Addressing Population Health
within the Patient-Centered
Medical Home (PCMH)
Coco Lukas, MPH – Quality Coordinator
Rick Reifenberg, MD – Associate Medical Director
Sheila Allen, MPH – Chief Compliance and Quality Officer
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HealthNet is a Federally Qualified
Health Center (FQHC)
Health Centers
School-Based Clinics
HIP Clinic/Shelters
HIP Housing Sites
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HealthNet is a Federally Qualified
Health Center (FQHC)
Providers
•
~70 MD/DOs – IM/Peds, Peds, FP, ObGyn, Psych
•
~45 Advanced Practice Nurses – Certified Nurse
Midwives, Ped NP, FNP, Women's Health NP,
Psych NP
Staff
•
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630 Full-Time Employees
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HealthNet is a Federally Qualified
Health Center (FQHC)
Joint Commission Accredited for:
•
Health Center
•
Laboratory Services
•
Patient Centered
Medical name
Home goes here
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(PCMH)
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Services Provided
•
Primary and Preventive Health Care
•
Dental Services
•
Behavioral Health Care
•
Homeless Programs
•
Support Services
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(e.g., WIC, social work)
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2014 By the Numbers
• 59,286 patients
‒ Serves 20% of all Hoosiers covered by Federally Qualified
Health Centers
•
263,167 family visits
‒ More outpatient visits than Riley Hospital for Children, which
serves patients statewide
•
3,748 women obtained prenatal care
•
2,216 OB deliveries01
•
3,092 homeless clients served
•
7,857 patients received dental care
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Payor Mix
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Patient-Centered Medical Home
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Patient-Centered Medical Home
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Population Health
Implementation in 3 Phases
1. Pre-visit identification and scheduling
2. During patient care visits
3. Post-visit reporting
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Population Health
Implementation in 3 Phases
• PHASE 1: Identification and scheduling
‒ Reports to identify children due for well child
care and those with chronic diseases
(diabetes, asthma) that were overdue for
visits.
Sectionpatients
name goes
‒ Data used 01
to schedule
duringhere
week
and also on special Saturday Clinics.
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The report is emailed monthly to clinic managers. The patients
have had the majority of their WCC at that clinic. Patients who are
in the system who haven’t had a WCC go to ALL clinic managers
Population Health
Implementation in 3 Phases
• PHASE 2: During patient care visits
‒ Templates
‒ Standing Orders
‒ Flowsheets
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Templates
• Well child assessment, nutrition/exercise
counseling, and billing codes
• Mandatory question on pediatric templates re:
vaccine status
• Required age-specific standard templates that
include tobacco use and referral questions
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• Asthma and Diabetes templates
• Nurse visits (e.g. Depo-Provera) with billing
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2
Templates
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2
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3
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3
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3
Standing Orders
• Standardized nursing based Standing Orders
that mirrored new EHR work flows put in place
HealthNet-wide.
• Staff are able to enter labs and vaccines on
office visits prior to the Provider seeing the
patient.
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name
here
• Depression (PHQ2,
PHQ9)
andgoes
Anxiety
(GAD7) done automatically when patient
checks in.
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Standing Orders
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Standing Orders
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Flow Sheets
• Helpful for documenting Cancer Screening
(Colon and Cervical).
• Diabetic Flow Sheet tracks LDL and
Aspirin use.
• Health Maintenance Flow Sheet tracks
Cancer Screening
and Aspirin
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nameuse.
goes here
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Flow Sheets
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Population Health
Implementation in 3 Phases
• PHASE 3: Post-visit reporting
‒
Gathering and Reviewing the Data from the
Outcomes from Phase 1 and 2 as noted on
the prior slides.
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Pediatric Measures
• Well Child Checks 0-15 months
• Well Child Checks 3-6 years
• Adolescent Well Care 12-21 years
• Weight Assessment and Counseling
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Well Child Checks
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Weight Assessment
and Counseling – Peds
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OB Measures
• First Trimester Entry
• Low Birth Weight Deliveries
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First Trimester Entry - OB
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Low Birth Weight Deliveries
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Adult and
Chronic Disease Measures
• Weight Screening and Follow Up
• Tobacco Assessment and Counseling
• Asthma Pharmacologic Therapy
• Hypertension – Blood Pressure Control
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• Diabetes – A1c Control
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Weight Screening and
Follow-Up – Adults
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Adult Tobacco Assessment
and Counseling
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Asthma
Pharmacologic Therapy
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Hypertension
Blood Pressure Control
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Diabetes
A1c Control
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Questions?
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Contact Information
Coco Lukas, MPH
Quality Coordinator
clukas@iuhealth.org
Rick Reifenberg, MD
Associate Medical Director
rreifenb@iuhealth.org
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Sheila Allen, MPH
Chief Compliance and Quality Officer
sallen6@iuhealth.org
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