exam rooms• Become a provider for Medicaid, TriCare, and other third party payors• Explore Medical Health Home and ACO activity