Community Health Centers and HIT Driving Innovation in the Patient-Centered Medical Home. Alliance for Health Reform Briefing: Medicaid and Health IT. Presented by: Judith Featherstone MD, FAAFP Medical Director HealthPoint August 1, 2011. Health Centers Today.
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Driving Innovation in the Patient-Centered Medical Home
Alliance for Health Reform Briefing:
Medicaid and Health IT
Judith Featherstone MD, FAAFP
August 1, 2011
Today, Health Centers serve as the health care home for more than 20 million patients nationally, including:
*Includes patients of federally-funded health centers, non-federally funded health centers or “Look-Alikes”
HealthPoint is the largest CHC in the 14th largest county in the US.
12 Clinics: 7 medical, 4 dental, 1 school-based
Patients = 62,542, Visits = 210,865
Medicaid, Medicare and Public Insurance- 55%
Uninsured – 37%
In addition to primary medical and dental care, services include:
Prenatal care and delivery
Complementary and alternative medicine including naturopathic medicine, acupuncture and nutrition counseling
Pharmacies in all clinicsHealthPoint: Your Community Health Center
Patient income by Federal Poverty Level
Patient by insurance
Nationally, three quarters of all health centers are now on the road to adopting integrated health information technology systems.
Reassignment of Medicaid HIT Incentive Payments
Health centers use Health IT in varied ways to meet the needs of their patients, for example…
Telehealth: patients, including those in rural or remote areas, can “see” a provider for screenings, behavioral health encounters, remote eye exams, and chronic disease management.
Referral Tracking: the record, patient history, medication and Rx plan follows the patient across health center sites and other health care providers.
Personal Chronic Care Management: electronic records notify providers and patients when it’s time for a check up or check in.
Mobile phones for health reminders
Website with links to mobile applications for healthy living.
Outreach to patients due for health maintenance services
Outreach to patients with chronic diseases which are uncontrolled or due for monitoring.
Reports can guide us in setting up appropriate systems such as community health workers for new immigrant populations.
Develop interventions targeting obesity based on our reports including language and ethnicity.
Time of visit activities
Invite in for individual visit or group with cohort.
Coordinate with specialists, ER and hospital, decrease redundant work.
Decision support built in for referral appropriateness, referral preparation, evidence based testing.
Patient-Centered Medical Home
Six standards align with the core components of primary care
1)Enhance Access and Continuity
2)Identify and Manage Patient Populations
3)Plan and Manage Care
4)Provide Self-Carte Support and Community Resources
5)Track and Coordinate Care
6)Measure and Improve Performance
Health IT is vital to meet these standards.