Physician Health Alliance, Inc

Physician Health Alliance, Inc Care Management Department

Overview of PHA • 60 physician group practice • IM, Family Practice, Pediatrics, OB/GYN, Podiatry, Pulmonology, Sleep Study and Hospitalists • 14 Regional sites in Lackawanna County Northeastern Pennsylvania

Care Management Staff • Lead Care Manager: Christina Phillips RN • Care Managers: Margaret Drouse LPN Marianne Perkins RN Natalie Woronchuk RN • Administrative Assistant: Cathy Riccetti • IT: Patricia Gallacher

Key Components • Infrastructure Changes • Population Management • Communication System • Care Managers Role

Infrastructure Changes • Staff : job descriptions, training, CEU’s • Supplies: laptops, cell phones, business cards • Assigned individual Care Managers (CM) to specific physician practices • Development of a tracking system to capture transitional patients

Population Management • Transitional Care Patients • Development of Chronic Care Registries: DM,HTN and CAD • Carrier High Risk Lists • Physician and/or Staff Referral • Self Referral **Incorporation of “risk stratification”

Communication System • EMR “ Centricity” • Chart Alerts “Banners” • Care Manager “Care Notes” • ER/Hospital Discharge notification: generated report’s, faxes and emails • Meetings: Individual, Combined and Departmental • CM introduction letters

Communication, Continued • Practice Graphs : trends, goals, inertia • Centralized Care Management Data base • Shared Drive: Registries, Active Call Lists • EMR Templates:

Registry Assignment

Post Discharge Follow Up

Care Management Referral Form

Intake Assessment Form

MD Notification Form

Care Plan

Patient Contact Form

Electronic Blue Cross Referral Form

Care Manager Role • Liaison: patient ,site leader, staff, physicians and regional resources • High Risk Registries • Transitional Care • Care Review / Planning/ Follow up

Summary “This is the piece that has been missing at the practice level that really closes the loop” 80 year old gentleman

Thank You ! • Administration • Physicians • Site Leaders and Clinical Staff • Reception Staff • Care Managers • Regional Partnerships • Patients • IT Department

Physician Health Alliance, Inc

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