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Our House

GVHC Experience with Patient-Centered Medical Home Practices. Our House. David Simenson, MD Associate Medical Director Golden Valley Health Centers May 26, 2011. Golden Valley Health Centers. Who are we?. GVHC—22 community health centers serving Merced & Stanislaus Counties.

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Our House

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  1. GVHC Experience with Patient-Centered Medical Home Practices Our House David Simenson, MD Associate Medical Director Golden Valley Health Centers May 26, 2011

  2. Golden Valley Health Centers Who are we?

  3. GVHC—22 community health centers serving Merced & Stanislaus Counties

  4. Focus on Empanelment

  5. Empanelment • Determine and understand which patients should be empanelled in the medical home and which require temporary, supplemental, or additional services. • Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, self-management status, community and family need. Safety Net Medical Home Initiative: Change Concepts

  6. Disease Registries • Diabetes • All pts with Dx 250.xx Diabetes mellitus • Hypertension • All pts with Dx 401.xx to 404.xx • Warfarin patients • All pts with Dx V58.61 Long-term (current) use of anticoagulants www.ICD9Data.com

  7. Chronic Care Model • Identifies the essential elements of a health care system that encourages high-quality chronic disease care. www.improvingchroniccare.org

  8. Model Elements • Health System • Delivery System Change • Use planned interactions to support evidence-based care • Decision Support • Embed evidence-based guidelines into daily clinical practice www.improvingchroniccare.org

  9. Model Elements • Clinical Information Systems • Provide timely reminders for providers and patients • Identify relevant subpopulations for proactive care • Facilitate individual patient care planning • Share information with patients and providers to coordinate care • Monitor performance of practice team and care system www.improvingchroniccare.org

  10. Model Elements • Self-Management Support • Emphasize the patient's central role in managing their health • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up • The Community www.improvingchroniccare.org

  11. Use planned interactions to support evidence-based care

  12. Embed evidence-based guidelines into daily clinical practice

  13. Provide timely reminders for providers HealthPort EMR

  14. Diabetes Patient Visit Summary i2iTRACKS

  15. Share information with patients and providers to coordinate care i2iTRACKS: Diabetes Patient Visit Summary

  16. Monitor performance of practice team and care system

  17. Panel Management • Use of a registry, clinical tracking software (i2iTRACKS) • Data from practice management software, EMR and clinical lab to registry • Panel reports to providers

  18. Panel Management • Panel Managers assigned to each medical provider • Contact diabetic patients whose most recent HbA1c is ≥ 9.0 • Contact diabetic patients who have not had a visit in 12 months • Over-the-phone motivational interviewing, goal setting

  19. Successes • Adopted corporate-wide performance measures for diabetes and hypertension care • At least 2 HbA1c’s per year • Annual comprehensive foot exam • Annual dilated retinal exam • Built disease-state registries for DM, HTN and warfarin patients

  20. Successes • Implemented interfaces bringing practice management data and clinical lab results into clinical tracking software, putting vital chronic disease management data in hands of all clinicians • Average HbA1c of 7.9 for 6300 diabetics • Support staff quality incentive that includes quality performance data (HbA1c and foot exam)

  21. Challenges • Less than universal acceptance of paper Diabetes Progress Note and EMR templates for diabetes and asthma • Manually entered clinical tracking data is labor-intensive, out-of-date, and inaccurate • Retinal scan • Foot exam • HbA1c • Getting Receptionists at 22 different offices to print Diabetes Patient Visit Summaries for all diabetes visits

  22. Challenges • Getting the performance data from a monthly committee meeting into the hearts and minds of all medical and support staff • Interfaces with multiple labs (Quest Diagnostics Inc., HealthCare Clinical Laboratories, LabCorp) and hospital results • Some performance data just does not seem to want to improve. Understanding the causes of variation when performance lags behind the goal.

  23. Questions? David Simenson, MD (209) 769-8809 dsimenson@gvhc.org

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