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Adelante Healthcare - PCMH

Adelante Healthcare Community Health Center - PCMH

Carlos Castaneda

on 17 June 2015

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Transcript of Adelante Healthcare - PCMH

Healthy People. Healthy Communities.
Lisa Blue, MHI, RN, Director of Clinical Programs
Robert L. Elk, MD, MMM, Chief Medical Officer
Partnership with one health plan
Medicaid population
3 cohorts
Transitions of Care
Access to Care
Care Opportunities
Access to care
Pilot group
Rapid cycle improvement/PDSA
Provider input
Leveraged staff to maximize reach
Care Opportunities Completed

>20% increase in 7 day follow up
care after inpatient admission or
emergency department visit
standards of care

Clinical team input
Process flow redesign

PCMH concepts incorporated

Job descriptions
Interview process
Candidate personality
Expanded staff

Added roles:
Clinical Coordinator (RN)
Health coach (MA)
Integrated Behavioral Health
Are we meeting our Triple Aim goals?
"I really like that with her I feel she actually cares about me. I feel she treats me as family and really cares about my health. It is not just a job to her."

"They talked to me about how to use my insulin. When I first went it was 400 now I have it controlled. I have met with different girls and they all are wonderful”


"The class helped me understand my diabetes. They explained about the insulin and where my numbers should be at. My numbers have gone down considerably."

Patient education
• face to face
• telephonic

• Phone or walk in

Provider administrative support
• Medication refills
• Pre-visit planning

RN responsibilities
Health Coach responsibilities
Referral coordination

Obtaining medical records

Patient outreach

Connecting the patient with
needed resources

Cost Savings
Grant funding opportunities

Unique payer agreements

Pay for performance goals; shared savings

Triple Aim
Extended the reach of our
current care teams and
transformed our approach to care

The Journey to a PCMH...are you on the right path?

Patient experience
Reduce costs
Population Health
Introduction of self management techniques & positive health behaviors

Motivational interviewing to assess readiness

Administration of PHQ-9

Positive parenting techniques
Behavioral Health responsibilities

Evidence based design

Team based approach to care
New health center
PCMH model
Some PCMH Building Design Elements
Hospitality focus
Inviting space
Small waiting spaces close to specialties
“Talking” rooms

Hospitality Focus
Inviting Space
Small Waiting Room Spaces
Talking Rooms
Starting off...
Before we built:
Executive leadership discussed the vision
Senior leadership involved
Joint Commission PCMH certified in 2012
Commitment to NCQA Level 3 PCMH preparation across the organization
Recognized the site would be a PCMH laboratory

Before we opened:
Hired staff in advance
RN, RD, LCSW, health coach
3 providers (IM, Peds, FM)
2 medical assistants per provider
Arranged meetings of staff with senior leadership to clarify the vision and plan
Distributed information on PCMH to educate

The missteps:
Lack of experienced MAs
ECG/spirometry new equipment problems in using as intended
One provider who didn’t buy in to team approach
Patient flow-referrals vs. team initiative

Provider change
Improved dynamics
New patient flow
Optimized productivity
Still learning-
Monthly meetings
Patients very satisfied
Staff energized and engaged
Still building capacity

New PCMH Start Up Site
Jessicca Moore FNP

Care team utilization
team introductions
identifying patients vs. referrals

patient may be seen before provider

Culture of Innovation
Full transcript