Primary Care/ Behavioral Health

integration

PCMH certification of all Primary Care

practices

Initiatives to address diversity and social

determinants of health

.

Our PACER Journey: POINT North: Primary Care Providers Organized

to INnovate Team-based Care at Northwell Health

CLINICAL

EDUCATION

Joint Grand Rounds • Primary care progress • Heath professions education • Transforming teaching practices • Coaching

Faculty Development

• IP Precepting • Mentoring

GME Retreat

• IP Education • Team-based Care

Meetings with residency Program Directors

Sharing best practices

(i.e. Huddles)

POINT North is an inter-professional collaborative between the primary care disciplines formed to catalyze meaningful change in clinical practice and education, transforming the face of primary care within our health system.

Objectives: Align Clinical and

Educational Initiatives

SETTING: Integrated Health System: large, expanding, geographically dispersed

OPPORTUNITIES: Co-occurring Health System Innovations

CHALLENGE: •Capitalize on the strengths of each PC discipline

•Leverage existing initiatives within the health system

Health System Stakeholder Meeting

Site visits by PACER team members Nursing joins

PACER

TDAP Research Project[?]

IP Workshops • IP Role Identification • Medication Management • Behavioral Health • Unconscious Bias • PCMH Concepts

PEDIATRICS Strengths:

IP Asthma program Anti-bullying initiative Screen for SDH

INTERNAL MEDICINE

Strengths: “IMPACcT” IP training program

Universal SBIRT screening Large IP team

FAMILY MEDICINE

Strengths: IP Diabetes program

High-risk patient conferences Strong nursing team

OUR PACER JOURNEY

FUTURE DIRECTIONS • Interdisciplinary community

health track for residents • NP students training within all

three departments • New interdepartmental SDH

project

LESSONS LEARNED • Start small • Nursing involvement is crucial • Need an “elevator speech” • Focus on training BARRIERS • Geographic distance • Time • Funding