Patient Centered Medical Home

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Patient Centered Medical Home
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Something has got to givehealth costs a factor
in US Competitiveness
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While others struggle to reform health care, we
cant wait Oklahoma is moving ahead and
transforming now.
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Over past 25 years, only State with worsening
Age-adjusted Death Rates
Tulsa and Oklahoma

• Oklahoma
• Last in the US in health system performance.
• Only state with worsening death rate.
• Last in US in physicians per capita.
• Tulsa - 14 year difference in life expectancy.
• Upper quarter of health care spending.
• Innovative health system and insurance
  expansions.
• OU School of Community Medicine
• Nations first School of Community Medicine
• Serves as the regions platform for change
• Goal Improve health of entire communities
• Recruit for and maintain altruism MDs, PAs,
  Nurse Practitioners using clinical experiences,
  scholarship and loan payback efforts to motivate.
  
• Curriculum add public health, systems
  engineering, student run clinical services.
• Expansive network of innovative primary care,
  specialty care programs out in neighborhoods most
  in need - e.g. 19 school based clinics.
• Patient Centered Medical Home for uninsured and
  Medicaid populations implemented.
• Partners with OU social work, early childhood
  education, school systems, urban planners etc.
• Health Information Technologies patient to
  doctor, doctor to doctor reduced need for face
  to face visits by 52. Consortia in place for
  Health Information Exchange and Health
  Information Coordination.

US
Death Rate
14 year difference In life expectancy between
North and South Tulsa
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TODAYS CARE
MEDICAL HOME CARE
My patients are those who make appointments to
see me
Our patients are those who are registered in our
medical home
Patients chief complaints or reasons for visit
determines care
We systematically assess all our patients health
needs to plan care
Care is determined by todays problem and time
available today
Care is determined by a proactive plan to meet
patient needs without visits
Care varies by scheduled time and memory or skill
of the doctor
Care is standardized according to evidence-based
guidelines
Patients are responsible for coordinating their
own care
A prepared team of professionals coordinates all
patients care
I know I deliver high quality care because Im
well trained
We measure our quality and make rapid changes to
improve it
Acute care is delivered in the next available
appointment and walk-ins
Acute care is delivered by open access and
non-visit contacts
Its up to the patient to tell us what happened
to them
We track tests consultations, and follow-up
after ED hospital
Clinic operations center on meeting the doctors
needs
A multidisciplinary team works at the top of our
licenses to serve patients
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Medical Care 2000
Specialty Dx/Rx Services
Surgical Intensive Services
Diagnostic Testing Imaging
Urgent Care Services
HEALTH CARE SYSTEM
Primary Care Services
Pharmacy Health Foods
Chronic Disease Service
Wellness Fitness Clubs
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Medical Homes 2009
Specialty Dx/Rx Services
Surgical Intensive Services
Diagnostic Testing Imaging
Patient-Centered Medical Home
Urgent Care Services
HEALTH CARE SYSTEM
Primary Care Services
Pharmacy Health Foods
Chronic Disease Service
Wellness Fitness Clubs
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Health Information Exchange 2010
Specialty Dx/Rx Services
Surgical Intensive Services
Diagnostic Testing Imaging
EMR HIE Web-based Communication
Portals Decision Support
Patient-Centered Medical Home Wellness
Evaluation Plan
Urgent Care Services
HEALTH CARE SYSTEM
Primary Care Services
Pharmacy Health Foods
Chronic Disease Service
Wellness Fitness Clubs
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Advanced Medical Home 2011
Specialty Dx/Rx Services
Surgical Intensive Services
Diagnostic Testing Imaging
EMR HIE Web-based Communication
Portals Decision Support
Team Based - Primary Care Health Information
Integration / Coordination
Urgent Care Services
HEALTH CARE SYSTEM
Pharmacy Health Foods
Chronic Disease Service
Wellness Fitness Clubs
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Lessons Medical Home Teamwork

• New roles and responsibilities
• Everyone functions at the top of their license
• New teamwork roles for students and residents
• New work flow
• Team meetings for planning and improvement
• Continuous training, learning, and improvement
• Non-visit touches deliver pro-active, planned,
  coordinated, and integrated care
• Data driven work not visit driven work
• New Approach to quality and safety
• Eliminate re-work
• Eliminate duplicated effort
• Eliminate work-a-rounds

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Lessons Project Management as the Implementation
Strategy
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48
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50
44
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70
30
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Our Organizations Enthusiasm Levels A Project
Lifecycle
Sept 08
Mar 09
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Getting Organized - Tulsa Health (black
established, blue in development or proposed)
Front Doors to Care
Primary Care Clinics and Medical Homes
Intensive Outpatient Programs

• Emergency Rooms
• Saint Francis Hospital
• St. John Medical Center
• Hillcrest Medical Center
• OSU Medical Center

I N S U R E O K L A H O M A -- MEDICAID

• OU Bedlam Longitudinal Clinic PCMH Model
• 6 sessions / week
• OU School-based Clinic 19 sites PCMH Model
• OU Housing Authority Clinics 2 PCMH Model
• OU Micro-clinics Day Center for the Homeless
  5 days
• per week
• Neighbor for Neighbor, Neighbors Along the
  Line,
• OU Physicians Clinics Hillcrest PCMH
• Schusterman Center - PCMH
• OSU Physicians Clinics SW Boulevard, Houston
  Park
• OSU Physicians Country Club Gardens
• Morton Clinics FQHC Lansing Park, East Tulsa
• Community Health Connections FQHC - East
  Tulsa,
• 3rd and Lewis.
• Patient Centered Medical Home Patient Portal
  with IBM
• Greater Tulsa Health Access Network Greater
  THAN
• Health Information Exchange and Care
  Coordination

• PACT Teams Severe mental illness
• COPES Team Emergency Psychiatry
• ER Frequent Flyer Team
• Multiple medical illnesses

• Acute Walk In Care
• OU Bedlam Evening Clinics
• OU Bedlam Evening Pharmacy
• OU Bedlam Evening Clinics
• Case Management and Referral
• Programs
• Good Samaritan Clinics

Specialty Care

• MAP / Voucher Specialty Care Network
• Northland Imaging Center
• OU Physicians Clinics at St. John, Saint Francis
• and Hillcrest Medical Centers,
• OU Schusterman Center Clinics
• OSU Physicians Clinics at OSU MC,
• Houston Park, SW Boulevard
• OU OB Outreach e.g. Margaret Hudson.
• Porter, Community Health Connections
• OU Xavier Breast Health Clinic
• OU Bedlam Specialty Clinics Derm, HIV,
• Gynecology, Hep C
• Heart Intervention Project
• OU Diabetes Center
• OU Cancer Institute
• OU Tisdale Specialty Health Center
• Doc 2 Doc e-consultations between primary care
• and specialists

Safety Net Clinics

• ER Diversion Programs
• OU Tisdale Health Center
• Urgent Care Clinic
• OU ER Diversion and
• Follow Up Clinic
• OSU / St. John Program

Pharmacy Services

• Tulsa County Pharmacy
• OU STEP Pharmacy
• OU Bedlam Pharmacist Program and
• 5 community pharmacies

Prevention Initiatives

• 211 Line
• Baby Line
• OU Nursing Prenatal Care
• Harvard Project - Cycle
• of Poverty
• PENN Project Anchor
• Community Schools

Clancy 8 / 2009