Physician Health Alliance, Inc

1. Physician Health Alliance, Inc Care Management Department

2. Overview of PHA • 60 physician group practice • IM, Family Practice, Pediatrics, OB/GYN, Podiatry, Pulmonology, Sleep Study and Hospitalists • 14 Regional sites in Lackawanna County Northeastern Pennsylvania

3. Care Management Staff • Lead Care Manager: Christina Phillips RN • Care Managers: Margaret Drouse LPN Marianne Perkins RN Natalie Woronchuk RN • Administrative Assistant: Cathy Riccetti • IT: Patricia Gallacher

4. Key Components • Infrastructure Changes • Population Management • Communication System • Care Managers Role

5. Infrastructure Changes • Staff : job descriptions, training, CEU’s • Supplies: laptops, cell phones, business cards • Assigned individual Care Managers (CM) to specific physician practices • Development of a tracking system to capture transitional patients

6. Population Management • Transitional Care Patients • Development of Chronic Care Registries: DM,HTN and CAD • Carrier High Risk Lists • Physician and/or Staff Referral • Self Referral **Incorporation of “risk stratification”

7. Communication System • EMR “ Centricity” • Chart Alerts “Banners” • Care Manager “Care Notes” • ER/Hospital Discharge notification: generated report’s, faxes and emails • Meetings: Individual, Combined and Departmental • CM introduction letters

8. Communication, Continued • Practice Graphs : trends, goals, inertia • Centralized Care Management Data base • Shared Drive: Registries, Active Call Lists • EMR Templates:

9. Registry Assignment

10. Post Discharge Follow Up

11. Care Management Referral Form

12. Intake Assessment Form

13. MD Notification Form

14. Care Plan

15. Patient Contact Form

16. Electronic Blue Cross Referral Form

17. Care Manager Role • Liaison: patient ,site leader, staff, physicians and regional resources • High Risk Registries • Transitional Care • Care Review / Planning/ Follow up

18. Summary “This is the piece that has been missing at the practice level that really closes the loop” 80 year old gentleman

19. Thank You ! • Administration • Physicians • Site Leaders and Clinical Staff • Reception Staff • Care Managers • Regional Partnerships • Patients • IT Department