essentia health ely clinic age and disabilities odyssey health care homes – minnesota style june...
TRANSCRIPT
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Essentia HealthEly Clinic
Age and Disabilities OdysseyHealth Care Homes – Minnesota Style
June 17, 2013
Essentia Health - Ely Clinic
Health Care Home
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Service Area
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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
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Ely Clinic – What We DoEssentia 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, OB-
GYN, general surgery
• 25,000 pt visits a year• Provide 24 / 7 ER services• OB-30-60 deliveries a year
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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
• 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
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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 services-
schedulers, 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
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TransitionsA. EBCH and Essentia Affiliated Hospital admissions, discharges, and ED admissions
reports to clinic DailyHigh acuity patients identified for care coordination and follow up
B. Clinical pharmacy consultation for all hospital discharges with extensive med lists.
C. Nursing Home DischargeNP provides transitional planning for patient in conjunction with the nursing home social work staff.
D. Acuity / Severity Report Reviewed WeeklyIdentify 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 HoldsEach provider has a hold on their schedule each day for discharged patients.
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Improving Outcomes ThroughCare Coordination
Provide Information and Resources
Provide Connection and Warm Handoff
Identify and Address Barriers
Team Care Coordination
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Patient
Community Care Team
Mission: The Community Care Team provides
collaborative care and
support to help you
achieve your wellness goals.
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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.
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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
• Free Clinic• Parish Nurse• Community College• Mental Health Clubhouse• Head Start• Hospice & Palliative Care• Local youth & Family Non-profit• Local Respite/Caregiver
Support Nonprofit• Food Shelf
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Breaking Down Silos
Monthly CCT Meetings Include Opportunities to:• Network• Learn About Other Services• Case Management• Develop Tools and Systems for Collaboration• Address Specific Concerns• Work Together on a Project
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Improving Outcomes
CCT Model In Action • Warm Handoffs• Holistic View of Individuals • Strong Community/ Provider Network• Emphasizes Strengths of Each Service• Fills in the Gaps• Supports the Individual and Family
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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
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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…)
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Ely Clinic’s Internal Model
Essentia Health
Ely Clinic
and Babbitt Clinic
Health Care Homes
Community Care Team
Care Coordination Team
•RN Care Coordination
•Community Health Worker
{Behavioral Health Specialist}