health home innovation fund convening oakland, ca june 4-5, 2013
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Health Home Innovation Fund Convening Oakland, CA June 4-5, 2013. SJGH Primary Care Clinics. PCMH Transformation Lessons Learned. Don’t Survey length to get best response. Change/feedback cannot be delayed Take on other new projects Bite what you cannot chew and swallow - PowerPoint PPT PresentationTRANSCRIPT
Health Home Innovation Fund ConveningOakland, CA
June 4-5, 2013
SJGH Primary Care Clinics
Do Implement disease registry
and Provider specific reports
Restructured leadership for the task at hand
Implementation team with weekly/biweekly Quality improvement meetings
Communication boards in clinics.
Dedicated meeting times for the whole clinic team.
Anticipate change fatigue/work arounds
Don’t Survey length to get
best response. Change/feedback
cannot be delayed Take on other new
projects Bite what you cannot
chew and swallow Forget to involve
providers. Create extra work for
staff.
PCMH TransformationLessons Learned
PCMH Initiatives
Population management(i2i),Titration clinic Clinic huddles Quality Improvement PDSA meetings Visit pre-planning Standardized orders Joint doctor / clinic staff meetings monthly Advanced access. Patient Experience review (Pext,CGCAHPS)
Community Medical Center - Channel
San Joaquin County Behavioral Health Older Adult Services (OAS)
Patient Success Story Patient is 70-year-old female with Schizoaffective Disorder with Diabetes
Transferred to Older Adult Services in 2005 from Adult Services
Long history of Mental Health services, including State Hospital admissions starting in her 20’s
More than twelve inpatient psychiatric admissions since 1992
Psychiatric inpatient admissions usually involved medication noncompliance
Physical health issues resulted in 5 hospitalizations prior to Sept. 2012
Unstable living situations, including Crisis Residential and evictions from several board and care facilities
First Health Home visit was 9/19/12o No hospitalizations of any kind since that dateo Significant improvement in medication compliance o Client told us she wants us to be proud of her…o Regular follow-up with Primary Care Physiciano Stable housing—client lives independently in an apartmento Vision exam scheduledo Routine Health Home lab work revealed undiagnosed UTI and under diagnosed thyroid conditiono Client comes in regularly to OAS for fingerstickso Client and significant other appear happy and contento Client eager to continue Health Home despite change in medical providers
So this lady’s story deserves a song… “Come and Listen to a Story ‘Bout a Gal Named Sal”
Patient Centered Medical Home (PCMH)Cost Report
SJGH-HPSJ Emergency Room Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
SJGH ER (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
400
SJGH ER (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
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HPSJ ER (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
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HPSJ ER (SPD)
PMPM
(In
Dol
lars
)
SJGH-HPSJ Inpatient Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
14000
16000
18000
SJGH IN (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
SJGH IN (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
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HPSJ IN (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
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12000
HPSJ IN (SPD)
PMPM
(In
Dol
lars
)
SJGH-HPSJ Medication Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
SJGH Rx (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
SJGH Rx (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
HPSJ Rx (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
HPSJ Rx (SPD)
PMPM
(In
Dol
lars
)
CMC-HPSJ Emergency Room Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
CMC ER (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
400
CMC ER (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
HPSJ ER (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
HPSJ ER (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
CMC IN (OVERALL)
PMPM
(In
Dol
lars
)CMC-HPSJ Inpatient Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
CMC IN (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
HPSJ IN (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
2000
4000
6000
8000
10000
12000
HPSJ IN (SPD)
PMPM
(In
Dol
lars
)
CMC-HPSJ Medication Costs
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
CMC Rx (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
CMC Rx (SPD)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
HPSJ Rx (OVERALL)
PMPM
(In
Dol
lars
)
Q1 '11 Q2 '11 Q3 '11 Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '120
50
100
150
200
250
300
350
HPSJ Rx (SPD)
PMPM
(In
Dol
lars
)
HPSJ, CMC, SJGH Overall PCMH Costs