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Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013

Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013. SJGH Primary Care Clinics. PCMH Transformation Lessons Learned. Don’t Survey length to get best response. Change/feedback cannot be delayed Take on other new projects Bite what you cannot chew and swallow

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Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013

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  1. Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013

  2. SJGH Primary Care Clinics

  3. PCMH Transformation Lessons Learned • Don’t • Survey length to get best response. • Change/feedback cannot be delayed • Take on other new projects • Bite what you cannot chew and swallow • Forget to involve providers. • Create extra work for staff. Do • Implement disease registry and Provider specific reports • Restructured leadership for the task at hand • Implementation team with weekly/biweekly Quality improvement meetings • Communication boards in clinics. • Dedicated meeting times for the whole clinic team. • Anticipate change fatigue/work arounds

  4. PCMH Initiatives • Population management(i2i),Titration clinic • Clinic huddles • Quality Improvement PDSA meetings • Visit pre-planning • Standardized orders • Joint doctor / clinic staff meetings monthly • Advanced access. • Patient Experience review (Pext,CGCAHPS)

  5. Community Medical Center - Channel

  6. San Joaquin County Behavioral Health Older Adult Services (OAS)

  7. Patient Success Story • Patient is 70-year-old female with Schizoaffective Disorder with Diabetes • Transferred to Older Adult Services in 2005 from Adult Services • Long history of Mental Health services, including State Hospital admissions starting in her 20’s • More than twelve inpatient psychiatric admissions since 1992 • Psychiatric inpatient admissions usually involved medication noncompliance • Physical health issues resulted in 5 hospitalizations prior to Sept. 2012 • Unstable living situations, including Crisis Residential and evictions from several board and care facilities •  First Health Home visit was 9/19/12 • No hospitalizations of any kind since that date • Significant improvement in medication compliance • Client told us she wants us to be proud of her… • Regular follow-up with Primary Care Physician • Stable housing—client lives independently in an apartment • Vision exam scheduled • Routine Health Home lab work revealed undiagnosed UTI and under diagnosed thyroid condition • Client comes in regularly to OAS for fingersticks • Client and significant other appear happy and content • Client eager to continue Health Home despite change in medical providers  So this lady’s story deserves a song… “Come and Listen to a Story ‘Bout a Gal Named Sal”

  8. Patient Centered Medical Home (PCMH)Cost Report

  9. SJGH-HPSJ Emergency Room Costs

  10. SJGH-HPSJ Inpatient Costs

  11. SJGH-HPSJ Medication Costs

  12. CMC-HPSJ Emergency Room Costs

  13. CMC-HPSJ Inpatient Costs

  14. CMC-HPSJ Medication Costs

  15. HPSJ, CMC, SJGH Overall PCMH Costs

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