LAMPREY HEALTH CARE MEDICAL HOME

1. LAMPREY HEALTH CARE MEDICAL HOME

2. Unique Facts About LHC • New Hampshire's oldest and largest community health center • 16,000 patients served each year • Urban and rural locations • The newest LHC site, is located in Nashua and one of 13 primary care practices located in a mental health setting

3. Goal for Presentation • Strategic Plan • Current Staff Design • Review framework used to achieve, expand and sustain Medical Home Efforts

4. Goal for Presentation • Impact on • Teamwork • Access • Population • Planned, Coordinated Care • Patient & Family-Centered Care

5. Strategic Objectives 2009-2011 • Patient Centered Care • Clinical Quality and Patient Safety • Workforce Retention, Recruitment and Development • Efficiencies and Financial V • Patient Growth • Capital Plan – Nashua Building

6. LHC Reporting Structure For Performance Improvement Committee Board of Directors Board PI Medical Leadership LHC PI Committee Site Audit Site Audit Site Audit

7. Framework For Achieving and Maintaining a Medical Home • Dartmouth • A microsystem is a place where: • Care occurs • Quality, safety, reliability, efficiency occur • Staff morale and patient satisfaction occur

8. Global Aim 3 2 SDSA 1 3 A P S D A P 1 D S Improvement Ramp A P S D PDSA Measures Change Ideas Specific Aim Global Aim Theme Assessment Dartmouth Microsystem Improvement Curriculum

10. Teamwork • Health Coach- Facilitator • Initial Microsystems Team Established –April 2009 • Provider, Nurse, MA, Patient Advocate and Team Coordinator • Weekly Meeting Scheduled • Data Collected • PDCA Cycle

11. Patient-Centered Medical HomePhase I • Initial Projects • Prescription Refill Process • Length of time until refill • Number of hand offs • Number of patient and pharmacy inquiries • Triage Process

12. Teamwork: Working to Scope

13. Access • Developed booking templates to accommodate patient requests • Open access piloted with provider • Standardized metrics organization wide

14. Access to Care: Acute Appointment

15. Population Management Driven by Clinical Quality Goals • PREVENTATIVE: Cervical cancer screening • PERINATAL: Low Birth Weight < 2,500g • PEDIATRIC: Childhood immunization status • ADOLESCENT: Use of adolescent risk assessment • ADULT: Cholesterol Screening • GERIATRIC: Percent receiving flu shots • CHRONIC DIEASE MANAGEMENT: HbA1c Testing, Asthma severity assessment, self-management goals

16. Patient Engagement • Give Us a Grade • Annual Patient Satisfaction Survey • Patient Ask Three • What is my main problem? • What do I need to do? • Why is it important for me to do this?

17. Patient Safety: Patient Ask 3

18. Patient-Centered Medical HomePhase II • Using the principals of the medical home apply the Clinical Microsystems approach to surveying the current clinical measures and the NCAQ/Meaningful use measures • Need for redundancy

19. Patient-Centered Medical Home

20. Accomplishments..... • In the past year we have increased access to care • Increased the percentage of patients with self-management goals to over 80% of the population • Decreased the average A1c to < 7.3 • Decreased provider turnover from 23% to 4%

21. Next Steps • Move the model organization wide • Increase clinical measure alignment (meaningful use, BPHC, NCQA, etc) • Improve patient access to data via the web

22. Q/A and Tour