Developing Your “Medical Neighborhood” · PDF file9/8/2011 · What is the Medical Neighborhood? • All health care systems that come ... Case Study • Pharmacist at ABC Pharmacy

Developing Your “Medical Neighborhood”g

Joann SciandraAugust 22 2012August 22, 2012

Agenda

• What is the “Medical Neighborhood” ?

• Key components of a Medical NeighborhoodMedical Neighborhood

• Strategy development

Geisinger Health System - ProprietaryNot for reuse or distribution without permission

What is the Medical Neighborhood?

• All health care systems that come into contact with the patient/family

– Nursing homesNursing homes– Emergency Departments– Hospitals

Specialists– Specialists– Home health agencies– Community agencies– Pharmacies


Primary Care Team taking 24/7 - 360 degree accountabilityy


Forging Partnerships with Stakeholders

• Education – Discuss purpose of medical home– Discuss ways to partner in transitions, etc. – Discuss the flow of information between the groups

• Role of Case Manager – Embedded in the practice– Extension of the physician practice– Brief overview of what they do– How to contact: direct phone line/faxHow to contact: direct phone line/fax– Review acute care protocols

• Communication


Communication|

Several Key Strategies Necessary

• Identify care systems creating the most value

• “Education Awareness Plan”

• Site visit– May take several to solidify the partnership– Medical Director & DON of the preferred SNFMedical Director & DON of the preferred SNF

• Develop partnership

• Steerage

• Nurture relationship


• Nurture relationship

Baseline Assessment


Points to Consider with Hospitals

• Identify which hospitals are utilized by the practice

• Do the PCP’s provide inpatient coverage?If not, who provides inpatient coverage?

• Hospitalist service

• Connectivity to the inpatient providers

Is there access to inpatient census list?p• How is practice notified of admission

/discharges

• Timeliness of discharge summaries

Will likely need to visit many different

Timeliness of discharge summaries

Connectivity to inpatient case managers?


y ystakeholders and visit often

Emergency Department

• Identify those ED’s utilized by the practiceby the practice

• Does the practice provide ED ?any ED coverage?

• Is the practice notified when patients have been treatedpatients have been treated in the ED?

– If not is there any opportunity to identify when a visit has occurred– If not is there any opportunity to identify when a visit has occurred (for example – does the ED send lab or x-ray reports?)


Case Study

• 80 y.o. female• Taken to ED by daughter• Difficulty getting around last few weeks; not as active

f• Reports her falling• Prior level functioning: ambulatory with straight cane• Socialized frequently: church and friends• Socialized frequently: church and friends• Medical workup completed – negative• Inpatient CM reaches out to Medical Home CMInpatient CM reaches out to Medical Home CM• Medicare Advantage plan• Plan: Admit to SNF for therapy; discharge to home


Home Health

• Identify those agencies preferred by practice

• What services are provided?Therapies such as PT OT Speech– Therapies such as PT, OT, Speech

– Respiratory, IV’s, Hospice– Disease management

• How do those agencies communicate with the practice?p

• Access & service practicesF id ft ?


– Friday afternoon?

Home Health Agency Assessment

Home Health Agency Assessment

Agency Name Agency AddressAgency Name _________________ Agency Address____________________

Main Contact _________________ 2nd Contact_______________________

Medical Director ______________ Social Worker______________________

Services provided:__ Peds ___ Hospice, if no who do they use? ___________________________ Physical Therapy (employed or contracted/ if contracted what time visits?____________________________________________________________________ OT ___Speech Therapy ___ Wound Care Nurse__ IV Program ___ DM Nurse ___ RD on staff

Established Programs i.e. CV/Resp/ etc: _________________________________

_________________________________________________________________

Home Monitoring / TeleHealth: ________________________________________


Ability to staff cases same day? ________________________________________

Case Study

• 45 y.o. male post MVA• Bed ridden at home due to pelvic and multiple fractures• Patient states he has pain in left calf; may be red

f• Wife is at work• CM discusses case with PCP• CM contacts Superior Home Health requesting same day• CM contacts Superior Home Health requesting same day

visit as well as mobile x-ray unit for doppler study in home• Superior sends nurse; doppler study is negativep pp y g• Nurse discusses with PCP• Continue current plan


Community Pharmacies

• Identify services pharmacy provides

– Home delivery– Filling pill boxesFilling pill boxes– Educational programs– Generic vs brand

Medication reconciliation– Medication reconciliation– Coverage gap help


Case Study

• Pharmacist at ABC Pharmacy contacts medical home site to speak to CM

• Informs CM that Mrs. Smith has not picked up her medications in two monthsmedications in two months

• CM reaches out to Mrs. Smith who reports she is not feeling well, not sleeping and more short of breath than usual

• Confirms that Mrs. Smith has not been taking medsM S ith t PCP f ffi i it• Mrs. Smith to PCP for office visit

• Lasix 40 mg IM• Collaborate with Mrs Smith on medication usage issues


Collaborate with Mrs. Smith on medication usage issues

Durable Medical Equipment

Identify providers that can meet your needs

– Special equipment• Vent management, bi-pap, apnea monitors

– 24/7, 365 day availability

– Disease management programs


Ancillary Services

• Radiology, lab, etc

• AccessSame day– Same day

• “One-stop shop”

• Free standing radiology is less costly

• Timeliness of communication with patient and practice


• Mobile services

Specialists

• Are there any specialty services at the site?services at the site?

• Who are the preferred specialists?

• What process do the PCPs use to refer to specialists?– Do they have any quality or y y q y

outcomes data for specialty groups?

• Are there any specialty gaps?– Types of specialists– Access issues– Communication issues


– Communication issues

Post Acute Options

• Approximately 30% of Medicare patients need post acute care– Skilled Nursing Facility– Intermediate Care FacilityIntermediate Care Facility

(Custodial Care)– Swing Bed

• PACE programs

• Assisted Living/Personal Care


Skilled Nursing Facilities

• Identify SNFs used by the tipractice

• Proximity to site• Does the practice provide

any coverage /medical directors

• Capability for acute care

• Availability for evening/weekend admissionsy g

• How is information from the SNF received (admissions, discharges, interim orders)


Skilled Nursing Facility (SNF)

• A skilled nursing facility provides 24-hour inpatient care

• Includes physician, skilled nursing, dietary, rehab services, pharmaceutical services and an activity program


Intermediate Care Facility (ICF)

• Intermediate care provides inpatient care to patients who have need for nursing supervision but not continuous nursing care

Considered primary residence with patient responsibility• Considered primary residence, with patient responsibility for room and board

• Part B (therapy services) provided by Medicare based onPart B (therapy services) provided by Medicare based on medical necessity


Assisted Living

• Suitable for individuals who need very little daily care– Assistance with medication or bathing, food preparation, etc.

• Dietary restrictions difficult based on common foodDietary restrictions difficult based on common food preparation and dining atmosphere (e.g., low salt diet)

f ( )• Part B benefits available (rehab, DME) based on medical necessity


Questions and Discussion

Documents

Developing Your “Medical Neighborhood” · PDF file9/8/2011 · What is the Medical Neighborhood? • All health care systems that come ... Case Study • Pharmacist at ABC Pharmacy