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Bella Vista Medical Center Medical Home
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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
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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.
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Care Team Coordinator
Medicare Annual Wellness VisitsPrevention, screenings
Patient registry Epic superuser Emmi/patient education coordinator Telemedicine monitoring Clinical expert “go to person”
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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
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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.
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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
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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
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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
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Communication
Weekly staff meetings Weekly provider meetings E newsletter Patient Advisory Board Transparency and openess
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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
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New Bella Vista Multispecialty ClinicAnticipated Completion 2014
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