Patient Centered Medical Home

1. Patient Centered Medical Home Urban, Rural, Wherever…

2. Presenters: • Sheila Allen—Director of Quality for HealthNet, Inc • Sherry Gray--Director of Rural and Urban Access to Health for St. Vincent Hospital • Dr. Risheet Patel—Private practice and executive of Indiana Academy of F. P. • Facilitator-Kathy Church—small HIE

3. Introduction • PCMH resembles “old time care” with use of “new time tools” • Key focus on the patient having a positive experience and actively participating • Value of managing groups of patients with like disease • Team based care

4. Why me as a facilitator • I said yes • Manage the operations of HealthLINC, community based HIE focused on transitions of care and patient inclusion • Work on PCMH with focus on Care Managers • Nurse with 40 years of varied experiences, the 10 lives of kc

5. PCMH Journey: A Marathon, Not a Sprint Sheila Allen, MPH, CHES Director of Quality HealthNet, Inc. (317) 781- 4871 sallen6@iuhealth.org

6. HealthNet’s Mission: To improve lives with compassionate health care and support services, regardless of ability to pay

7. 8 Primary Health Care Centers 5 Dental Clinics 1 OB/GYN Center 1 Maternal-Fetal Medicine Center Pediatric Residency Continuity Clinic 5 School-Based Clinics Homeless Initiative Program Healthy Families/Better Indy Babies Service Information: HealthNet has been serving central Indiana residents since 1968

8. Health Center Locations • Barrington Health & Dental Center • Care Center at the Tower • Eastside Health Center • Martindale-Brightwood Health & Dental Center • Pediatric & Adolescent Care Center • People’s Health & Dental Center • Southeast Health & Dental Center • Southwest Health & Dental Center • Maternal-Fetal Medicine Center • Pediatric Evening Clinic • West Health Center • Northeast Health & Wellness Center (Opening Fall 2013)

9. 2012 By the Numbers HealthNet, Inc. • 56,624 individual patients • 250,107 outpatient visits • 3,069 babies delivered • 10,230 homeless visits

10. Joint Commission Accredited as an Ambulatory Practice since 1980 Joint Commission PCMH Recognition in October 2012 – the first in Indiana and 1 of only 30 in the US!

11. How PCMH Practice Transformation Planning Yielded Certification • Started with Self Assessment Tool to determine our greatest improvement areas • Recognized many standards had already been achieved through JC accreditation and other initiatives • Formed multidisciplinary team from beginning

12. How PCMH Practice Transformation Planning Yielded Certification(cont.) • Selected small group of patients to begin with • Perfected PCMH program with them first • Then spread to other patient groups 

13. Tips and Tricks -Navigating Readiness to PCMH Achievement • Do not try to implement changes organization-wide at the very beginning • This cannot be 1 person’s job • This isa culture change that everyone will have to embrace if a practice is to earn PCMH recognition

14. Tips and Tricks -Navigating Readiness to PCMH Achievement (cont.) • Be sure to involve a Multidisciplinary team • Remember – Patients have an important role   • All of the work does not fall on the Practice • We have to educate our Patients about their rights AND responsibilities as part of our/their Medical Home.

15. HealthNet’s Next Steps: • Review proposed changes to Joint Commission PCHM standards for 2014 • Continue to educate patients, providers and staff about PCMH • Improve health literacy assessment and patient education • Improve self management goal setting and assessment of progress

16. QUESTIONS??? • to follow • 3rd presenter… • Make notes to ask

18. Transforming Healthcare with a World Class 21st Century Workforce:Patient-Centered Medical Home & Community Health Worker Ivy Tech Corporate Challenge and Culinary Center March 14, 2013 Sherry E. Gray, System Director St. Vincent Health Rural and Urban Access to Health

20. RUAHRural and Urban Access to Health Purpose: To connect our friends, family, and neighbors to a comprehensive, integrated delivery network of health, human and social services resulting in improved access and removal of barriers to needed resources. Meaning and Mission: The word Ruah, in Yiddish means “Breath of Life”. The Goal? …to breathe new life into a health care system that will we serve our most vulnerable community members compassionately, with quality and efficiency

21. RUAH “from the start” (a little history) • RUAH Partnership initiated: 2000 • SV Health • Indiana Health Centers, Inc. • Health and Hospital Corporation of Marion County • ADVANTAGE Health Plans, Inc. • Butler College of Pharmacy, later added • Community Interface Groups: local partner groups responsible for program implementation. • Funded by HRSA, Ascension Health from 2001-2005 • Additional private funding through the Anthem Foundation: establish 3 additional sites • Sustained through local hospital funding and captured reimbursement through enrollment efforts and cost avoidance

22. Program Outcomes • Four community programs expand to Eight community programs (+1 in next quarter) • 2013: Managed Medicaid Funded HAW: SVMG office • Outcome Focused: Pathway Model Integration • 5 Pathways implemented; 2 in development • Outcome Measure reporting effective 9/11 (Pathways) • Used to count what we did “to/for” clients vs. outcomes! • AHRQ Innovation Site • Community Care Coordination Learning Network Site • National Institute of Health Research Partner • Indiana CHIPRA grantee • $43.7 million worth of low/no cost drugs provided • Language Access • 1360 interpreters trained through Bridging the Gap • 1105 documents translated Integration with Federal, State and County Stakeholders

24. Infrastructure and Operations(support for eight program sites and system-wide LEP work) • 10 HAW’s • 6.0 MAC’s • Direct Hires • Community-agency based • System Administrative Support • Health Access Manager; Operations Facilitator; Administrative Assistant; Language Access Staff; System Director • Annual Budget • $1.1 million

25. How RUAH addresses ACCESS • Health Access Workers • Client advocates & “system navigators”: COMMUNITY BASED CARE CONNECTION • Pathways: medical home, medical referral, enrollment, social services, pregnancy • Community “Hub”: partnerships between and among community stakeholders • Pharmacy– access to low or no cost drugs through Medication Access Workers (MAC’s) (RXASSIST+; Dispensary of Hope; Vouchers ;etc.) • Language Access: translation of core documents, interpretation, cultural brokering/advocacy • Integrate and Facilitate: the “5 Rights” • Right Care • Right Time • Right Place • Right Provider • Right Payer

26. Workforce Challenges: • Hospital/Provider Team Member role • Community Integration--Relationships • Scope of Work • Site of Service • Communication/Information-Sharing Structure • Stakeholder Focus • Accountability Structure

27. Ultimately: • Un/underinsured community members can receive care “sooner vs. later” • Consistent and familiar care is provided along with follow up & follow through: treatment is across time and not episodic • Resources are used as effectively as possible, including: • Human • Providers, Practitioners, Care Coordinators, Administrative support, etc. • Financial • Reimbursement, Funding, Cost-Avoidance, “Write-Off’s” • Technological • Connecting Information in a timely, meaningful way • Support (wrap-a-round) Services • Connecting medical treatment, public health practices, & psychosocial principles • Vital connections are made • Integrate and coordinate care not duplicate and replicate care • “Best Practice” Learning's are shared; and solutions are not “re-created”

28. Questions to follow 3rd presenter

30. Olio Road Family CareFishers, Indiana Risheet Patel, MD

31. Our patient-focused approach

32. Time for questions????Thanks to all 3 speakers!