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PCMH Transformation Update Cohort 2

PCMH Transformation Update Cohort 2. Tara Fouts & Kim Thurston QI Specialists – Region 4. Total 13 clinics 4 Parent Organizations 1 RHC 4 FQHC 1 Reverse Integration 1 Free Clinic 2 Private Clinics. Cohort 2. PCMH Transformation Focus Areas. NCQA 2014/2017

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PCMH Transformation Update Cohort 2

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  1. PCMH Transformation UpdateCohort 2 Tara Fouts & Kim Thurston QI Specialists – Region 4

  2. Total 13 clinics • 4 Parent Organizations • 1 RHC • 4 FQHC • 1 Reverse Integration • 1 Free Clinic • 2 Private Clinics Cohort 2

  3. PCMH Transformation Focus Areas • NCQA 2014/2017 • Care Management/Risk Stratification “Package” • Public Health District Grants • EHR/HIT Pre-Validation • Pre-Visit Planning • Team-Based Care • Care Coordination • Empanelment

  4. All Seasons Mental health • NCQA Application in 2018 • Team-Based Care • Intake Team/Community Health Worker (CHW) • Care Management/Risk Stratification

  5. Cascade Family Practice • Team-Based Care • Provider Panels • Pre-visit Planning • Care Coordination • Care Management/Risk Stratification

  6. Family medicine Residency of Idaho Kuna, Meridian Schools Clinic, and Center-Fort Street • NCQA 2017 Application • Care Management/Risk Stratification • Quality Improvement: • Increase depression screening rates for +12 years of age and older • Tracking healthy children and their knowledge of healthy behaviors

  7. Genesis Community Clinic • Access • Referral Tracking and Closed Loop • Care Management • Community Health Worker (CHW) • Medical Health Neighborhood

  8. Primary Health Medical Group Crossroads, Eagle, and Meridian • NCQA 2014 Recognition for 12 clinics • Online Scheduling • Huddle Documentation • Care Coordination

  9. Saint Alphonsus Medical Group Bown Crossing and Meridian Health Plaza • NCQA 2014 Recognition for 2 Clinics • EHR • Population Health RNs and MAs • Care Management/Risk Stratification • Transitional Care Management • Standardizing Processes and Policies in all SAMG Clinics

  10. Terry Reilly Health Services Boise Latah Clinic • No Show Policy • Team-Based Care • Pre-Visit Planning

  11. Treasure Valley Family medicine • NCQA 2017 Application • Care Management/Risk Stratification • Team-Based Care • Mentorship • PHD Staff • Clinics - Cascade • Webinar

  12. Cohort 2 Successes • PCMH Workforce Sustainability Presentation • Coordinating Athena Webinar • Cross Clinic Collaboration & Mentoring • Care Management • Hypertension, Diabetes, & Colorectal Cancer Screenings • Risk Stratification

  13. Barriers/Challenges of Transformation • PCMH Transformation Timeframe • Electronic Health Records • IHDE • Resource Allocation • Staff Turnover/Repurposing Roles • PCMH Team

  14. Cohort 3 & Next Steps • Engage Cohort 1 and 2 clinics • Goals for Cohort 3 clinics • Resource Sharing • Building Relationships • Medical Health Neighborhood • Sustainability • Clinics • Pathways

  15. Q and A

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