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Dive into the Rhode Island Care Transformation Collaborative's goal of achieving quality care, patient engagement, and integrated health systems through the Patient-Centered Medical Home model. Explore the key elements driving this transformation, from data-driven practices to integrated behavioral health initiatives. Discover how Nurse Care Managers play a pivotal role in improving care quality and patient experience while reducing costs and enhancing staff satisfaction.
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Patient Centered Medical Home: Overview of the Primary Care Footprint in Rhode Island Nurse Care Manager Best Practice Sharing Day Debra Hurwitz, MBA, BSN, RN CTC Co-Director May 5, 2015
The Rhode Island Care Transformation Collaborative(CTC- RI) Vision: • Rhode Islanders enjoy excellent health and quality of life. They are engaged in an affordable, integrated healthcare system that promotes active participation, wellness, and delivers high quality comprehensive health care. Mission: • To lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care and health of the population we serve
The key to building PCMH is measured progress toward the Triple Aim
CTC-RI helps plans and practices build sustainable Patient-Centered Medical Homes • Data-driven practice transformation • NCQA Level 3 • Nurse Case Manager on the team • Common Contract • All-payers involved • PMPM paid on attributable lives • PMPM based on performance
Improving Primary Care Architecture • Increasing Primary Care Spend: 10.7% of commercial insurers’ medical spend devoted to primary care • Increased focus on payment for value • Electronic health record, interoperability, Current Care • ACA: patient benefit to seeking care in patient centered medical homes
Improving Primary Care Architecture • Integrated Behavioral Health • 12 CTC practices • Practice team meets with integrated behavioral health practice facilitator to implement integrated behavioral health model • Webinars for all practices • Community Health Teams • Two pilots : South County and Pawtucket • Identification of high risk patients • Shared resources among CTC practices • Behavioral Health and Community Resource Specialists
Improvements in Primary Care Architecture NCM • Practice team focused on knowing patients who are most vulnerable and creating high risk patient registry • NCM focused on patients who are “high risk” and “at risk” • Reporting on patient engagement and collaboration with health plan resources
Anticipated Outcomes • Improved quality of care • Improved patient experience • Reduced cost as measured by reduced ER/IP utilization • Improved staff satisfaction • Practice readiness for shared savings