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.
What do we do differently as a PCPCH?
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Proactive (vs. Reactive) Team-Based Care
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Chart Scrubs
Daily Huddle
Chronic Care Model – ACTIVE management of ongoing conditions.
Outreach for Preventive Care
Patient Education
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Shared Decision Making (utilizing decision aids)
Community Outreach:
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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
PCPCH – How to get there:
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Lay the foundation
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Build Relationships
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Empanelment
Continuous, Team-Based Healing Relationships
Change Care Delivery
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Engaged Leadership
Quality Improvement Strategy
Patient-Centered Interactions
Organized, Evidence-Based Care
Reduce Barriers to Care
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Enhanced Access
Care Coordination
PCPCH – Care Coordination:
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Goals:
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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:
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Build Trust
Care Touches over Time
Community Linkages
Creating non-traditional alliances and community linkages:
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Wallowa County Network of Care:
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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:
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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.
PCPCH – Enhanced Access
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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)
Winding Waters Clinic Annual Outpatient Visits
Shift to increased number of
Outpatient Visits 12 months after
EHR adoption (median of 901).
ER Visits for Wallowa County
Improved WWC access
Ongoing trend of decreasing ER visits.
Winding Waters Clinic Annual Inpatient Visits
ER/Readmissions Data
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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
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# Repeat ER visits since tracking – 7
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(Same patient, same issue)
# Hospital readmissions since tracking – 3
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(Same patient, same issue, within 6 months)
Barriers to PCPCH transformation
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Knowledge
Time
Culture Change
Financial Resources
Staff Shortages
What do we need from a CCO to
continue as a highly functioning PCPCH?
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Reliable Payment Structure
PMPM Payments (stratified based on PCPCH functionality)
 Additional payments for quality outcomes.
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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…
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Technical Assistance
Quality Improvement Training
 Team Training starting with Communication Skills: motivational
interviewing, Team STEPPS, etc.
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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.
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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!
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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.
A Transformative Innovation for CCO’s:
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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.
Wallowa Valley Network of Care
Alder Slope Family Medicine
Alpine Chiropractic
Board of County Commissioners
Building Healthy Families
Community Connections
Department of Public Health
Olive Branch Family Health Inc.
Olive Branch Pharmacy
Safeway Pharmacy
Wallowa Memorial Hospital
Wallowa Mountain Acupuncture
Wallowa Mountain Medical
Wallowa Valley Center for Wellness
Winding Waters Clinic
Windspirit Medicine
Chantay Jet – Secretary
[email protected]
Winding Waters Clinic
Elizabeth Powers, MD – Managing Partner
[email protected]
Keli Christman – Practice Administrator
[email protected]