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Primary Care's Role in Reducing Unnecessary Hospital visits and Re-admissions within 30 Days

Session #QU4, February 19, 2017

Jim Olver and Rinku Singh, Horizon Family Medical Group

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Speaker Introduction

Jim Olver, CEO,Horizon Family Medical Group

Rinku Singh,Head of IT,Horizon Family Medical Group

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Conflict of InterestJim Olver, CEO,Horizon Family Medical Group

Rinku Singh,Head of IT,Horizon Family Medical Group

Has no real or apparent conflicts of interest to report.

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Conflict of InterestJim Olver,

Rinku Singh,

We have no conflict of interest to report.

Salary:

Royalty:

Receipt of Intellectual Property Rights/Patent Holder:

Consulting Fees (e.g., advisory boards):

Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g.,

speakers’ bureau):

Contracted Research:

Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual

funds):

Other:

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Agenda

• Brief background on Horizon Family Medical Group

• Patient Engagement strategies

• Hospital 30/90 day Readmissions

• Reducing Costs

• Importance of building in workflow efficiencies to increase face to face time

with patients

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Patient Engagement

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Patient Engagement

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Patient Engagement

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Hospital 30/90 day Readmissions

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Increasing Face To Face Time With Patients

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Reducing Costs of Medicine

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Learning Objectives

• Leverage Health IT to identify patients at risk for a hospitalization or

readmission

• Identify EHR-enabled standardized care bundles that more effectively

manage chronic disease patient outcomes

• Align care delivery with CMS MIPS/APM requirements

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How Benefits Were Realized for the Value of Health IT using the Huddle Report

• The Huddle Report concept was the vision of the CEO and created internally by the IT team.

• Office staff uses the Huddle Report to prep for patient visits in an efficient manor and it allows the visits to be through, improving patient outcomes and reducing duplication of testing.

• Providers get a one page overview of the patient and all the care opportunities are in a one page summary, listed as actionable items. It saves providers time from flipping through many different screens, trying to remember all the preventative care measures for the patient.

• With the Huddle, we were able to increase overall Group efficiency in every aspect of the practice, increase patient outcomes, reduce costs, which led to improvement in financial returns across all incentive programs.

• It is changing the Groups culture from volume to outcomes based care.

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A Summary of How Benefits Were Realized for the Value of Health IT• Foundation to success is a good EMR, we use eClinicalworks and it helps our group

achieve our goals in an efficient manor.

• Being able to extract data is important but if you are not able to turn that data into actionable items, it will not serve any purpose to a group.

• Use of technology to eliminate manual workflows

• Weekly updates to providers and staff on group goals

• Importance of behaving as one large Care Team to improve patient satisfication

• Education and Self-Management goals for patients.

• Building a sustainable model to achieve the high levels of outcomes

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Questions

• If you have any further questions, please feel free to contact us through

email at rinku.singh@hfmg.net

• Please complete online session evaluation

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