Parkview Medical Group Presents

1. Parkview Medical Group Presents KNOW Heart Disease June 3, 2014

2. Inefficiencies in Healthcare • Patient’s care is often very fragmented, involving many specialists and/or agencies working independently of each other. • Poor clinical outcomes can be due to noncompliance to care. • Patients utilize high cost facilities for care due to poor access to their primary care provider. • Duplication in imaging and laboratory testing often occur leading to wasted resources and increased cost. • Testing and Referrals tracking often are lacking, resulting in delayed diagnosis and increased burden of illness and cost. • Costs are escalating and are unsustainable.

3. PCMH is a model of care delivery for primary care practices focused on organizing evidence-based care around patients, working in teams, and coordinating and tracking care over time.

4. Elements of PCMH • Comprehensive Care - Providing Wellness, Acute, and Chronic Care • Patient-Centered - Care is relationship-based; patient is a valued team member • Coordinated Care - Care is tracked across the entire health care system • Accessible Services - Increased access to care; 24/7 access to care team • Quality and Safety - Using evidence-based medicine; focused on performance measurement and improvement

5. Patient Primary Care Provider Care Coordinator PCMH – Care Model

6. Seeing PCMH in Practice… • Having same day appointments for urgent/acute issues. • ER having access to patient’s chart after hours via on-call provider. • Proactively reaching out to patients who are overdue for their Wellness/Chronic Disease care. • Giving ‘care plans’ to certain patient populations; having care coordination for complex and noncompliant patients. • Proactively calling patients who have been recently discharged from the hospital. • Calling patients who have not completed their testing and/or referrals to improve their compliance to care. • Reviewing medications, inquiring about recent specialist visits, and giving visit summaries at every visit. • Measuring clinical performance and patient satisfaction.