Yakima Neighborhood Health Services

YNHS 2012• 5 sites -- 64,580 encounters• Health Coverage

• 33% uninsured• 53% Medicaid

• Ethnicity• 66% Hispanic

• Living in Poverty= 74%

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Yakima County Profile• Health Coverage

• 15% uninsured• 13% Medicaid

• Ethnicity• 40.8% Hispanic/Latino

• Living in Poverty = 16.1%

Southeast Community Center Central WA Comp Mental Health

Neighborhood Connections @Triumph Treatment Services

Homeless Resource Center- Partnership w/ Homeless Network

YNHS – Sunnyside Campus

Supportive Housing Programs – Private Landlords, YWCA, Triumph, Housing Authority

YNHS Satellites

5 years ago …

• Successfully passed 3 Joint Commission surveys• All reporting was EPM driven – diagnoses and

procedure codes• Diabetes Collaborative (PECS !)• Evidence Based clinical outcomes and population

management

• Health Care for the Homeless expanded “patient centered care” to include recuperative respite and housing

• EHR was fully implemented for medical services, but learning curve was still steep;

Journey to PCMH

• PCMH work group established -- COO, CMO, QI Coordinator and Medical Assistant Supervisors

• Goal -- showcase current integration and patient-centered care to obtain Level 3 Recognition. “Play on our Strengths”.

• MA’s “lead the horse to water” in DM templates and medication reconciliation (open the templates as part of patient intake).

• Strengthen EHR report-writing, and ability to know what matters.

5 years later…

• NCQA- Level 3 Recognized (2008 Standards) for 2 sites in June 2011.• Applying in June 2013 for 4 sites ((2011 Standards)• Open templates,• Sharing across programs— dental, behavioral health, outreach, public

health• allergy lists, medication lists, histories, chronic problems, vitals

• QI Projects: Meaningful Use, Immunization Rates, Cervical Cancer Screening

• No noticeable changes in overall patient satisfaction ratings. New questions added related to self-management support and safety practices with high ratings received. (4.86 and 4.96, respectively, out of 5)

• Staff satisfaction higher than average CHC’s (Staff Pulse)• 68 % of medical/dental patients leave with an individualized Patient

Plan

MA Vitals Report

SSRS report that allows us to monitor completion of vitals by medical assistants.

Pre-visit Summary

Our “virtual” huddle – automatically emailed to provider and team for next day’s appointments.

Challenges & Obstacles We’ve Overcome

Challenges• Balance between

population management and individual care

(resources)• Creating maximum

access AND connection to one PCP

Lessons Learned• Providers will use the

template if it is there for them

• A team approach to care is better for the patient and better for the team