Transforming a Resident Clinic into a PCMH

1. Andrew Vasey, MD University of Nebraska Medical Center September 2, 2011 Transforming a Resident Clinic into a PCMH

2. Disclosures • I have no financial disclosures • Our resident clinic at UNMC is not NCQA certified as of yet

3. Objectives • Discuss how a resident continuity clinic can be a PCMH. • Show how the PCMH joint principles are incorporated at Midtown Clinic. • Discuss resident driven projects.

4. Midtown Clinic • Site for resident continuity clinic • Social worker and mental health provider • Pharmacy support • EMR • More than 10,000 patient visits annually

5. Resident Board • Consists of: • Ambulatory chief resident • Residents from each half day clinic • Clinic nurse manager • Faculty clinic director • UNMC-P representative • Make decisions on how the clinic works

6. PCMH • Seven joint principles • Personal physician • Physician directed medical practice • Whole person orientation • Coordinated and integrated care across all elements of the complex health care system • Quality and safety • Enhanced access • Payment reform

7. Personal Physician • Resident patient panels • Residents build their panels during training • Patient input • Teams

8. Physician Directed Practice

9. Whole Person Orientation • ‘Birthday’ visit • Dedicated visit to discuss health care maintenance issues, medications, advance directives, etc • Lab reminder postcard • Patient screening/intake • Proactive visits

10. Intake Form

11. Orders

12. Coordinated and Integrated Care • Nurse coordinator • Social worker/mental health provider • Diabetes registry • HgB A1C, blood pressure, LDL cholesterol, eye exam etc • Colonoscopy • Mammograms/Pap Smear

13. Quality and Safety • Patient Education Discharge Form • Diabetes Education Class • Medication Adherence Project

14. Patient Education Discharge Form • All Midtown clinic patients • Residents complete prior to discharge • Review with patient prior to leaving • Stored within the electronic record

16. ClinicFollow-up Rate with and without PEDF

17. Pre- and post-intervention 30-day hospital reutilization p<0.001

18. Diabetes Education Class • Held monthly at clinic • Residents, staff, pharmacist, diabetes educator, nutritionists

19. Medication Adherence Project • Comparing medication adherence post discharge between two resident continuity clinic sites • Patient demographics

20. Enhanced Access • Creation of ‘walk-in’ hospital follow up slots on day of normal clinic • Same day/acute appointments available • Contacting residents

21. Payment Reform • Nothing yet • Support from Dept of Internal Medicine, UNMC-P and the Nebraska Medical Center

22. Questions?