123 4 567 89 10 engaged leadership data-driven improvement empanelmentteam-based care patient-team...

1 2 3 4 5 6 7 8 9 1 0 Engaged leadersh ip Data- driven improveme nt Empanelmen t Team- based care Patient- team partnersh ip Populatio n managemen t Continuit y of care Prompt access to care Coordinat ion of care Template of the future Building Blocks of High-Performing Primary Care The Share-the-Care TM Model

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Engaged leadership

Data-driven improvement

Empanelment Team-based care

Patient-team partnership

Population management

Continuity of care

Prompt access to care

Coordination of care

Template of the future

Building Blocks of High-Performing Primary CareThe Share-the-CareTM Model

Page 2: 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care

Level 3: 5% Complex

healthcare needs

Level 2: 80%Multiple chronic conditions:

diabetes, HTN, COPD

Level 1: 15%Uncomplicated chronic disease or risk factors: obesity, pre-

diabetes

Complex Care Management Team: RN, SW, Health Coach

Primary Care Team: PCP, continuity NP, RN, MA, Clerk, Behaviorist

SF Partnership for Population-focused careSFCCC, CEPC, SFDPH, SFHP

Page 3: 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care

Team member Roles

RN Care Manager

Initial assessment and Care Plan Complex clinical issues and medication issues Clinical back-up for Health Coach

Medical AssistantHealth Coach

Outreach to patients Coaching toward care plan goals Focus on self-management Primary point of contact for patients

Provider (Resident, attending, or NP)

Refer patients Collaborate with CM team Titrate medications, plan diagnostic work ups

Coordinator Manages referrals, data tracking, reporting

Social Worker Referrals to entitlements and community-based programs

Physician CM lead

Program development and evaluation Clinical back-up to team Lead quality improvement

GMC Care Management Team Roles

Page 4: 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care

Year prior to enrollment in CM

During CM Percent reduction

Hospital days per year per patient

9.37 5.75 39%

ED Visits per year per patient

1.48 1.02 31%

Utilization data for patients in CM for > 6 months (n=27)

Page 5: 123 4 567 89 10 Engaged leadership Data-driven improvement EmpanelmentTeam-based care Patient-team partnership Population management Continuity of care

2012 Colorectal Cancer Outreach Project

• Joint effort: SFDPH-PC, CEPC , SFHP• Training: colon CA, registry, outreach

skills. Outreach Work - off site, early evening. Mass mail out, phone banks

• CEPC: In Time training on registry use, scripts + role play talking to patients, coaching during phone banks

• 10 clinics, 35 staff – 4900 postcards mailed (4 languages), 6

phone bank sessions: 2400 calls, 1200 FIT tests done in outreach group

• Repeated in Sept 2012 • Screening rate 10 participating clinics

up 19% over baseline from 02/2012 to 11/2012 (at 54% 11/2012)

Slide Courtesy of Lisa Golden, M.D.

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Engaged leadership

Data-driven improvement

Empanelment Team-based care

Patient-team partnership

Population management

Continuity of care

Prompt access to care

Coordination of care

Template of the future

Building Blocks of High-Performing Primary CareThe Share-the-CareTM Model

Continuity of Care Maturity Model Going Beyond EMRAM

Why Choose Home Care? - Health First3. Continuity of Care Home care typically is provided by the same nurse or team of nurses. This ensures continuity of care and familiarity of care

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Continuity and coordination of care · assessment, care planning and coordination to integrate services to meet the needs of people with long-term conditions. Continuity of care:

Continuity of Care Document

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Access to care and continuity of care

Continuity in Gatekeepers: Quantifying the Impact of Care ...public.kenan-flagler.unc.edu/2017msom/SIGs...Continuity in Gatekeepers: Quantifying the Impact of Care Fragmentation

Measuring continuity of care: psychometric properties of

Future impact of continuity on quality of care within Primary Care

Continuity of care for older hospital patients - King's Fund · PDF filen The obstacles to continuity of care for older patients in modern hospitals are ... Continuity of care for

Midwifery continuity of care versus standard maternity

Continuity and coordination of care - WHO

2 Improving Continuity of Care - socialserviceworkforce.org · ANC antenatal care ART antiretroviral treatment CHIS community health information system(s) COC continuity of care CPIMS

Pillar VI : Continuity of Care, Relationships, Information Care should be provided continuously over time. Should foster continuity of relationships

Continuity of Care Task Force Preliminary Recommendations

CONTINUITY OF CARE AND THE GERIATRIC PATIENTclasses.kumc.edu/coa/education/AMED900/CONTINUITY OF CARE.pdf · CONTINUITY OF CARE AND THE GERIATRIC PATIENT James T. Birch, Jr.,

Department of Children and Families CHILD CARE REGULATION ... Care Continuity... · Department of Children and Families CHILD CARE REGULATION Continuity of Operations Plan (C.O.O.P)

Validation scale continuity of care - IreneGarciaSubirats · continuity of care between care levels from the ... (IC) - Care coherence across care levels (MC) ... Item 7 0.8765 0.1648

Continuity of Care Task Force...Continuity of Care Task Force Final Report – August 2010 Page 20 Appendix 2: List of Continuity of Care Task Force Meetings Task Force Meetings February

Continuity of Care · Continuity of care with specialists, providers, & family Management of chronic diseases Management of acute pain The utmost in compassionate and attentive care

Care and Continuity: Contingency planning for provider failure · Care and Continuity: Contingency planning for provider failure ... Contingency planning for provider failure

Continuity of Care A5 Web.pdf

RESIDENTIAL CARE ESTABLISHMENTS BUSINESS CONTINUITY PLAN ... · PDF filepage 1 of 1 residential care establishments business continuity plan template west midlands 1st edition

Continuity of Midwifery Care 2013

Illinois Continuity of Care & Administrative ... · Illinois Continuity of Care & Administrative Simplification 1115 Waiver . Purpose, Goals, and Objectives: ... 2011-2016.2. The