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Patient Centered Medical Home at a CHD

Patient Centered Medical Home at a CHD. Okaloosa County Health Department Opportunity Health Clinic. Opportunity Health Clinic- Patient Centered Primary Care at the Okaloosa County Health Department.

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Patient Centered Medical Home at a CHD

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  1. Patient Centered Medical Home at a CHD Okaloosa County Health Department Opportunity Health Clinic

  2. Opportunity Health Clinic- Patient Centered Primary Care at the Okaloosa County Health Department • The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults in a setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. • The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association have agreed on joint principles of the PCMH and programs to assure quality care within this model is available

  3. Joint Principles of the Patient Centered Medical Home • Personal Physician -each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care • Physician directed medical practice - the personal physician leads a team who collectively take responsibility for the ongoing care of patients • Whole person orientation - responsible for all health care needs personally or by arrangement through all life stages and for acute, preventive, chronic, and end-of-life care • Coordinated and integrated care - across complex health system elements • Quality and safety - Evidence-based medicine, use of IT, voluntary recognition process, patient participation in QI • Enhanced Access - through open scheduling, expanded hours and new communication options • Payment recognizes the added value of the medical home concept

  4. Okaloosa CHD - PCMH • PCMH • For persons living with HIV/AIDS for 9 years • For uninsured individuals for 1 year • Linkage to a PCMH for Medicaid and uninsured has the potential to reduce ambulatory care sensitive hospital admissions and readmissions

  5. HIV/AIDS PCMH- Examples of Long term success – 4 patients • Enrolled in program for 8-9 years • Male/Female ages 38-54 yrs • Besides HIV have 7-13 other serious diagnoses • Average number of medications: 13 (7-19) • 3 employed, 1 disability due to stroke • 1 uninsured small business owner, 2 TPI, 1 Medicaid/Medicare • ALL CD4 >200; VL undetectable; no hospitalizations in at least the last 2 years

  6. Prior to enrollment in OH clinic Repeated hospital admissions for DKA Inability to obtain Levamir brand insulin- using 70/30 because of cost No diabetic test strips or nutritional counseling No access to physician care No lab testing access Fasting glucose 589 mg/dl Wt 116 lbs Ht 5’ 10’’ Couldn’t hold a job due to illness Enrolled in OH clinic for 2 months No admission since enrollment On Levamir insulin with much improvement in glucose control Completed diabetes education class on Day 1 of enrollment Tests sugars daily Seen frequently by OH provider and has phone contact with nurse HgbA1c = 8% and average glucose now 120 mg/dl Wt gain of 13 lbs in one month Now holds full-time job Michael: IDDM since age 9 yrs; lost Medicaid, now age 21 yrs

  7. The POWER of Patient –Centered Primary Care to Reduce Hospital Readmissions • Excellent primary physician care • Compassionate nurse case management • Access to medication & assistance with medication adherence • Nutrition counseling • Behavioral health care • Coordination of specialty care & other care • Continuity between inpatient & outpatient care

  8. Other resources in Okaloosa County to decrease hospital readmission • Hospital-based coumadin clinics post discharge • Referral to FQHC or CHD clinics • Medicaid providers for children • Hospital-based urgent care clinics • Non-hospital based urgent care clinics

  9. Other ideas to reduce readmissions • Assure there is communication between inpatient and outpatient providers especially when inpatient care is provided by hospital employed physicians • Hospitals provide means for patients/families to have questions answered following discharge with goal of early intervention to prevent readmission • Hospitals consider routine immediate post-discharge calls (24-72 hrs) to check on status of patient

  10. Opportunities • Hospitals working with CHDs providing primary care • Targeted use of laboratory, radiology services, and other hospital resources to support patients in care in medical homes • Enhanced communication as care networks are stabilized and providers become known to hospital staff

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