LAKEWOOD HEALTH SYSTEM
MEDICAL HOME
FALL 2013 LEARNING DAYS
Nicole Worden, R.N.
Medical Home Care Coordinator
Christine Albrecht, M.D
Medical Home Co-director
Tina Kuhl
Medical Home Patient
November 13, 2013
STARTING MEDICAL HOME
PROGRAM DEVELOPMENT
PRESENT STATUS
• Pre-development
conceptions and educationlate 2006
• Development and planningsummer 2007
• Patient entry or initial trialJanuary 2008
• Full implementation-June
2008
• Medical Home Care
Coordinated patientsapproximately 760
• Medical home providers-12
Family Medicine Physicians
and 1 Pediatrician.
• Care Coordinators – 5 FTE’s
CHANGES INSTITUTED BY LHS IN
DEVELOPING HCH
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Same Day Appointment Development
POD Concept
Medical Home Care Coordinators
Provider Philosophies
Patient Advisory Council
EMR/Registry/Care Plans
Same Day Appointments
DEVELOPMENT
• Daily Same Day
appointment with MD and
extenders
• Define LHS “URGENT CARE”
according to needs of LHS
• Assign patients to
appropriate providers
through scheduling, triage
and Medical Home Care
Coordinators
WHY SAME DAY APPOINTMENTS?
• Better Patient Access
• Makes more time available
for Physicians to schedule
the more complicated
patients
• Better Patient Care and
education
POD CONCEPT
What is a POD
POD Benefits
• POD/Confinement within
• Each POD has MDs and
small groups-more likely to
Extenders along with their
see familiar faces
LPN/MA’s
• More availability within the
• 4 PODS, Staples, Motley, Pillager, POD
Browerville/eagle bend
• Faster response to patient’s
• Each POD has an RN call back
nurse and LPN triage nurse
MEDICAL HOME CARE COORDINATORS
RN’S
• Hire assertive, experienced, patient-friendly
and team playing R.N.’s
• Train to work within the medical home
definitions/regulations with the care trio of
MD, patient and care coordinator utilizing the
team that is associated with the patient (PT, OT,
Social Services, pharmacy, etc)
MEDICAL HOME CARE COORDINATORS
How does that improve patient experience?
High Quality and Efficient Care
•
RN’s provide value to patients, providers and consultants by improving the quality, appropriateness,
timeliness and efficiency of care activities
Interface with Patients:
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Answers phone and e-mail questions from Medical Home patients using own knowledge, charts and
discussions with provider as needed.
Updates Medical Record:
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Corrects and completes records (including all preventative care categories) upon admission to Medical
Home or ongoing health changes using EMR or patient telephone calls
Acts as Patient Advocate:
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Is innovative in concepts of preventative and therapeutic care for chronic disease, especially groupbased activities and education sessions
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Has a personal relationship with patients, acting in roles of educator as well as patient advocate for
optimizing care
(cont.)
OTHER CASE MANAGEMENT AT LHS
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Medical home(coordinated patient’s)
Women’s Health
Diabetic education
Palliative Care
Joint Connection
Cardio/Gastro
Call Back/Coumadin Clinic
Surgery Coordinators
PROVIDER PHILOSOPHIES
• Great care starts at the schedulers/receptionists
• Comprehensive care with each visit
• Better Access for complex patients (because of Same Day
appointments and saved spots in schedules)—keep patients
from needing the ER and hospitalization
• Engage patients in their care. Starting with pre-visit chart
review and after visit summaries.
• All Coordinated Care patients get extended visits (minimum of
30min) (99214)
• Utilize your extra eyes and ears from your care coordinators
MEDICAL HOME PROVIDERS
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By definition, must be physicians practicing primary care
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Must be willing to provide care according to the Joint Principles:
1.
2.
3.
4.
5.
whole person care
team care
coordinated care
enhanced access/communication
meeting established guidelines for safety and quality
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Accept new degree of responsibility to the entirety of the patient’s
healthcare
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Contribute to the Medical Home through analysis and suggestions
BETTER CARE : Enhanced Access
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Personal physician
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Direct access to Care Coordinator via phone, email and web
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Interdisciplinary team, whole-person approach to care
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Heightened access to designated and expanded clinic hours
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Ongoing education and newsletters
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Inclusion in decisions, care and responsibilities
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Electronic medical records (EMR)
PATIENT ADVISORY COUNCIL
Patient Engagement
• Quarterly patient advisory
meetings
• Better Access
• Education
• Welcome letters
• Medical home binders
• Monthly Newsletters
How does this improve
patient experience?
• The patient has a voice in the care
they receive
• Patients know that their opinion
counts, and feel comfortable giving
their opinion.
• Patient are kept in the loop with
any changes made.
• They can be seen or have there
questions answered that same day,
either by there primary physician
or by a “pod” partner.
• Patients are more knowledgeable
about their health.
EMR/REGISTRY/CARE PLANS
Specific Tools and Metrics of Quality
• Periodic Care Coordinated
Patient Screenings
– Monthly and Annually
• LHS Preventative Care
Guidelines, and Joint Principles
• Alerts/Directives
• Performance Metrics
– Surveys
– Internal statistics
– Payer Statistics
• Development of care plans
into our EMR
• Development or pre-visit
and post-visit summaries
• Development of our
workspace- for tracking
• Devoted e-mails
• AIDET training for all staff
Pillager Chart
Top Box Trends
Pillager
Displayed by Received Date
Medical Practice
Pillager
Overall
Pre – Visit Summary
Pre-Summary Documents
Post - Visit Summary
Post Visit Documents
Tina giving the patient perspective
Thank you!
Questions?