Practice Transformation

Thriving in a Time of Change

Stephen Weeg

A fundamental redesign of the organization’s:

Mission, vision, and strategic goals Organizational responsibilities and roles Policies and procedures Care processes Use of data Relationships with patients and community

Transformation

Six clinics (1 urban, 5 rural) in southeast Idaho

located within a 50 mile radius 5 of the 6 have a single medical provider each

day; Pocatello has 3-4 providers per day. 9,000 patients with 31,000 visits annually 45% Uninsured Annual budget: $3.5 million Migrant and community health center; 2 sites

serve over 60% Hispanic patients

Health West Background

Strategic Position

Patient Care

Staff Satisfaction & Empowerment

Financial Advantage

Why PCMH

Meeting HRSA Program Requirements UDS Clinical and Financial Indicators Seeing patients Fiscal stability Meaningful Use, Affordable Care Act & politics Changing healthcare environment Tyranny of NOW

Challenges

Before PCMH

Safety Net Medical Home Initiative: July 2009 Team-based care & huddles: 2009 EMR: December 2009 Empanelment, Data, Position redefinition: 2011 New mission: 2011 NCQA Site Recognition: March – July 2012 Embed and strengthen roles: 2012 Meaningful Use Incentive: 2012

Health West Journey

After PCMH

56 yo diabetic female suffering from obesity

and depression. She had a poor self image and lacked motivation to make changes. Her primary care provider reviewed with her all aspects of her current situation including her current lab work, medications, goals, feelings towards her current health, and more…”

Patient Impact

Over the next two months, and with a little

encouragement, she was able to do the following: Meet with our health educator and mental health

counselor Adjust to a better medication regimen Begin a regular exercise program and improve her

diet, helping her shed 6 pounds, have more energy throughout the day, have longer, more restful sleep, and improve her mood

Move forward in her life with help of the counselor

Patient Impact

“The very best part of the Patient Centered

Medical Home is that the patient gets, better, more effective care than ever before, and the provider, because everyone is working as a team, can deliver this care with even less effort than before.  More for less—you can’t beat that!” Mark Horrocks, MD, Medical Director

Provider Impact

“With Team-based care, we can better anticipate our

patients’ needs when it comes to medication refills, scheduling lab work, and setting up for an office visit, etc. Plus, our patients’ needs are better served. I also feel that I can work more comfortably with my provider.” RH, LPN

“Team-based care helps our patients by giving them a support group and the exceptional care they need. They are always followed up with and have a medical team they can count on to help with their needs. “ MP, Receptionist

Staff Impact

Elements of Success

Vision

Focus

Team Focus

Technical Assistance & Support

Humor

Organizational Engagement & Leadership

Passion

Persistence

Data

This is the kind of care that wewould

want for ourselves and for the persons we know and love. It is the

right way to care for the whole person.

Why Become a Patient Centered Medical Home?