Best Practice:
Clinical Redesign Approach
Centric to the LPN Coordinated
Care Model
Laura Nicosia, MD
Chair – Primary Care – Ochsner WB
October 29, 2015
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Agenda
• Purpose of program
• Program overview
• Short and long term program goals
• Preliminary results
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Purpose of Program
“Today we are primarily in the
business of delivering care
one patient at a time. By
contrast, a population health
practitioner is concerned with
achieving healthy outcomes
for an entire population.”
-Steven Lefar, Sg2 President and CEO
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Purpose of Program
• Use Epic to maximize population health
management through the use of a registry
• A registry is a group of patients who
match a specified criteria and, based on
that population, have relevant clinical and
miscellaneous metrics.
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Purpose of Program
•
•
A diabetes registry could include an Epic inclusion rule
that looks at patients who have a diabetes-related
diagnosis on their problem list and/or have had an
encounter with a diabetes diagnosis documented within
the last five (5) years – regardless of age, insurance, etc.
Based on this criteria we may want to see for a specific
provider all of their patients with diabetes and:
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–
–
–
–
–
Patient’s Last Office Visit Date
Patient’s blood pressure (BP) - goal less than 140/90
Patient’s Last LDL result
Patient’s Last Positive Urine Protein Result
Patient’s Last Foot Exam Date
Patient’s Last Eye Exam Date
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CCC LPN Program - Overview
•
•
•
Piloted in Baton Rouge in April 2015
Expanded system wide to all of Primary Care (including
the WB) in June 2015
Currently have 23+ CCCs in place system wide – 3 on
the WB (ratio is about 1 CCC per 7-8 physicians) for the
Ochsner Primary Care employed providers
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CCC LPN Program - Overview
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CCC LPN Program – Goals
short term
• #1 Goal is to close primary care gaps
– Place bulk orders based on the diabetes registry (Hgb
A1c, urine for microalbumin, lipid panel)
– Call patients that have not been seen in a year to
schedule an appointment
– Pre-visit planning – look at patients that will be
coming in next 2 weeks to close care gaps
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CCC LPN Program – Goals
short term
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CCC LPN Program – Goals
short term
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CCC LPN Program – Goals
long term
•
•
•
•
•
Referrals to outpatient case management
Attend QBPC meetings on Fridays to address barriers
with patients scheduled to see PCP in 2 weeks
Teach providers about the metrics – roll out just
beginning
Meet with providers at least once every 2 weeks to
review patient needs with scheduled appointments –
align with HEDIS and STAR goals
Support Population Health: understand the programs
and navigate patients to the support needed (i.e., DM patients
that may need a health coach, or empowerment program, or a visit with a nutritionist)
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CCC LPN Program - Goals
• Other registries to come:
– HTN
 in progress
– COPD
 role out spirometry to satellite clinics
– Wellness
– Immunization
Population
Health:
Care TOuch
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CCC LPN Program - Goals
• Other considerations:
– Once orders are fulfilled the orders and gap disappear from the
registry
– Orders remain good for 1 year
– Will recontact patients with open gaps quarterly
– Patient Groups can be prioritized:
Humana Gold
MSSP (Medicare)
Employee Group
Blue Cross: Quality Blue Primary Care
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CCC LPN Program - Goals
• Other considerations:
– We are working with Registration on capturing the patient’s
PCP in Epic
– We are working with lab to create a walk up mechanism for
several selected sites (other sites will need an appointment)
– At this time bulk notifications will be sent as follows:
Portal Patients will be notified via the portal
Non-portal patients will be notified by phone or letter based
on preference
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CCC LPN Program - Results
West Bank
(~ inception through August 2015)
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•
•
•
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Total # of patients in registry:
Outreach: # pts who received a notification:
Total # of labs/tests completed:
Unique # pts that completed labs:
Avg # of labs/tests completed by patient:
•
Percent of patients reached out to that completed labs: 24%
5497
2430
1938
581
3.3
(In line with the total system result which is ~ 24%)
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