Mariposa Community Health Center -

Location

Santa Cruz County Demographics

Population (2012): 48,088

Uninsured (2012): 10,734 (26.2%)

# below 200% of FPL: 24,765 (51.5%)

Hispanic: 84%

Unemployment: 20.8% (Aug. 2013)

Mariposa Community Health Center

Five clinical delivery sites

Eight locations

Medical Specialties – Peds, Internal Medicine,

Ob/Gyn, Family Medicine

Dentistry

Radiology (digital mammo./x-ray, ultrasound)

Lab

Pharmacy

Telemedicine

Integrated Behavioral Health

Health and Wellness Department

Calendar Year 2012

Annual Budget - $20 million

235 employees

17 medical providers

5 dental providers

21,214 patients (44% of County)

65K medical and 15K dental visits

2,735 behavioral health visits

64,000 prescriptions filled

2,500 WIC clients

Mariposa Community Health Center

Population – based Care Management

Standard Pop – based Care

Management Same day access

Preventative Care Reminders

Hospital Discharge Follow Up

Post ED Visit Follow Up

Visit planning

No-show follow-up

Referral tracking

Chronic disease classes

Care Optimization ProgramStandard care management strategies,

PLUS

MCOP Team

− PCP

− Clinical Interventionist (FNP)

− Medical Assistants

− Patient Navigators (CHW’s)

− Patient Care Coordinator

− Paramedic (as indicated)

Mariposa Care Optimization Program

MCOP

Hospital Admits/Readmits

ED Visits

High Risk Cohort (Health Plans/ACO)

Clinical Indicators

(EHR)

Rio Rico Fire Department

Referrals

PCP Referrals

Care Optimization Team

Primary Care Provider (MD/NP)Clinical consultation

Enhanced access with same day appointment availability

Identify specific patients from panel that face unusual challenges

Clinical Interventionist (FNP) In home patient clinical assessment

Medication reconciliation

Medication adherence

Maintain close consultation with PCP

Medical Assistants Improve compliance – complete identified clinical tasks via

standing orders

Contact patients post hospital/ED discharge to schedule PCP appt. as indicated

Contact all MCOP member “No-Shows” for follow-up

Facilitate contact/communication with patients

Care Optimization Team, Cont.

Patient Navigators (CHW’s)Home assessment for fall risk, food shortage, clothing

shortage, medication adherence, asthma trigger abatement, utility audit, etc.

Education with patient/family re. diabetes, hypertension, asthma, CHF, nutrition, fitness, etc.

Assist patient/family with self-management plan and with logistics for specialist appointment, etc.

Assist patient/family Connect patient/family with supportive community resources, e.g. community food bank, eligibility assistance ACA/AHCCCS/MHP, DES, SNAP, etc.

Socialization/emotional support – build trust, assist with isolation and loneliness

Document in NextGen

Care Optimization Team, cont.Patient Care CoordinatorUtilizes i2i, a population health management system,

to pull data from NextGen to support proactive management of patient populations and identify missed opportunities for visit planning.

Presents care summary at clinical team meetings

Rio Rico Fire Dept. Community Paramedic ProgramIdentify high utilizers of EMS services

Meet with MCOP team for care development

Scheduled home visits for patient clinical assessment, home safety survey, asthma triggers, food availability, etc.

Outcomes

U of A Prevention Research Center - model

design and evaluation

AHCCCS plans (UFC and United Community

Plan) on care management strategies and

evaluation

Az Connected Care for Medicare/United

Medicare Advantage and commercial plans

Dashboard of key clinical indicators