• Started 1974
• 38 Resident Graduating Classes
• Expanding Resident Class Size
• Current Class Size 8-10-10
• Future Clas...
• Part of a Health
Pavilion
• State-of-the-art
• 16,000 sq. ft
• 30 Exam rooms
• Two procedure
rooms
• OMT/Therapy
room
• 226,000 Patient
clinic visits
annually
• Approximately 7600
patients
• 60% Medicaid
• 20% Medicare
• 20% Private
Insuran...
Without continual growth and progress, such words as
improvement, achievement, and success have no meaning.
–Benjamin Fran...
Never doubt that a small group of thoughtful and
committed citizens can change the world. Indeed, it’s
the only thing that...
Define a Protocol
Regular Maintenance
Provider’s Panel
• Labs, procedures, imaging
• Immunizations
• Controlled medications
• Communication
• Well adult, Well child exams
• Foll...
Preventative
Health
Maintenance
• MA Reports for
Clinic
• Immunizations
Chronic Disease
Management
•Pre-Visit Planning
•Gr...
• Development
• Responsibilities
• Elevation of
Practice
• Evolving position
Motivational Interviewing
Nurse Care Manager Office Visits
Self Assessments
MyChart
Transition of Care Program
Group Visits
Epic reports
Patient feedback
Staff feedback
Provider feedback
Our Measured Outcomes
Preventative
Health
Maintenance
• Immunizations
• Pap Smears
• Colonoscopy
• Chlamydia
Screening
Chr...
Questions?
Population Health Management in a PCMH Family Residency
Population Health Management in a PCMH Family Residency
Population Health Management in a PCMH Family Residency
Population Health Management in a PCMH Family Residency
Population Health Management in a PCMH Family Residency
Population Health Management in a PCMH Family Residency
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Population Health Management in a PCMH Family Residency

Presentation was given at the invite only Nursing Leadership Forum at EPIC UGM 2014. If you use EPIC as your EMR, you may listen to the presentation and see the slides on EPIC.com. The presentation discusses how my clinic has implemented changes to improve our metrics, the benefits we saw with the changes, and how to make the changes at a provider level.
Published on: Mar 4, 2016
Published in: Healthcare      
Source: www.slideshare.net


Transcripts - Population Health Management in a PCMH Family Residency

  • 1. • Started 1974 • 38 Resident Graduating Classes • Expanding Resident Class Size • Current Class Size 8-10-10 • Future Class Goal 12-12-12 • 40 practicing providers • 22 clinical and front office support staff • Additional clerical staff
  • 2. • Part of a Health Pavilion • State-of-the-art • 16,000 sq. ft • 30 Exam rooms • Two procedure rooms • OMT/Therapy room
  • 3. • 226,000 Patient clinic visits annually • Approximately 7600 patients • 60% Medicaid • 20% Medicare • 20% Private Insurance or uninsured
  • 4. Without continual growth and progress, such words as improvement, achievement, and success have no meaning. –Benjamin Franklin
  • 5. Never doubt that a small group of thoughtful and committed citizens can change the world. Indeed, it’s the only thing that ever has. -Margaret Mead
  • 6. Define a Protocol Regular Maintenance Provider’s Panel
  • 7. • Labs, procedures, imaging • Immunizations • Controlled medications • Communication • Well adult, Well child exams • Follow-up • STD
  • 8. Preventative Health Maintenance • MA Reports for Clinic • Immunizations Chronic Disease Management •Pre-Visit Planning •Group Visits •Diabetes IVR High Risk Patient Intervention •ED and Inpatient •Transition of Care
  • 9. • Development • Responsibilities • Elevation of Practice • Evolving position
  • 10. Motivational Interviewing Nurse Care Manager Office Visits Self Assessments MyChart Transition of Care Program Group Visits
  • 11. Epic reports Patient feedback Staff feedback Provider feedback
  • 12. Our Measured Outcomes Preventative Health Maintenance • Immunizations • Pap Smears • Colonoscopy • Chlamydia Screening Chronic Disease Management High Risk Patient Intervention •ED Visits •Hospital Admissions •HbA1c, BMP, Lipid •Diabetic Foot Exams •Diabetic Eye Exams
  • 13. Questions?

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