Primary care redesign webinar


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  • To start off, I wanted to give you an overview of what we will cover.To walk you through the overview of our presentation
  • This slide represents our care coordination framework specifically around how we work with complex, high utilizing patients.“The Push” Communicating with hospitals to facilitate the hospital to community handoff“The Carry” Community-based care coordination for high risk/high needs patients post discharge “The Catch” Primary care redesign; analyzing and modifying workflows to provide proportional care to high-needs patients
  • This video is of one of our provider champions, Dr. Bhalodia talking about the importance of team-based care.“You can’t do this yourself. Even as one single family practice office, the tougher to treat your patients the more you need it. It’s not just about extra resources and extra reminders it’s actually learning ways to help patients learn and manage their conditions better. I’ve been learning a lot it’s more than just an extra set of hands.” - Dr. Amit BhalodiaHelp PCP develop resources to better treat complicated patientsPatients who have a medical home are less likely to misuse the EDRegular monitoring/management of a chronic illness helps avoid hospital readmissions
  • Why Is the Catch So Important?With our first cohort of patients, we have seen a reduction in it has been challengingbecause patients are not always consistent with lab follow-up, and we are working with patients to change that trend. We are currently implementing an evaluation structure at the Coalition, and this is data we will actively be able to give you over the coming months
  • 64 year-old African American male with COPD
  • Total of 11 high utilizer patients at Virtua
  • Care Coordination, QI and Patient Engagement
  • Primary care redesign webinar

    1. 1. Camden Coalition of Healthcare Providers Primary Care Redesign Webinar Nadia Ali, Director, Clinical Redesign Victoria DeFiglio, Associate Clinical Director
    2. 2. Overview • Rationale • Care Coordination Framework • Program Success to Date • Staffing Model • Patient Impact • Practice Transformation • Looking forward • Q & A
    3. 3. Care Coordination Framework Patient’sLevelof Dependence Time PUSH Bedside Higher Warm Hand-off CARRY CATCH
    4. 4. Rationale
    5. 5. Program Success to Date • A1c reduction seen in 67% of patients to date • Seen decrease in hospital utilization and 30-day readmissions • Improved linkages, greater collaboration between diabetes educators and primary care providers • Greater Patient Satisfaction • Standardization of practice protocols
    6. 6. Our Embedded Team SWRN LPN HC HC CHW
    7. 7. Patient
    8. 8. Patient Pre-Intervention 13 30-day readmissions Post-Intervention 2 30-day readmissions.
    9. 9. Provider
    10. 10. Vision for Primary Care Care Coordination •Nurse Care Transitions •Accompanied PCP visit •Care coordination rounds •Accompanied specialty visits •HIE training •Social work assistance Quality Improvement •Patient registries •Team meetings •Protocols •Provider/staff Education •EMR Meaningful Use assistance •Data collection/analysis Patient Engagement •Chronic Disease self- management education •Group medical visits •Mental health assessment & counseling •Peer support groups •Wellness programs