In Spring 2013, we are on the precipice of dramatic, disruptive change in the health field that offers an unprecedented opportunity and challenge to transform health care and population health. We know that traditional public health approaches along with more and better health care are not enough to improve health outcomes, equity, and cost. We must also: - implement sustainable, fundamental "upstream" changes that address the root causes of disease and disability; and - transform the way we deliver health care to ensure access to quality, affordable health care for all. Enjoy this Bright Spot presentation from Judy Li, Vice President, Health System Innovation and Community Benefit, Sutter West Bay Region, and Russell Lee of St. Luke's Health Care Center, which was presented at the 2013 Annual Leadership Conference, co-sponsored by the Center for Health Leadership (CHL) and the California Pacific Public Health Training Center (CALPACT) at UC Berkeley's School of Public Health. To learn more about this event, please visit: http://calpact.org/index.php/en/events/leadership-conference Learn more about CALPACT: http://calpact.org/ Learn more about the CHL: http://chl.berkeley.edu/

1. St. Luke’s Primary Care Redesign:
HealthFirst Project Plan
Excerpts (5/31/2013)

2. St. Luke’s Neighborhood Clinic:
Primary Care Redesign In Action
Pre-HealthFirst HealthFirst Current Implementation New Integrated Clinic
1996 - 2006 2007 - 2011 2011 - 2015
Five decentralized solo-physician primary
care practices, which eventually merged
to create a two-physician practice
Two separate locations: physician
primary care practice on 5
th
floor and
HealthFirst on 6
th
floor of MOB
Integrate HealthFirst and physician
practice; Increase physician practice
from two to four physicians
MD treated patients one at a time Chronic disease management pilot of
selected patients with community health
workers worker extending licensed
professionals
Interdisciplinary team of physicians,
nurse practitioners, chronic disease
educators and community health workers
treats a population of patients; Panel
management
Primary focus on symptoms Patient self-management Focus on disease prevention & patient
self-management of chronic illnesses
Paper medical records Paper medical records Electronic Health Record
SF Health Exchange
Mostly Medi-Cal and Medicare-covered
patients
Mostly Medi-Cal and Medicare-covered
patients
Increase commercial and Medicare-
covered patients
Significant financial losses Improved efficiencies to increase
throughput; Reduced operating losses
Apply "Guided Care" model; Apply LEAN;
Increase throughput; Reduce operating
losses through realization of economies
of scale
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3. Clinical Outcomes:
HealthFirst produced notable improvements in asthma
management
4.48
1.89
1.08
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Baseline Follow-Up 1 Follow Up 2
16%
46%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
HealthFirst Enrolled
Patients
Non-HealthFirst
Enrolled Patients
Mean # of Nights Awakened in the Previous Month % of ED Patients Seen in the ED for an Asthma Event
Source: Regina Otero-Sabogal, PhD. “Final Evaluation Executive Report 2007-2010: HealthFirst Pilot Program”, 11/05/10

4. Clinical Outcomes:
HealthFirst produced notable improvements in diabetes
management
10.55
8.72
0
2
4
6
8
10
12
Baseline Follow Up
100.38
89.92
0.00
20.00
40.00
60.00
80.00
100.00
Baseline Follow-Up
Average HbA1c Mean Glucose Level Mean LDL Cholesterol Levels
Source: Regina Otero-Sabogal, PhD. “Final Evaluation Executive Report 2007-2010: HealthFirst Pilot Program”, 11/05/10

5. Phase II Redesigned Clinic Team Roles
Clinic Team Role Description
Physician l Lead team
l Assess new ,unstable, and complex patients
l Provide initial diagnosis and treatment
l Supervise team care
Nurse Practitioner l Serve as physician extenders
l Manage stable chronically ill
l Provide uncomplicated urgent care
Certified Diabetic /
Asthma Educator
l Serve as physician extenders
l Adapt treatment plan to individual patients
l Teach patient self-management
Clinic Manager l Coordinate case-management
l Oversee information system & panel management
Social Worker l Assist patients with accessing outside resources (e.g.,
immigration, insurance, housing, etc.)
Community Health Worker l Serve as educator extenders
l Provide patient navigation
l Address cultural and language barriers with patients
l Reinforce and monitor self-management
4