Transcript Slide 1

Dr. Steven Roth
Jennifer Nappi RN NCM
Thundermist Health Center
What We Hear Patients Want
 Relief From What Ails
- Our patients want to be healthy, but…
- Easier treatment is better, e.g.
The Silver Bullet
Epedient ( fewer doses, shorter courses)
 Convenience
- Right time
- Right place
- No wait
What We Hear Patients Want
 Instant Information
- X- Ray
- Rapid tests – flu, mono, strep, urine, HbA1C, pregnancy,
lipids, etc.
- Answers to all their questions
 The latest and the greatest:
- what they learn from the media (drug ads, doc shows,
news reports)
- one myth perpetuated by the present healthcare system:
the higher the tech the better the care.
What Patient a Patient Centered
Medical Home Offers
 Access
 Affordability
 Appropriate Diagnosis and Treatment
 Education
What Thundermist Has Done
 Open Access – doing today’s work today
 Extended hours: three evenings until 8pm, Saturday
hours at all sites
 construct sliding scales
 offer discounted medication via 430B grant with CVS
 Comprehensive services
 Incorporate NCMs in each office
For Hospital Inpatients (IP)
 Collection of daily admission and discharge data by
our NCM’s (South County & Woonsocket)
 THC – South County physician does hospital social
rounds connecting with our sickest patients and
tracking of admissions and discharges
Hospital IP continued
 NCM follow up on labs & imaging studies the PCP
received which is some cases is the first indication of
ED/IP admit
 Beginning relationships with SCH discharges case
managers
New Work Flow
 NCM follow-up on Inpatient visits
 RNs follow-up on ER visits
 Front line staff follow-up on Urgent care
 Developed Patient education materials to be mailed to
all patients - Appropriate Use Packages for ED/UC
visits
Use of template
 Tracking patient ER/Hospital visits
 Tracking type of follow-up
 Produce data for insurance companies
Preliminary data
 Tracking NHPRI ER/Urgent care visits for 2 years
 ER visits - decrease
 Inpatient stays – about the same
 Urgent care visits – about the same
Steps taken
 THC – South County has established relationships
with hospital care managers
 THC – South County & Woonsocket Receive/can
access daily ER visits/inpatient admits
 THC Quality Management Team - Reassess & develop
work flow based on clinical data
Challenges
 Strengthen established hospital relationships
 Establish relationship with Kent County for WW office
(in progress)
 Continue to assess & revise work flow as needed to
improve patient care
 Work in concert with insurers to improve patient
education on the patient’s plan of care
Challenges continued
 Process to expedite DI & lab tests from the office
 Facilitate process to send visit information to
specialists
 Educate the patient, staff, general community & the
medical community on the role of primary care giver
as the orchestrator of the patient’s health care