Building Blocks of High-Performing Primary Care
The Share-the-CareTM Model
10
Template of
the future
1
Engaged
leadership
8
9
Prompt
access to care
Coordination
of care
5
6
7
Patient-team
partnership
Population
management
Continuity of
care
2
3
4
Team-based
care
Data-driven Empanelment
improvement
SF Partnership for Population-focused care
SFCCC, CEPC, SFDPH, SFHP
Level 3: 5%
Complex
healthcare needs
Complex Care
Management Team:
RN, SW, Health Coach
Level 2: 80%
Multiple chronic conditions:
diabetes, HTN, COPD
Primary Care Team:
PCP, continuity NP, RN, MA,
Clerk, Behaviorist
Primary Care Team:
Level 1: 15%
Uncomplicated chronic disease or risk factors: obesity, prediabetes
PCP, continuity NP, RN,
MA, Clerk, Behaviorist
GMC Care Management Team Roles
Team member
Roles
RN Care Manager



Medical Assistant
Health Coach




Provider (Resident,
attending, or NP)
Initial assessment and Care Plan
Complex clinical issues and medication issues
Clinical back-up for Health Coach
Outreach to patients
Coaching toward care plan goals
Focus on self-management
Primary point of contact for patients

Refer patients
Collaborate with CM team
Titrate medications, plan diagnostic work ups
Coordinator

Manages referrals, data tracking, reporting
Social Worker

Referrals to entitlements and community-based programs
Physician CM lead





Program development and evaluation
Clinical back-up to team
Lead quality improvement
Care Management Weekly Dashboard: Summary of Nov 26-30, 2012
avg/wk
4 wks ago 3 wks ago 2 wks ago last week
Hospitalizations
2
0
2
0
2
New Hospitalizations
Home Visits
1
1
0
0
0
2
Clinic Visits
4
6
1
5
1
Phone Calls
50
59
66
25
35
Home Visits
Consults
15
61
34
20
21
0
Who's in the hospital
this week?
Year prior to
During CM
Percent
What's coming up?
Who are our new patients?
Patient Name (11/25 - )
enrollment in
reduction
Phone Assessments
Patient Name (11/28
-)
CM
Number of Days Hospitalized per month before and after Care Management
Hospital days
per year per
18
5
patient
9.37(n = 21)
5 mo prior
23
22
6
8
1 mo after
2 mo after
1
4 mo prior
3 mo prior
1.48
2 mo prior
1 mo prior
13
7
3 mo after
4 mo after
5 mo after
2
31%
6 mo after
Total Care Management Patients Enrolled
Total Care Management Patients Enrolled
1
7
Total
2
3
6
3
40
#REF!
6
Enrolled
4
10
5
IA
5
1
35
PRE
5
Pre
40
10
1.02
Utilization
data for patients
in CM for > 6 months (n=27)
CRITICAL
3
TOTAL
39%
59
ED Visits per
Level
Breakdown
year
per patient
6 mo prior
5.75
5
4
1
Jan
1
2
8
Feb
Mar
15
Apr
#REF!8
7
4
2
30
33
35
35
Aug
Sep
Oct
Nov
61
4
24
25
Jun
Jul
4
19
May
Enrolled
Dec
PRE
Printed on: 1/11/2013
2012 Colorectal Cancer Outreach Project
• Joint effort: SFDPH-PC, CEPC , SFHP
• Training: colon CA, registry, outreach
skills. Outreach Work - off site, early
evening. Mass mail out, phone banks
• CEPC: In Time training on registry use,
scripts + role play talking to patients,
coaching during phone banks
• 10 clinics, 35 staff
– 4900 postcards mailed (4 languages), 6
phone bank sessions: 2400 calls, 1200 FIT
tests done in outreach group
• Repeated in Sept 2012
• Screening rate 10 participating clinics
up 19% over baseline from 02/2012
to 11/2012 (at 54% 11/2012)
Slide Courtesy of Lisa Golden, M.D.
Building Blocks of High-Performing Primary Care
The Share-the-CareTM Model
10
Template of
the future
1
Engaged
leadership
8
9
Prompt
access to care
Coordination
of care
5
6
7
Patient-team
partnership
Population
management
Continuity of
care
2
3
4
Team-based
care
Data-driven Empanelment
improvement