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Together.

Today. Tomorrow. Together. 21 st Century Model of Primary Care for Chronic Diseases Jane Allen Calhoun, Director, Clinical Services Anna Lyn Whitt, Executive Assistant to CEO. Board of Directors. Delta State University - John Hilpert, Chairman MS Valley State University – Donna Oliver

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Together.

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  1. Today. Tomorrow. Together. 21st Century Model of Primary Care for Chronic Diseases Jane Allen Calhoun, Director, Clinical Services Anna Lyn Whitt, Executive Assistant to CEO

  2. Board of Directors Delta State University - John Hilpert, Chairman MS Valley State University – Donna Oliver Univ. of MS Medical Center - James Keeton Mississippi State University - Melissa Mixon Delta Council - Bill Kennedy Community Members – Bruce Brumfield Representative Willie Bailey Cass Pennington

  3. DHA Overview Access Increase access and availability of care Education Offer health education programs Research Conduct and apply health research

  4. Access, Education & Research

  5. Service Area

  6. Mississippi Mississippi’s National Ranking • % obese adults1 48th • % diabetes2 1st • Number of adults who smoke cigarettes 42nd • Asthma-related disease among school age students 50th • Teen pregnancy Highest • Infant mortality 49th

  7. Vital Stats Physician Patient Load by County = 5 or less physicians residing in county = no physicians in county Map 1: Patients per Primary Care Physician, 2002 Within recommended patient load (1,429 patients PCP) Up to double recommended patient load 2x to 4x recommended patient load More than 4x recommended patient load No PCP in County http://www.healthpolicy.msstate.edu/ publications/healthmaps/primcarephys.pdf MSDH State Health Plan 2007

  8. The Destructive Cycle of Health Disparities in the Delta

  9. When Good Health Drives the Economy of the Region

  10. What are we doing to address this? • Mathematica • External evaluation • GAP analysis • Project Portfolio Shift from small, narrow research projects to broader, infrastructure building projects that are likely to have near-term effect on improving healthcare knowledge, access or quality. Source: Social-ecological model from CDC.

  11. Partners

  12. Additional Collaborators • Delta Area Health Education Center (AHEC) • Mathematica Policy Research Inc. • Oak Ridge National Laboratories • Hamilton Eye Institute • Vanderbilt University • University of Chicago • Northwestern University

  13. Delta Health Initiative Highlights

  14. Addressing Solutions Today • Investments in Technology • Streamline Rural Programs • Enhance Rural Infrastructure

  15. Investments in Technology • Consistent use of best practices regardless of clinic location

  16. Electronic Health Records EHRs Benefit Our Communities • ~329,000 Patients in Delta Database • 13 site locations - DRMC • Patient education for chronic disease self-management • Improved medication management • Improved tracking of long-term outcomes • Reduction of health disparities

  17. Expanding Infrastructure Rural TeleStroke VISICU—Telemedicine for Intensive Care—University of MS Medical Center TelePsychiatry Program—University of MS Medical Center Vision Screening

  18. 21st Century Primary Care Model • Transforming primary care practices in rural health clinics and free clinics in target counties • Measuring impact on access to care, treatment outcomes, & provider and patient satisfaction

  19. 21st Century Model of Primary Care ∙ Utilizing the TransforMED Patient-Centered Model to better serve the needs of both patients and practices

  20. 21st Century Model of Primary Care ∙ The model encourages ∙ Clinician-patient communication: trust, respect, shared decision- making ∙ Patient engagement ∙ Provider/patient partnership ∙ Culturally sensitive care ∙ Continuous relationship ∙ Whole person care

  21. 21st Century Model of Primary Care Goal 1: Improved health outcomes for people with diabetes and hypertension Goal 2: Increased access to goal Goal 3: Increased community awareness Goal 4: Evaluate the effectiveness of the process and the outcomes of a PCMH model in the Delta and its impact on overall health outcomes

  22. 21st Century Primary Care Model Applying PCMH principles to the traditional chronic care model Enhancing access to a clinical team Adopting new technologies Improving quality, equity, and efficiency

  23. Workforce Development Successful Communities Literacy Appropriate Healthcare Early Childhood Interventions Successful Communities

  24. Tomorrow. Together. Today.

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