dr. steven roth jennifer nappi rn ncm thundermist health center
TRANSCRIPT
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Dr. Steven RothJennifer Nappi RN NCM
Thundermist Health Center
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What We Hear Patients WantRelief From What Ails
- Our patients want to be healthy, but…- Easier treatment is better, e.g.
The Silver BulletEpedient ( fewer doses, shorter courses)
Convenience- Right time- Right place- No wait
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What We Hear Patients WantInstant 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.
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What Patient a Patient Centered Medical Home Offers
AccessAffordabilityAppropriate Diagnosis and TreatmentEducation
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What Thundermist Has DoneOpen Access – doing today’s work todayExtended hours: three evenings until 8pm,
Saturday hours at all sitesconstruct sliding scalesoffer discounted medication via 430B grant
with CVSComprehensive servicesIncorporate NCMs in each office
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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
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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
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New Work Flow
NCM follow-up on Inpatient visitsRNs follow-up on ER visitsFront line staff follow-up on Urgent careDeveloped Patient education materials to be
mailed to all patients - Appropriate Use Packages for ED/UC visits
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Use of template
Tracking patient ER/Hospital visits
Tracking type of follow-up
Produce data for insurance companies
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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
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Steps takenTHC – 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
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ChallengesStrengthen established hospital relationshipsEstablish relationship with Kent County for
WW office (in progress)Continue to assess & revise work flow as
needed to improve patient careWork in concert with insurers to improve
patient education on the patient’s plan of care
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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