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Building an Integrated System for Personalizing Care

Building an Integrated System for Personalizing Care

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Building an Integrated System for Personalizing Care

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  1. Building an Integrated System for Personalizing Care Tim Johnson, MD Spring, 2014

  2. 1,056 physicians • 342 primary care • 491 secondary care • 86 hospitalists • 17 radiologists • 120 urgent care • 265 advanced practice clinicians • 81 primary care clinics Intermountain Medical Group

  3. Dual Model for the Medical Home • Distributed Model • Intensive Model

  4. Distributed Model: Personalized Primary Care • Intermountain Medical Group and SelectHealth • Modeled on 2011 PCMH NCQA Standards • Team members • Primary Care Clinician • RN Care Manager • MA Health Advocate(s) • Advanced Practice Clinicians • Doctor of Pharmacy • Mental Health Integration

  5. Personalized Primary Care • Implementation 2010 - 2014 • 64 adult primary care clinics • 17 pediatric clinics • 345 physicians and advance practice clinicians • ~100 care managers and health advocates • Hybrid model: central and region leadership • Level 2 and level 3 within 2-3 years

  6. Personalized Primary Care: Results Clinical Quality Allowed Per Member Per Month • Intermountain diabetes bundle: • HgbA1c < 8% • LDL < 100 • BP < 140/90 • Annual nephropathy screen • Eye exam every 2 years 35% 20% Total Cost Trend* Patient Satisfaction Years after Implementation *Preliminary results, risk-adjusted and normalized for contractual payment differences

  7. Intensive Model: Personalized Care Clinic • An outpatient clinic that provides intensive medical, behavioral, and social management for Intermountain’s high-risk patients • Patients in the top 5-10% of costs for 2 of the last 3 years

  8. Personalized Care Clinic: The Team • Internal Medicine Physician • Palliative Care Physician (0.2) • RN Care Manager • Psychiatry APRN • LCSW • Pharmacist • 2 Medical Assistants • PSR • Clinic Manager • Assistant Region Operations Officer • Region Medical Director

  9. Personalized Care Clinic: Process of care • Acts like a primary care office with more resources to coordinate care, address mental health conditions, and manage complex medication issues • Ensure patients receive care in appropriate setting – focus on acute care utilization • Coordinate and collaborate with all of the patient’s specialists • Committed to eliminating all avoidable health care emergencies

  10. Your comments and questions…