Deizel Sarte, Chief Operations Offi cer June 24, 2015

ACA-PCMH-TBC and The Medical Assistant-Health

Coach Initiative

Today’s Agenda

NCHS-The OrganizationACA: Affordable Care ActWhere NCHS Fits in This JourneyPCMH: Patient Centered Medical

HomeThe Medical Assistant Health Coach

Initiative

NCHS-The OrganizationEstablished in 197111 Sites

MedicalDentalWHS

59,262 Patients16,194 New Patients in 2014242,233 VisitsAll Primary Care Clinics NCQA PCMH

Recognized at Level 3 since 2012

Historical Perspective

ACA

PPACA: Patient Protection and Affordable Care Act Signed into law: March 23, 2010

EXPANDED COVERAGE

Medi-Cal Expansion (Also known as Medicaid) Medi-Cal was expanded beginning January 2014. Medi-Cal became available to adults under 138% of the

federal poverty level who are citizens or legal California residents for 5 or more years. For example, under 2011 FPL levels, a single individual making less than $1252 per month, or a couple making less than $1,691 per month, would be eligible.

NCHS At The ForefrontStrategic Planning Process

SWOT AnalysisInternal and External ScanBoard of Directors and the Executive TeamCommunicating the PlanImplementing the Plan

Patient Centered Medical HomeWhat is PCMH?A PCMH facility is a health care setting that facilitates

partnerships between individual patients, and their personal clinicians, and when appropriate, the patient’s family.

Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

There is a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.

Patient Centered Medical HomePCMH

Why PCMH?Health care quality and access are

suboptimal, especially for minority and low-income groups

Health care in the community is fragmentedPoor health outcomesIncreased costsPoor morale amongst primary care healthcare

professionalsSupports IHI’s Triple Aim

Medical Assistant Health Partners Initiative

Received a grant from The California Endowment to establish a MA Health Coach Program Curriculum

A collaborative between UCSD, FHCSD, NCHS and San Diego Mesa College

Grant provided:Funding to create a Health Career Ladder

ProjectFunding to create a community health

workforce development partnership

Medical Assistant Health Partners Initiative

Started in 2013First year: 2 cohortsSo far: 7 cohort16 sessions

Train the “Mentors”General Class81 Medical Assistants graduated

Medical Assistant Health Partners Initiative

The Curriculum:8 week program with two 4 hour sessions

per week taught by core instructor groupCore instructor group comprised of RNs

and health educators with expertise in area of focus

Comprised of theoretical and clinical skills modules with focus on family medicine

Available for review http://ca-hwi.org/

Medical Assistant GraduatesConsidered a promotionAble to trigger “orders” from the “Pre-Visit

Protocols”40 year old female: Screening mammograms50 year old: Colon cancer screening

Establish a care plan with patients through motivational interviewing, teach back method, etc

Provide health education from a structured program

Reach out to patients from a disease based registry for coordination and follow ups

Loma Alta Implemented TBC Q4 2013 >> Q2 2014

75

80

85

90

95

100

Medical Core Experience Scores by Quarter

Q3 2013

Q4 2013

Q1 2014

Q2 2014

Chronic Disease Management - Diabetes 2013 to 2015

2013 2014 201520.00%

22.00%

24.00%

26.00%

28.00%

30.00%

32.00%

34.00%

A1c Poor Control - Loma Alta

 

Prevention Improvement Team Based Care Implemented in 2013 to Current

2013 2014 20150.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Colorectal Screening - Loma Alta

Questions and Discussion

For details, please contact:

Lisa McGerald, NCHS Director of Nursing

Email: Lisa.McGerald@nchs-health.org