Progressive Visits - Oregon Primary Care Association

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Progressive Visits - Oregon Primary Care Association
Knowing your population and
providing access to care in an
advanced care model
______________________________________________________________________________________________________________________________________________________
Oregon Primary Care Association
July 21, 2014
What is our aim?
• Provide the right care, at the right time, in the
right place by the right people
• Engage and “own” the target population
• Gain an understanding of the individual needs
and tailor services to those needs
• Optimize our care team resources
Defining Access
For whom?
To what?
For what purpose?
Where?
How?
When?
If you were a
commercial company
what would you do?
As a Care Organization
what do you need to do?
Existing Patients
Collaborative Care: Proactively engaging patients
Gather Patient Experience
• Health Risk Assessment
• PAM/ HARMS-8
Gather Clinical Data
Triple Aim
• Proactive outreach
phone/mail/ text
• IVR Calls
• Remote monitoring
• Improved Population Health and
Well Being
• Excellent Patient Experience
• Team Engagement & Retention
• Reduced Cost
PREPARE
Provide Team Care
Follow Up
•
•
•
•
Health (Patient) Portal
Email/Secure Message
Nurse Advice Call Lines
Call Center
ENGAGE
•
•
•
•
•
Behaviorist
Medical Assistants
Nurse/ Complex Care Manager
Pharmacy Visits
LCSW
Innovate on the Provider Exam
CONNECT
Community Linkage
• On demand education
programs
• Care (Health) Navigators
• Community-based delivery
• Health Fairs
Connect to Peer Support
• Lay-led groups
• Web-based support
• Promotoras
•
•
•
•
•
•
•
•
•
Locums
Group Visit
Group On-boarding
Home Visit
Virtual Visit
Mobile Clinic
Fast Track Urgent Care
Urgent Care
Extended Hours
As a Care Organization
what do you need to do?
New Patients
Reaching All:
Considerations for New Patients
Population
Stratification
(New Mexico)
Orientation
Clinic
(Chinatown
Public Health)
Group
On-Boarding
(Centering
Pregnancy)
Progressive
Visits
(Virginia
Garcia)
Expand faceto-face access
using
team-based
care
(Bodenheimer)
“If you always do
what you’ve
always done,
you’ll always get
what you’ve
always got.”
- Henry Ford
New partners or team members
supporting patients…
•
•
•
•
•
•
Email/secure message
Text
Phone calls
Virtual visits
Home visits
Nurse call lines/advice
lines
• Web-based peer support
In their
homes?
• MA specialist
• MA Health Coach
• Nurse complex care
manager
• Clinical Pharmacist
• LCSW
• Group Visits
• Care coordinator
In the
practice?
•
•
•
•
Health fairs
Care navigators
Peer led classes
Community based care
delivery
• Mobile clinics
• Promotoras
• Urgent Care
In the
community?

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