Patient
Centered
Medical Home
Urban, Rural, Wherever…
Presenters:
 Sheila
Allen—Director of Quality for
HealthNet, Inc
 Sherry Gray--Director of Rural and Urban
Access to Health for St. Vincent Hospital
 Dr. Risheet Patel—Private practice and
executive of Indiana Academy of F. P.
 Facilitator-Kathy
Church—small HIE
Introduction
 PCMH
resembles “old time care” with use
of “new time tools”
 Key focus on the patient having a positive
experience and actively participating
 Value of managing groups of patients
with like disease
 Team based care
Why me as a facilitator
I
said yes
 Manage the operations of HealthLINC,
community based HIE focused on transitions
of care and patient inclusion
 Work
on PCMH with focus on Care Managers
 Nurse with 40 years of varied experiences, the
10 lives of kc
PCMH Journey:
A Marathon, Not a Sprint
Sheila Allen, MPH, CHES
Director of Quality
HealthNet, Inc.
(317) 781- 4871
sallen6@iuhealth.org
HealthNet’s Mission:
To improve lives with
compassionate health care
and support services,
01 Section name goes here
regardless of ability to pay
Service Information:
•
•
•
•
•
•
•
•
8 Primary Health Care Centers
5 Dental Clinics
1 OB/GYN Center
1 Maternal-Fetal Medicine Center
Pediatric Residency Continuity Clinic
5 School-Based Clinics
Homeless Initiative Program
Healthy Families/Better Indy Babies
01 Section name goes here
HealthNet has been serving
central Indiana residents since
1968
Health Center Locations
1.
Barrington Health & Dental Center
2.
Care Center at the Tower
3.
Eastside Health Center
4.
Martindale-Brightwood Health & Dental
Center
5.
Pediatric & Adolescent Care Center
6.
People’s Health & Dental Center
7.
Southeast Health & Dental Center
8.
Southwest Health & Dental Center
9.
Maternal-Fetal Medicine Center
10. Pediatric
Evening
Clinic
01 Section
name
goes
here
11. West Health Center
12. Northeast Health & Wellness Center
(Opening Fall 2013)
HealthNet, Inc.
2012 By the Numbers
• 56,624 individual patients
• 250,107 outpatient visits
• 3,069 babies delivered
• 10,230 homeless01
visits
Section name goes here
 Joint
Commission Accredited
as an Ambulatory Practice since
1980
 Joint Commission PCMH
Recognition in October 2012 –
the first in Indiana and 1 of only
01 Section name goes here
30 in the US!
How PCMH
Practice Transformation Planning
Yielded Certification
 Started
with Self Assessment Tool to
determine our greatest improvement areas
 Recognized
many standards had already
been achieved
through name
JC accreditation
01 Section
goes here and
other initiatives
 Formed
multidisciplinary team from beginning
How PCMH
Practice Transformation Planning
Yielded Certification (cont.)
 Selected
small group of patients to begin with
 Perfected
 Then
PCMH program with them first
01toSection
name groups
goes here
spread
other patient
Tips and Tricks Navigating Readiness to PCMH
Achievement

Do not try to implement changes
organization-wide at the very beginning
 This
 This
cannot be 1 person’s job
01 Section name goes here
is a culture change that everyone will
have to embrace if a practice is to earn PCMH
recognition
Tips and Tricks Navigating Readiness to
PCMH Achievement (cont.)

Be sure to involve a Multidisciplinary team

Remember – Patients have an important role
 All of the work does not fall on the Practice
01 Section name goes here

We have to educate our Patients about their rights
AND responsibilities as part of our/their Medical
Home.
HealthNet’s Next Steps:

Review proposed changes to Joint Commission
PCHM standards for 2014

Continue to educate patients, providers and staff
about PCMH

Improve health literacy assessment and patient
01 Section name goes here
education

Improve self management goal setting and
assessment of progress
QUESTIONS???
to follow
3rd presenter…
Make notes to ask
17
Transforming Healthcare
with a World Class 21st Century Workforce:
Patient-Centered Medical Home &
Community Health Worker
Ivy Tech Corporate Challenge and Culinary Center
March 14, 2013
Sherry E. Gray, System Director
St. Vincent Health
Rural and Urban Access to Health
19
RUAH
Rural and Urban Access to Health
Purpose:
To connect our friends, family, and neighbors to a
comprehensive, integrated delivery network of health,
human and social services resulting in improved access and
removal of barriers to needed resources.
Meaning and Mission:
The word Ruah, in Yiddish
means “Breath of Life”.
The Goal?
…to breathe new life into a
health care system that will we serve our most vulnerable community
members compassionately, with quality and efficiency
20
RUAH “from the start” (a little history)

RUAH Partnership initiated: 2000
 SV Health
 Indiana Health Centers, Inc.
 Health and Hospital Corporation of Marion County
 ADVANTAGE Health Plans, Inc.
 Butler College of Pharmacy, later added
 Community Interface Groups: local partner groups responsible for
program implementation.

Funded by HRSA, Ascension Health from 2001-2005

Additional private funding through the Anthem Foundation: establish 3
additional sites

Sustained through local hospital funding and captured reimbursement
through enrollment efforts and cost avoidance
21
Program Outcomes

Four community programs expand to Eight community programs (+1 in next
quarter)

2013: Managed Medicaid Funded HAW: SVMG office

Outcome Focused: Pathway Model Integration



5 Pathways implemented; 2 in development
Outcome Measure reporting effective 9/11 (Pathways)
Used to count what we did “to/for” clients vs. outcomes!

AHRQ Innovation Site
Community Care Coordination Learning Network Site
National Institute of Health Research Partner
Indiana CHIPRA grantee

$43.7 million worth of low/no cost drugs provided

Language Access





1360 interpreters trained through Bridging the Gap
1105 documents translated
Integration
with Federal,
State and
County
Stakeholders
22
23
Infrastructure and Operations
(support for eight program sites and system-wide LEP work)

10 HAW’s

6.0 MAC’s
 Direct Hires
 Community-agency based

System Administrative Support
 Health Access Manager; Operations Facilitator; Administrative
Assistant; Language Access Staff; System Director

Annual Budget
 $1.1 million
24
How RUAH addresses ACCESS




Health Access Workers
 Client advocates & “system navigators”: COMMUNITY BASED CARE
CONNECTION
 Pathways: medical home, medical referral, enrollment, social services,
pregnancy
 Community “Hub”: partnerships between and among community
stakeholders
Pharmacy – access to low or no cost drugs through Medication
Access Workers (MAC’s) (RXASSIST+; Dispensary of Hope; Vouchers ;etc.)
Language Access: translation of core documents, interpretation, cultural
brokering/advocacy
Integrate and Facilitate: the “5 Rights”
 Right Care
 Right Time
 Right Place
 Right Provider
 Right Payer
25
Workforce Challenges:
 Hospital/Provider
Team Member role
 Community Integration--Relationships
 Scope of Work
 Site of Service
 Communication/Information-Sharing
Structure
 Stakeholder Focus
 Accountability Structure
26
Ultimately:



Un/underinsured community members can receive care “sooner vs. later”
Consistent and familiar care is provided along with follow up & follow through:
treatment is across time and not episodic
Resources are used as effectively as possible, including:
 Human


Financial


Connecting Information in a timely, meaningful way
Support (wrap-a-round) Services


Reimbursement, Funding, Cost-Avoidance, “Write-Off’s”
Technological


Providers, Practitioners, Care Coordinators, Administrative support, etc.
Connecting medical treatment, public health practices, & psychosocial principles
Vital connections are made
 Integrate and coordinate care not duplicate and replicate care
 “Best Practice” Learning's are shared; and solutions are not “re-created”
ST. VINCENT HEALTH, INC.
INDIANAPOLIS, IN
CONSOLIDATED SUMMARY
CARE OF PERSONS LIVING IN POVERTY & OTHER VULNERABLE PERSONS AND COMMUNITY BENEFIT REPORT
(Ex clude s Ba d
De bt Ex pe nse in
RCC)
(Ex clude s Ba d De bt
Ex pe nse in RCC)
(Ex clude s Ba d De bt
Ex pe nse in RCC)
FYE 6/30/2011
Ca te gory I
Actua l
FYE 6/30/2010
$
52,739,731
Ca te gory II
$
97,100,455
$
Ca te gory III
$
4,523,133
$
Ca te gory IV
$
$
36,966,815
$
E
Q
AF
O
AA
D
N
AE
M
K
AB
I
38
39
41
42
43
44
45
46
47
48
49
P
X
Z
AD
AC
S
U
F
L
G
AD
$
$
191,330,134
$
179,227,006
$
157,213,641
$
106,507,694
$
Tota l
$
348,543,775
$
285,734,700
$
FACILITIES
Ca rme l
Cla y
Dunn
Fra nkfort
He a rt Ce nte r of India na
India na polis
Je nnings
La fa ye tte La b
Me rcy
Ne w Hope
MCNE
Physicia n Ne tw ork
Physicia n Ne tw ork-Ra ndolph
Physicia n Ne tw ork-Fra nkfort
Physicia n Ne tw ork-Je nnings
Physicia n Ne tw ork-Me rcy
Physicia n Ne tw ork-St. John
Physicia n Ne tw ork-Sa le m
Physicia n Ne tw ork-Dunn
Physicia n Ne tw ork-St. Joe
Physicia n Ne tw ork-Cla y
Ra ndolph
St. Joe - Kokomo
St. John's - Ande rson
SVH Corpora te
SVMG-The CARE Group
Sa le m
Se ton - India na polis
Se ton - La fa ye tte
Stre ss Ce nte r
W illia msport
W ome n's
Tota l Fa cilitie s
Se lf-Che ck
$
$
4,086,618
29,623,763
$
$
I
(Tra ditiona l
Cha rity)
26
27
28
29
30
31
32
33
34
35
36
37
Actua l
FYE 6/30/2009
50,718,894
94,797,731
Subtota l
Ca te gory VI
II
(Unre imburse d
Me dica id)
$
2,142,584
973,583
1,049,203
774,478
2,058,099
21,932,789
1,410,699
3,022
1,873,021
539,955
276,911
404,336
127,953
552,538
58,384
359,890
197,920
139,490
139,204
7,855
1,751,442
2,246,071
8,927,971
532,066
492,336
535,835
28,604
560,894
949,818
1,692,780
$
4,328,988
1,724,761
2,852,643
(1,734,129)
1,793,877
39,243,990
2,259,818
32,962
2,389,165
1,446,803
1,485,508
1,271,216
948,080
893,381
1,061,317
172,424
1,157,883
521,844
730,418
633,416
74,231
(287,152)
5,994,337
9,803,851
3,202,691
1,756,046
1,106,041
618,837
983,212
1,493,466
9,140,527
$
$
$
52,739,731
52,739,731
-
$
$
$
97,100,455
97,100,455
-
III
(Ca re of the
Poor)
PERIOD 12 FYE 6/30/2011
IV
(Community
Be ne fit)
$
184,650
14,400
16,800
39,137
80
2,304,733
156,829
81,859
129,500
126,740
352,796
715,472
340,097
540
10,260
2,530
220
4,243
42,246
$
4,523,133
4,523,133
-
$
$
373,223
148,027
66,581
105,666
41,025
26,830,264
57,042
60,093
60
31,648
8,943
107,438
120,256
264,246
7,985,289
50,552
81,921
46,829
57,140
208,304
322,269
$
$
36,966,815
36,966,815
-
$
$
$
$
29,623,496
84,080,610
3,459,225
27,004,174
144,167,505
101,014,618
245,182,123
VI
(Unre imburse d
Me dica re )
Sub Tota l
7,029,446
2,860,771
3,985,227
(814,847)
3,893,081
90,311,776
3,884,388
35,984
4,404,138
1,446,863
2,057,111
1,686,570
1,352,416
1,021,334
1,613,855
230,808
1,517,773
719,764
869,908
772,620
82,086
1,698,468
8,713,460
19,711,540
8,325,386
3,734,757
2,299,474
1,734,057
696,800
1,601,466
2,655,832
11,197,821
191,330,134
191,330,134
-
$
$
$
$
11,240,919
(79,049)
(126,004)
(90,208)
12,684,544
66,749,341
(64,273)
600,303
(94,065)
1,470,940
2,104,320
443,211
509,482
415,620
174,058
1,108,295
648,894
493,317
789,640
11,679
(96,237)
10,405,711
15,729,780
29,999,576
(69,225)
223,815
690,418
659,117
(85,747)
765,473
157,213,641
157,213,641
-
Tota l
$
18,270,365
2,781,722
3,859,223
(905,055)
16,577,625
157,061,117
3,820,115
636,287
4,310,072
1,446,863
3,528,051
3,790,890
1,795,627
1,530,816
2,029,475
404,866
2,626,068
1,368,657
1,363,225
1,562,260
93,765
1,602,231
19,119,171
35,441,320
8,325,386
33,734,333
2,230,249
1,957,872
1,387,218
2,260,583
2,570,084
11,963,294
$
$
$
348,543,775
348,543,775
-
27
Questions to follow 3rd
presenter
28
29
Olio Road Family Care
Fishers, Indiana
Risheet Patel, MD
Our patient-focused approach
Time for questions
????
Thanks to all 3 speakers!