Population Health Management in a PCMH Family Residency Larissa Davids, RN Barb Kirk, RN Community Hospital East Family Medicine Residency Indianapolis, IN
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Population Health Management in a PCMH Family Residency
Larissa Davids, RNBarb Kirk, RN
Community Hospital East Family Medicine Residency
Indianapolis, IN
• Community-based network of healthcare providers
• Serving Central Indiana since 1956
• More than 2 million patient encounters each year
• Over 1 million outpatient visits per year
• Eight hospitals and more than 200 sites of care
• 700,000 annual patient encounters
• EPIC Go-Live June 2012
• First Hospital in Indiana to meet Meaningful Use Stage 2
• Started 1974
• 38 Resident Graduating Classes
• Expanding Resident Class Size
• Current Class Size 8-10-10
• Future Class Goal 12-12-12
• 40 practicing providers
• 22 clinical and front office support staff
• Additional clerical staff
Our Residency
• Part of a Health Pavilion
• State-of-the-art
• 16,000 sq. ft
• 30 Exam rooms
• Two procedure rooms
• OMT/Therapy room
Home Front
Patient Demographics
• 226,000 Patient clinic visits annually
• Approximately 7600 patients
• 60% Medicaid
• 20% Medicare
• 20% Private Insurance or uninsured
What is Practice Based Population Health
Management?
The doctor of the future will give no medications, but will interest his patients in the care of the human frame, in
diet, and in the causes and prevention of disease. -Thomas Eddison
Why Practice Based Population Health
Management?
It can be argued that the largest yet most neglected health care resource worldwide, is the patient…
-Dr. Warner Slack
Where We Were
Without continual growth and progress, such words as improvement, achievement, and success have no meaning.
–Benjamin Franklin
Our PCMH
Journey
Never doubt that a small group of thoughtful and committed citizens can change the world. Indeed, it’s
the only thing that ever has.-Margaret Mead
How Do We Utilize Practice Based
Population Health Management?
It’s easy to make a buck. It’s a lot tougher to make a difference.
-Tom Brokaw
Define the population
Identify gaps in care
Manage careEngage the patient
Measure outcomes
Define the Population
Define a Protocol
Regular Maintenance
Provider’s Panel
Identify Gaps in Care
• Labs, procedures, imaging• Immunizations • Controlled medications• Communication• Well adult, Well child exams• Follow-up• STD
Preventative Health
Maintenance
• MA Reports for Clinic
• Immunizations
Chronic Disease Management
•Pre-Visit Planning•Group Visits•Diabetes IVR
High Risk Patient
Intervention
•ED and Inpatient•Transition of Care
Manage Care
Nurse Care Managers
• Development
• Responsibilities
• Elevation of Practice
• Evolving position
Engage the Patient
Motivational Interviewing
Nurse Care Manager Office Visits
Self Assessments
MyChart
Transition of Care Program
Group Visits
Measure OutcomesEpic reports
Patient feedback
Staff feedback
Provider feedback
Our Measured Outcomes
Preventative Health
Maintenance
• Immunizations• Pap Smears• Colonoscopy• Chlamydia
Screening
Chronic Disease
Management
High Risk Patient
Intervention
•ED Visits•Hospital Admissions
•HbA1c, BMP, Lipid•Diabetic Foot
Exams•Diabetic Eye
Exams
Questions?
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