Transcript Tale of Two Jeffery’s - Florida Hospital Association

Patient Centered Medical
Home at a CHD
Okaloosa County Health Department
Opportunity Health Clinic
Opportunity Health Clinic- Patient Centered Primary
Care at the Okaloosa County Health Department
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The Patient Centered Medical Home (PCMH) is an
approach to providing comprehensive primary care for
children, youth, and adults in a setting that facilitates
partnerships between individual patients, and their
personal physicians, and when appropriate, the patient’s
family.
The American Academy of Family Physicians,
American Academy of Pediatrics, American College of
Physicians, and the American Osteopathic Association
have agreed on joint principles of the PCMH and
programs to assure quality care within this model is
available
Joint Principles of the Patient Centered
Medical Home
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Personal Physician -each patient has an ongoing relationship with a
personal physician trained to provide first contact, continuous and
comprehensive care
Physician directed medical practice - the personal physician leads a team
who collectively take responsibility for the ongoing care of patients
Whole person orientation - responsible for all health care needs personally
or by arrangement through all life stages and for acute, preventive, chronic,
and end-of-life care
Coordinated and integrated care - across complex health system elements
Quality and safety - Evidence-based medicine, use of IT, voluntary
recognition process, patient participation in QI
Enhanced Access - through open scheduling, expanded hours and new
communication options
Payment recognizes the added value of the medical home concept
Okaloosa CHD - PCMH
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PCMH
For persons living with HIV/AIDS for 9 years
 For uninsured individuals for 1 year
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Linkage to a PCMH for Medicaid and uninsured
has the potential to reduce ambulatory care
sensitive hospital admissions and readmissions
HIV/AIDS PCMH- Examples of
Long term success – 4 patients
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Enrolled in program for 8-9 years
Male/Female ages 38-54 yrs
Besides HIV have 7-13 other serious diagnoses
Average number of medications: 13 (7-19)
3 employed, 1 disability due to stroke
1 uninsured small business owner, 2 TPI, 1
Medicaid/Medicare
ALL CD4 >200; VL undetectable; no hospitalizations
in at least the last 2 years
Michael: IDDM since age 9 yrs; lost
Medicaid, now age 21 yrs
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Prior to enrollment in OH
clinic
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Repeated hospital admissions for
DKA
Inability to obtain Levamir brand
insulin- using 70/30 because of
cost
No diabetic test strips or
nutritional counseling
No access to physician care
No lab testing access
Fasting glucose 589 mg/dl
Wt 116 lbs Ht 5’ 10’’
Couldn’t hold a job due to illness
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Enrolled in OH clinic for 2
months
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No admission since enrollment
On Levamir insulin with much
improvement in glucose control
Completed diabetes education
class on Day 1 of enrollment
Tests sugars daily
Seen frequently by OH provider
and has phone contact with nurse
HgbA1c = 8% and average
glucose now 120 mg/dl
Wt gain of 13 lbs in one month
Now holds full-time job
The POWER of Patient –Centered Primary
Care to Reduce Hospital Readmissions
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Excellent primary physician care
Compassionate nurse case management
Access to medication & assistance with
medication adherence
Nutrition counseling
Behavioral health care
Coordination of specialty care & other care
Continuity between inpatient & outpatient care
Other resources in Okaloosa County to
decrease hospital readmission
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Hospital-based coumadin clinics post discharge
Referral to FQHC or CHD clinics
Medicaid providers for children
Hospital-based urgent care clinics
Non-hospital based urgent care clinics
Other ideas to reduce readmissions
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Assure there is communication between inpatient and
outpatient providers especially when inpatient care is
provided by hospital employed physicians
Hospitals provide means for patients/families to have
questions answered following discharge with goal of
early intervention to prevent readmission
Hospitals consider routine immediate post-discharge
calls (24-72 hrs) to check on status of patient
Opportunities
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Hospitals working with CHDs providing
primary care
Targeted use of laboratory, radiology services,
and other hospital resources to support patients
in care in medical homes
Enhanced communication as care networks are
stabilized and providers become known to
hospital staff