Bella Vista Medical Center Medical Home

Care Team 3 Physicians, 3 Advanced Practitioners Case Manager Care Team Coordinator Chaplain

Clinical Pharmacist, Diabetes Educator Clinical coworkers – RN, LPN, MA, Lab, X-ray Nonclinical coworkers Management Patient Advisory Board

2

Advantage of the team approach

The team allows us to meet the demands of a

varying patient population. The strengths and

skills of the team members blend, overlap and

complement each other as parts of a whole.

Care Team Coordinator

Medicare Annual Wellness VisitsPrevention, screenings

Patient registry Epic superuser Emmi/patient education coordinator Telemedicine monitoring Clinical expert “go to person”

Annual Wellness Visit

Scheduled in 2 parts – scripting for schedulers Care Team Coordinator visit

preventative, wellness, screenings

referrals (i.e. polypharmacy, Emmi education)

places orders per protocols Reimbursed by Medicare for both visits Provider visit – focus on medical issues

Case Manager

Case Management referrals - provider Home visits Telemedicine set up and monitoring Problem solver – social/medical issues/barriers Educator Liaison with outside groups – OT,PT,Home

Health, DME, etc.

Pastoral Services/Chaplain

Referrals to Pastoral Care - provider Patients experience a higher level of wellness when

spiritual, emotional care is the needed piece to complete their total health

Coworkers become a more cohesive community with like goals and are uplifted and more loved and loving as a result

The burden of providing emotional and spiritual care is removed from the providers and taken over by someone educated in theological and clinic assessment and support

Investment in Coworker Team

Staff Development with weekly meetings Buy in to the team culture Consistent education Standard processes Feedback from all areas on patient satisfaction Problem solving Attended by all coworkers and providers Retreat, teambuilding

Investment in the Provider Team

Two meetings a week – 1 with all providers,

1 with Dr Lee and Advanced Practitioners Continuing medical education Standard of workflow and documentation Model for training – establish templates Make it easy for Advanced Practitioners to do

the right thing and hard to do the wrong thing Support functioning at highest level of license

Communication

Weekly staff meetings Weekly provider meetings E newsletter Patient Advisory Board Transparency and openess

Growth Potential

Expand PharmD role• Provider and coworker education• Expanded patient visits• Management of HTN, other protocols

Partnering with outside groups• PCPS medication safety• CMS pilot• Grants/research

Satellite clinic/extended hours/new facility

New Bella Vista Multispecialty ClinicAnticipated Completion 2014