Transcript Slide 1
Essentia Health - Ely Clinic
Health Care Home
Essentia Health
Ely Clinic
Age and Disabilities Odyssey
Health Care Homes – Minnesota Style
June 17, 2013
Service Area
Service Area
• Co-located with Ely Bloomenson Community
Hospital (EBCH)
– a non-affiliated critical access hospital
• Service Area = 6 communities, 7 townships
– 12,214 residents + 15,000 seasonal residents
• Closest tertiary care facility is 50 miles away
– Essentia Health – Virginia Hospital, Virginia, MN
Ely Clinic – What We Do
Essentia Health – Ely Clinic (Ely Clinic)
– Sole provider of primary care and specialty
outpatient services
– 7 physicians-including 1 internist
– 2 Nurse Practitioners
• Outreach Services
– Orthopedics, behavioral health, derm, cardiology, OBGYN, general surgery
• 25,000 pt visits a year
• Provide 24 / 7 ER services
• OB-30-60 deliveries a year
The Nature of EH – Ely Clinic
• Professionals
– Live here because we want
to live here
• Community of limited
resources
– 17.4% Poverty
• St. Louis-15.1%
• Hennepin-12.1%
• Ramsey-15.8%
– Highest poverty among
those 6-34 years of age
– Age
• 22% > 65 years of age
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Have been a clinic of “firsts”
– Certified Health Care Home:
2012
– Anticoagulation
– Electronic Health Record-2004
– Integrated Behavioral Health
with Primary Care
– Telemedicine (behavioral
health, wound care, derm)
– DIAMOND
– Current Primary Care
Redesign Pilot Site
– MDH Community Care Team
Site
Our Health Care Home
• Strong Chronic Disease Management Program
– Top in Diabetes Care for NE MN
• “Grow” Nursing-woefully under utilized in Clinic setting
• Clinic Support Clerk-performs non nursing clinical
functions
• Integrate ALL employees in coordination of servicesschedulers, registration
– All staff are on look out for patients in need
• Reserved schedule slots for hospital discharges
• Community Care Team & Community Health Worker
• Strong Infrastructure Means Strong Programs
– Hardest work is developing the infrastructure
Transitions
A. EBCH and Essentia Affiliated Hospital admissions, discharges, and ED admissions
reports to clinic Daily
High acuity patients identified for care coordination and follow up
B. Clinical pharmacy consultation for all hospital discharges with extensive med lists.
C. Nursing Home Discharge
NP provides transitional planning for patient in conjunction with the nursing home social work
staff.
D. Acuity / Severity Report Reviewed Weekly
Identify any patients that may have been "missed" because they are seen outside the local
hospital.
E. Capture of Hospitalizations / ED admits from Non Essentia Facilities---In development
F. Current Care Coordination Patients (includes MSHO & eldercare)
Care coordinators participate in discharge planning for all enrolled patients.
G. Appointment Holds
Each provider has a hold on their schedule each day for discharged patients.
Improving Outcomes Through
Care Coordination
Team Care
Coordination
Identify and
Address Barriers
Provide Connection and
Warm Handoff
Provide Information and Resources
Community Care Team
Patient
Mission: The
Community
Care Team
provides
collaborative
care and
support to
help you
achieve your
wellness
goals.
Vision
• Adequate resources are available to citizens when
needed to help them with their physical health, mental
health and psychosocial challenges.
• Professionals in health, education, and public service are
trained in recognizing when someone is confronted with
such challenges and are prepared to provide an
appropriate response in giving assistance.
• Patients and their supporters have the tools and
resources to help them be a partner in meeting their
wellness, treatment and recovery goals.
Ely Area Community Care Team
• Essentia Health-Ely &
Babbitt Clinics
• Community Hospital
• Nursing Home
• 2 Mental Health Agencies
• 2 School Districts
• County Public Health &
Human Services
• 2 Community/Family
Members
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Free Clinic
Parish Nurse
Community College
Mental Health Clubhouse
Head Start
Hospice & Palliative Care
Local youth & Family Nonprofit
• Local Respite/Caregiver
Support Nonprofit
• Food Shelf
Breaking Down Silos
Monthly CCT Meetings Include Opportunities to:
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Network
Learn About Other Services
Case Management
Develop Tools and Systems for Collaboration
Address Specific Concerns
Work Together on a Project
Improving Outcomes
CCT Model In Action
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Warm Handoffs
Holistic View of Individuals
Strong Community/ Provider Network
Emphasizes Strengths of Each Service
Fills in the Gaps
Supports the Individual and Family
Community Health Worker
• Coordinate non-medical issues that affect health and
wellness of our patients
• Care Manager for patients whose primary needs are not
medical
• Provides support to RN care coordinator for
psychosocial needs of CDM patients.
• Provides information and warm referrals for patients who
need connections to additional resources, but do not
need care coordination
• Provides resource for ALL staff
CHW Certification
• MN certification
• Several schools in person and South Central
College online program
• Opens DHS billable stream for diagnosis based
education
• Education we are excited to explore offering:
– New ADD medication
– Budgeting (making sure you allow funds for good
food, medications, laundry…)
– Organization (state benefit paperwork…)
Ely Clinic’s Internal Model
Essentia Health
Ely Clinic
and Babbitt Clinic
Community
Care
Team
Health Care Homes
Care Coordination Team
•RN Care Coordination
•Community Health Worker
{Behavioral Health Specialist}