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Benefits of PCMH Transformation and
Integration of Allscripts to Achieve Success
in Value Based Care
AUGUST 9 – 11, 2016

WELCOME!
AUGUST 9, 2016
Natasha Jain, MBA, CMPE
Natalie Jain, MPH

Copyright © 2016 Allscripts Healthcare Solutions, Inc. 3
Cookeville Medical Clinic RHC & Affiliated Entities
•  Patient Centered Medical Home- Level 3 by NCQA
•  Rural Health Primary Care Clinic
–  Main Clinic: Cookeville, TN
–  Satellite Clinic: Gainesboro, TN
•  Physicians Urgent Care
•  7 Providers
•  25,000 Active Patients
•  65% Medicare and Medicaid
•  Ancillary Services
•  EHR since 1997
–  Allscripts Professional 15.0
–  Allscripts PM

AGENDA
Value Based Care
What is PCMH?
Allscripts Integration in PCMH Transformation
Benefits
Lessons Learned
Q&A

TRIPLE AIM Objectives
•  QUAILITY CARE
²  Improving Patient Experience of Care
•  POPULATION HEALTH
² Improving the Health of Populations
•  COST
² Reducing the per Capita Cost of health
care

The Future is NOW

Are you a PCMH Recognized
Practice?
What does patient-centered
care mean to you?

Patient Centered Medical Home (PCMH)
A care delivery model whereby patient treatment is coordinated through their
primary care physician to ensure they receive the necessary care when and
where they need it, in a manner they can understand.

PCMH Standards
1.  Enhance Access and Continuity
2.  Team-Based Approach
3.  Population Health Management
4.  Plan and Manage Care
5.  Track and Coordinate Care
6.  Measure and Improve Performance

Integration of Allscripts in
PCMH Transformation

How Allscripts can Help…
q  Interoperability
q  Continuity
q  Reporting Module
q  Care Plans and Goals
q  Risk Stratification
q  Referral Tracking
q  Care Management
q  Client Connect

Increased Access: Interoperability
q  Allscripts PM
§  Customizable Patient-Centered Appointment
q  Chronic Care Management Program
§  Medicare Patients with 2+ Chronic Conditions
q  Relatient
§  Text Alerts
§  Email Blasts/Campaigns
§  Electronic Messaging
q  Follow My Health
Ø Patient Portal
Ø Electronic Messaging

What role does the person
sitting next to you have?

Team-Based Care
² Healthcare Team is the to
coordinate care from prevention,
treatment, and management
² Continuity of Care Team
² Transparent Communication
² Provide Culturally Competent Care
² Patient Care Liaison
² Defined Team Roles
² Huddles

Population Health
Management:
Comprehensive Heath
Assessment
§  Health Risk
§  Depression Screening
§  Fall Risk Assessment
§  Mental Health

Population Health Management:
Reporting Module
1

Population Health
Management: Patient
Information
Ø  Allscripts PM
² Demographics
Ø  Relatient
² Reminders Alerts
for Preventative
Screening or
Appointments

Plan and Manage Care:
Care Plans and Goals
q  Document Care
Plans & Goals
with Barriers to
discuss with
patients
q  Track Patient
Progress
q  Include in H&P
Encounter Note
q  Added to Clinical
Summary

Plan and Manage Care: Risk Stratification
q  Identify High Risk Patients
q  Develop Site Level Risks

Plan and Manage Care:
Care Management Tools
q  Clinical Decision Support
q  Care Management
q  Medication Refills
q  Future Orders
q  Use Evidence Based Guidelines

Plan and Manage Care: Medication Management

Plan and Manage Care: E-Prescribing

1
2

Track and Coordinate Care: Referral Tracking

Track and Coordinate Care: Transitional Care Management
q  Transitional Care Management
q  Proactively Call Patients within
2 Days of Discharge for
Follow-Up Appointment
q  Provide Discharge Summary
q  Reduce Hospital Readmission
q  Track ER Visits
q  Continuity of Care

Measure and Track Performance: Quality Initiatives
q  Meaningful Use
q  HEDIS
q  PQRS
q  Patient Satisfaction and Experience
q Relatient Survey Tool
q Patient Care Liaison
q  Continuous Quality Improvement
q  Allscripts- Certified EHR Tecnhology

²  Better care coordination
²  Patient experience
²  Partnerships between providers and patients
²  Continuity of care
²  Disease management outcomes
²  Enhanced Access to Care
²  Clinical data and transparency
²  Increased reimbursement for quality outcomes

Successful Practices in Value Based Care
q  Patient centered
q  Strong primary care is the backbone of our healthcare system
q  Adaptable and user-friendly EHR software
q  Environment of clinician and executive collaboration
q  High Morale in Team
q  Engaged and empowered employees and patients
q  Low turnover
q  Use data and benchmarking tools
q  Invest in future to enhance patient experience and quality of care
q  Navigate regulatory environment and understand impact

One Size Does Not Fit All
q  Customize
q  Innovate
q  Continuous Training
q  Process Improvement
q  Staff and Patient Feedback
q  Measure Performance
q  Sustainability
1 Efficient Quality Care
Cost Effective
Population Health
Management
2
3

Contact
²  Natasha Jain, MBA , CMPE
Practice Administrator & Chief Marketing Officer
natasha@cookevillemed.com
²  Natalie Jain, MPH
Director of Quality & PCMH Project Manager
natalie@cookevillemed.com
²  Navin Jain, MHA, RHIA, CHTS-PW, CHTS-TS
CIO & Director of Billing Services
navin@cookevillemed.com

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