Maternal Medical Home
WOMEN’S HEALTH CENTER OF SOUTHERN
OREGON
*
PRIMARYHEALTH OF JOSEPHINE COUNTY
Background
 Women's Health Center of Southern Oregon (WHCOSO)
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is located in Josephine County, a large rural county in
Southern Oregon.
WHCOSO is the sole OB/GYN clinic in the county.
WHCOSO has 6 OB/GYNs and 2 NPs. A specialist in
MFM practices from WHCOSO ½ day each week.
There are two CCOs in Josephine County, AllCare and
PrimaryHealth.
Josephine County has high rates of poverty, drug and
alcohol abuse, and tobacco addiction, all of which are
risk factors for healthy birth outcomes.
“What if we
could seize the
window of
opportunity
presented to us
in pregnancy,
and use this to
help make
moms, babies,
and families
healthier?”
Vision
“The intention of the Maternal Medical Home is to
facilitate the coordination of a collaborative
team of providers and staff, both internal and
external, to meet the special needs of each woman
during her pregnancy. Pregnant women seeking
obstetrical care at WHCOSO will receive an
experience of care, which extends beyond the
traditional obstetrical care model. The goals of
the MMH are to improve birth outcomes
through increased compliance, education, and
outreach, focusing care management resources on
those women at highest risk.”
Paradigm Shifts in the MMH
Current State
Future State
Characteristics
1
Individual Focus
Population Focus
•
•
Focus teams on a panel of patients
Risk Stratification
2
Fee for Service
Global Budget
•
•
Supplemental Payment Models
Understanding the costs of pregnancy
3
Incident Focus
Episode of Care; Preconception-60
Days Postpartum
•
•
Early Entry to Care
Whole person healthcare including screenings and
follow up actions
4
Isolated Care Silos
Integrated Care
•
Effective transitions and collaborations of care between
PCP, OB, Baby Doctor, Specialists
Effective integration with other health providers
(Behavioral Health, A&D)
•
5
Individual Provider/Pt
Relationship
Team Based Care
•
•
•
Addition of Health Coach and Co-Located BH therapist
Use of staff to the height of their licensure
Pt engagement
6
Individual Provider
Preferences
Evidence Based, Highly Reliable
Quality Measured
•
•
Use of protocols for outreach, intake and pt engagement
Structured processes and quality outcomes measured
7
Information isolation between
organizations
Information sharing between
multiple organizations
•
Real time sharing of health information between
organizations : PCP, Hospital, Specialists, etc.
8
Provider effectiveness based on
productivity
Provider effectiveness based on
population metrics
•
•
Data
Non-visit based tools (web, email, etc)
Support for the Pilot from Community Partners
Resources from Community Partnerships and CCOs:
Options for Southern Oregon
(Community Mental Health
Program)
•
Provides a licensed mental health therapist who is co-located
at the clinic ½ day each week
PrimaryHealth of Josephine
County
•
Financial support in the form of a risk-stratified supplemental
PMPM payment for qualifying patients (APM pilot)
Educational resources directed towards medical home
transformation and PCPCH certification
•
AllCare
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Sponsors a full-time health coach that is out stationed at
WHCOSO and works will all patients
Provided assistance with PCPCH certification
“We needed both staff and financial resources to
support our efforts.”
A Few Accomplishments
 Implementation of Team Based Care, including
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direct access for patients to the team.
Development of a MMH leadership team.
Development of a Data strategy.
Implementation of standard screening protocols,
and also protocols for positive screenings.
Implementation of non-traditional staff support
positions (such as a Health Coach).
Became certified as a Tier 3 PCPCH in 2013.
Non-Traditional Staff Positions
 High Risk Coordinator
 Meets with all newly pregnant patients
 Administers screening (5P’s) for Alcohol, Drugs, Tobacco, Domestic Violence and
Depression.
 Institutes protocols for positive screenings (whether related to medical or
social/environmental factors)
 Provides orientation to team based care
 Health Coach
 Follow-up on all positive screenings
 Health Coaching and Care Coordination throughout the pregnancy for high risk
mothers
 Helps coordinate all members of the care team
 Visit at 36-wks with all pregnant mothers to assist with planning, teaching, and
coordination of care
 Mental Health Therapist
 On-site behavioral health support
 Based on a brief therapy model
Data
“Aligning the data strategy to your overall goals is
incredibly important.”
Examples of measures used by WHCOSO:
 Early entry to care
 SBIRT (Alcohol and Drug Screening)
 Early elective delivery
 Depression screening
Early Success in Depression Screening
Patients with Depression Screening
Completed and Documented
120%
100%
100%
99%
84%
80%
60%
40%
20%
20%
0%
13-Jun
13-Jul
13-Sep
13-Nov
Protocols
“We learned quickly that, while we had great
protocols for high risk medical
complications, we did NOT have them for
things like positive depression screenings.
We created those protocols and shared
responsibility with all members of the team,
not just the doctor. Now it is clear what each
person does when we have a positive
screening.”
Involvement in Community Efforts
 Opiate Prescribers Group
 Perinatal Task Force
 Jefferson Health Information Exchange
 CCO Governance (Both CCOs)
 PrimaryHealth’s Medical Home Leadership Group
Maternal Medical Home: A Work in Progress
“The further I get into this, the more I realize we will
never be done. Sometimes I feel like we are just
barely at the tip of the iceberg with this
transformation. It is hard to reflect on the progress
that has been made when there is so much left to do.
But I have this vision in my mind, of how it could be if
all the pieces were there and in place. It’s slow going,
but we are chipping away at it one piece at a time.”
Contact Information
Jennifer Johnstun, RN
PrimaryHealth
jen@ohms1.com
Lisa Solomon, CEO
Women’s Health Center of Southern Oregon
lisas@womenshealthso.com