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Overview of Primary Care Coalition Programs and Activities


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Title: Overview of Primary Care Coalition Programs and Activities

Overview of Primary Care CoalitionPrograms and
Primary Care Coalition Vision and Mission
  • PCC Vision All Montgomery County residents will
    have the opportunity to live healthy lives.
    Montgomery County will be the healthiest
    community in the nation and a model for providing
    access to high quality and efficient care for
  • PCC Mission The PCC will lead the development
    and coordination of a community-based health care
    system that strives for universal access and
    elimination of health disparities for all county

Primary Care Coalition Organizational Structure
  • The Center for Health Care Access develops and
    maintains care delivery networks for adults and
    children a pro-bono specialty care network an
    information and referral service and oral
    health, behavioral health, and health care for
    the homeless projects.
  • The Center for Medicine Access assures that all
    patients have access to generic and brand
    medicine through a point-of-care distribution
    system, enrollment into the pharmaceutical
    industrys patient assistance programs, and
    through a pharmacy-benefit management program.
  • The Center for Community-Based Health Informatics
    designs and supports a Web-based, shared,
    open-source electronic medical record for
    Montgomery County clinics and supports a variety
    of health information exchange (HIE) activities.
  • The Center for Health Improvement seeks to
    improve quality, efficiency, equity, and outcomes
    for children and adults.
  • The Center for Childrens Health is a
    public/private partnership program, The Tree
    House Child Assessment Center, for abused and
    neglected children.

Primary Care Coalition Governance
  • The PCC was founded in 1993 as an independent,
    non-profit organization, governed by a 20-member
    volunteer Board of Directors with community
    representation and expertise in health policy and
    administration. Beyond policymaking and
    financial oversight of the organization, the
    Board of Directors is engaged in the advocacy and
    outreach, program development, and fundraising

Carol W. Garvey, MD, MPH Marilyn Hughes Gaston,
MD Alan S. Gregerman, PhD Arva J.
Jackson Tristram Kruger, DDS,
MS Marion Ein Lewin John G.
Luke, III Kevin J. Mell
Jorge Ribas, DVM
Jeffrey M. Rubery
Roberta Milman, Chair Richard Bohrer, Vice Chair
Wilbur Malloy, Secretary Steve Braunstein,
Treasurer Steven Galen, President Horace W.
Bernton, MD Betsy Carrier
LeCount R. Davis Charles H. Fleischer,
JD Hiawatha B. Fountain, PhD
What does the PCC contribute?
  • The PCC builds, energizes, and maintains the
    collaborative effort to improve the health of
    low-income, uninsured, and ethnically diverse
    Montgomery County residents. The PCC aligns,
    leverages, and enhances public and private
    interests, resources, and expertise.
  • The PCC functions as an
  • Advocator
  • Convener
  • Integrator
  • Innovator
  • Capacity builder
  • Gap filler
  • Contractor
  • Contract administrator

PCC Revenues County vs. Other
Center for Health Care Access
Center for Health Care Access Mission Statement
  • The PCC Center for Health Care Access (CHCA)
    plays a strategic role in planning and
    implementing a comprehensive health care system
    for Montgomery County residents who lack health
    insurance and the resources to pay for care.
  • Montgomery Cares
  • Health Care for the Homeless
  • Oral Health Pilot
  • Behavioral Health Pilot
  • Information and Referral
  • Project Access/Specialty Care
  • Care for Kids
  • Case Management
  • Specialty Care/CMS

Montgomery Cares
  • Montgomery Cares is a public/private partnership.
  • This unique local health care initiative supports
    the development of an integrated health care
    network that will provide high quality health
    care to 40,000 uninsured Montgomery County adult

Montgomery Cares Model
How It Works
  • Montgomery County Council is committed to the
    concept of Universal Health Care.
  • DHHS establishes program policy and leads program
    planning efforts.
  • Montgomery Care Advisory Board recommends policy
    and participates in planning process.
  • PCC implements the program and manages operations
    and infrastructure development.
  • Community-based clinics are responsible for
    providing care to uninsured patients.
  • Hospitals support primary care service providers
    with community benefits and partnerships.
  • Community-based partners provide support services
    and population access/expertise.

Participating Primary Care Clinics
Program Eligibility And Continuity
  • Montgomery Cares
  • 18 or older
  • Uninsured
  • 250 Federal Poverty Level
  • Care For Kids
  • 0-18
  • Not eligible for MCHIP or other Federal or State
  • 250 Federal Poverty Level

eligible until 19th birthday
Unduplicated Clients
FY08 Demographics Age and Gender
Does not include data for CCI.
Does not include data for CCI and Marys Center.
FY08 Demographics Race and Ethnicity
Does not include data for CCI.
Does not include data for CCI.
Rand Evaluation Report February, 2007
  • Serving the Underserved An Evaluation of the
    First Year of the Montgomery Cares Program
  • Challenges
  • Access
  • Capacity
  • Quality of Care
  • Cultural Competency
  • Data Quality and Integrity
  • Public Education and Outreach
  • Organizational and Infrastructure Development

Access and Capacity
  • Expansion of Access Points
  • Marys Center for Maternal Health
  • Mobile Med Germantown Facility
  • Proyecto Salud Olney Facility
  • Expansion of Hours of Operation
  • Proyecto Salud Evening and Saturday Hours
  • Muslim Community Center Clinic Evening and
    Sunday Hours
  • Montgomery Cares Public Education
  • Montgomery Cares Brochures Available Six
  • Information and Referral Line Established
  • Increased Outreach and Community Engagement
  • Process Improvements
  • Increasing Appointment Availability
  • Decreasing Wait Times for Appointments
  • Improving Telephone Systems and Customer

Organizational Development and Cultural Competency
  • Organizational Development
  • Capacity Building Grants for Strategic and
    Business Planning
  • Capacity Building Grants for Volunteer
    Coordination and Human Resource Management
  • TA to Develop Emergency Preparedness Plans
  • On-Line OSHA and HIPPA Training
  • Workforce Development and Leadership Training
  • Shared Services Framework
  • Cultural Competency
  • Language line extended to all Montgomery Cares
    clinics and Project Access specialists
  • Culturally Competent Care Workshops (Center for
    Health Disparities)
  • Qualified Bilingual Staff Training
  • Need system-wide strategic plan to address
    cultural competency to meet multi-lingual,
    multi-cultural needs of the population

Quality Improvement and Data Quality and Integrity
  • Quality Improvement
  • Establishing Quality Standards
  • Tracking Quality Indicators in CHL Care
  • Quality and Health Improvement Committee (QHIC)
  • Participation in IHI Office Redesign Learning
  • Improvements to Clinic Data Management and CHL
  • Data Quality and Integrity Report
  • Assessment of Data Management Workflows
  • Redesign of CHL Care to Improve Use and
  • Training to Improve CPT and ICD-9 Code Entry
  • AHRQ Mini-Grants to support data management
  • Regular User Group Meetings and On-Going
    Technical Assistance

Specialty Care
  • Project Access is the Montgomery County network
    of private physicians developed in collaboration
    with the Montgomery County Medical Society and
    hospitals who provide low-cost specialty
  • FY08 Referrals Completed 1,210
  • Archdiocesan Health Care Network is the Regional
    network of private physicians and hospitals
    maintained by Catholic Charities that provides
    low-cost specialty care.
  • FY08 Referrals Completed 1,642
  • Hospital Care is provided at low or no cost to
    patients referred through PA or AHCN. Four of
    five Montgomery County Hospitals accept the
    PA/AHCN co-pay, which does not usually excess

Health Care for the Homeless (HCH)
  • Mobile Medical Care, Inc. and Community Clinic,
    Inc. provide services for homeless adults and
    families through a federal grant through HCH, MD.
  • Montgomery Cares contracted with Mobile Medical
    Care, Inc. to conduct six shelter-based clinic
    sessions per week and serve 1,000 patients.
  • Patients Served 756 Encounters 2,205
  • Case Management has been linked to health service
    delivery, and service delivery is linked to
    shelter sites.
  • Patients Served 470 Encounters 858
  • PCC is facilitating coordination of services
  • shelter and housing providers
  • emergency and social service providers
  • hospitals and mental health care institutions
  • medication access programs.

Montgomery Cares Pilot Projects
  • Oral Health Pilot links dental care to primary
    health care through direct referrals from all
    Montgomery Cares clinics to dental services
    provided by Spanish Catholic Center.
  • Patients Served 625 Encounters 1,129
  • Behavioral Health Pilot, a collaborative care
    model, provides on-site mental health
    assessments, medication management, short-term
    therapy and referrals at three Montgomery Cares
  • Patients Served 490 Encounters 1,215
  • Eligibility Pilot provided eligibility
    determination for Maryland Primary Adult Care
    (PAC) and Medicaid/MA on-site at Mercy Health
    Clinic from August 2006 through June 2008.
  • Applications Processed 741 Enrolled 374
  • Denied/Withdrawn 290 Applications Pending 78

Montgomery Cares Information Referral
Call Volume 7/1/2007 to 6/30/2008
Total Calls Processed 1,761
Montgomery Cares Information Referral
Caller Need 7/1/2007 to 6/30/2008
Care for Kids
  • Care for Kids provides primary health care to
    children of low-income families who can not
    afford health insurance and are not eligible for
    other state and federal programs.
  • Primary health care
  • Specialty care
  • Medications
  • Case Management
  • Dental and Eye Care Referrals

Care for Kids Providers
Program Growth
Race and Age
Race of Participants
Age of Participants
Federal Poverty Level and Geographic Region
Income of Participants Families
Region of Participants Residence
FY08 Program Metrics
  • Care for Kids served 3,810 children during FY08.
  • Average monthly enrollment is 2,599 children.
  • 925 new children were enrolled in FY08.
  • 98 of children who continue to be eligible for
    the program are recertified annually and retained
    in service.

Center For Medicine Access

Significance of Medicine Access
Access to medicine is an important component of
primary health care. Nationally, approximately
20 of individuals do not fill their
prescriptions, because they cannot afford to.
Were working to eliminate that problem in
Montgomery County.

A Multi-strategy Approach to Medicine Access
Pharmacy Benefit Management
Community- Based Organizations
  • Community Pharmacy
  • Point of Service
  • Over the Counter
  • Diabetic Supplies
  • Flu vaccine and Pneumovax

Medbank Program
Pharmacy and Therapeutic Committee Members
Staff Representatives Rosemary Botchway and
Gabriel Hidalgo

Pharmacy and Therapeutic Committee Guides Process
  • Assists in the formulation of policies and
    procedures relating to drug and pharmacy
    management within the clinic settings
  • Provides oversight and development of the various
  • Supported by evidence-based medical evaluation
  • Reviews medical directors and clinic provider
    requests for drugs to be added or deleted from
    the formulary through a completed formulary
    drug-change request form
  • Evaluates rationale for drug request
  • Conduct a review process and apprises the
    requesting provider of the committee decision
    with rational
  • If requested, conducts an appeal at which time
    the provider is requested to offer further
    rational for formulary inclusion (in writing or
    in person before the committee)

1. Community Pharmacy Point of Service (POS)

  • Unit of use pre-packaged drugs dispensed at the
    point of an encounter within the clinic setting
  • Evolving formulary currently consists of 40
    generic drugsmeets 80 of medication needs
    within clinic population
  • Point-of-service medications are dispensed for
  • CHL network clinics
  • Montgomery Cares pilot programs
  • behavioral health
  • dental pilot
  • CHL diabetes management program
  • Medication and diabetic supplies

Community Pharmacy Point of Service (POS)
  • The dispensing system meets all state and federal
  • The medications are
  • supplied by a licensed
  • drug re-packager.
  • Medication comes to the
  • clinics in pre-packaged
  • unit doses ready to
  • dispense.

Community Pharmacy Formulary
  • Amlodipine
  • Atenolol
  • Captopril
  • Clonidine
  • Diltiazem SR
  • Furosemide
  • Gemfibrozil
  • Hydrochlorothiazide
  • Isosorbide Mononitrate
  • Lisinorpril
  • Lovastatin
  • Potassium Cl ER
  • Simvastatin
  • Spironolactone
  • Triamterene / HCTZ
  • Verapamil ER
  • Verapamil HCl
  • Verapamil SR
  • Amoxicillin
  • Cephalexin
  • Ciprofloxacin
  • Ery-tab
  • Metronidazole
  • Penicillin (PVK)
  • Buproprion SR
  • Fluoxetine
  • Phenytoin ER
  • Sertraline
  • Trazodone
  • Venlafaxine HCl
  • Tac Acetonide
  • Albuterol Inhaler
  • QVAR

A generic equivalent in a custom blister pack.
Community Pharmacy Formulary Montgomery Cares
Pilot Programs
  • Montgomery County Behavioral Health Pilot
  • Buproprion HCl
  • Citalopram
  • Cymbalta
  • Effexor XR
  • Fluoxetine
  • Trazadone
  • Venlafaxine
  • Wellbutrin XL
  • Sertraline
  • Seroquel
  • Gabapentin
  • Montgomery County Dental Health Pilot
  • Penicillin
  • Amoxicillin
  • Ery-Tab

Community Pharmacy Diabetic Supplies
  • In addition to medication, Community Pharmacy
    provides diabetic supplies to approximately 1,600
  • Glucometer
  • Strips
  • Lancets
  • All diabetics receiving supplies also receive
    self- management support to help them utilize the
    supplies and manage their health.

  • Patient Assistance Programs (PAP)
  • Maryland Medbank Program
  • Facilitates access to pharmaceutical companies
    free and
    reduced-cost brand name medications
  • Eligibility guidelines
  • lt250 FPL for 2008 (26,000/1 53,000/4)
  • Citizenship status
  • Residency Status (Residing in the U.S. or
    documented status)
  • Programs have individual requirements/paperwork
  • Programs offer access to over 2,500 brand
  • Formulary of 30 brand-name medication
  • Application to companies
  • Drawback 1 to 8 weeks for shipment of

CMA PAP FormularyBrand Name Medication
3. Pharmacy Benefit Management (PBM)
  • Current PBM relationship Catalyst RX
  • Offers HMO pricing on defined formulary
  • Brand/Generic medication available
  • Convenience of a pharmacy card and access to
    local retail pharmacies
  • Provides utilization and cost data
  • Standard, custom, ad hoc report generation
  • Presently utilized for Care for Kids Program and
    futuristic Project Access specialty physicians
    and disease state management programs

Programs Utilizing Medicine Access Strategies
Administered by the Center for Medicine Access
Montgomery Cares Safety Net Clinics Montgomery
Cares Pilot Programs (behavioral
/dental) Montgomery Cares Health Care for the
Homeless The Montgomery County Maternity
Partnership DHHS Adult Mental Health
Program Tobacco Dependence Treatment Clinic CHL
Care Diabetes Management Program Care for Kids
Program Community-based physicians
Value of Medication Provided to Patients FY 08
  • Purchased Medicines
  • Community Pharmacy
  • Medicine Value 1,169,637
  • 76,078 Bottles of Medicine
  • 985 vials flu/pneumovax vaccine
  • Diabetic Supplies 229,792
  • Catalyst RxPBM 19,577
  • Free Medicine
  • Medbank of Maryland
  • Value Free Meds Received 1,302,748
  • 3,132 Prescriptions Processed

Center for Community-Based Health Informatics
Information Technology for Better Health Care
  • For PCC, Information technology is not an end in
    itself, but rather a means to support a system of
  • Information technology, properly deployed, can
    help address the challenges of
  • Quality of care, in an increasingly complex
    medical world
  • Access to care, for the low income, uninsured in
    the county
  • Efficiency of care, to keep the countys costs
    low for the services provided
  • Safety of care, where information available at
    the right time can mean the difference
  • Disparities, to help eliminate the healthcare gap
    across societal boundaries

Health Care Information Data Flow and Benefits
Quality, Safety, and Efficiency benefits occur at
each level
Link Safety Net Clinics to Mainstream Healthcare
Link Safety Net Clinics Together in cohesive
system of care
Establish Safety Net IT Infrastructure in each
Information Technology Projects
  • CHLCare
  • a unique approach to a shared Electronic Health
    Record (EHR) to connect safety-net clinics in an
    integrated system of care
  • Metro DC Health Information Exchange (MeDHIX)
  • a regional, patient centered health information
    exchange (HIE) focused on safety net clinics
  • Montgomery County Health Information Exchange
  • a PCC and Maryland State funded project to
    advance HIE statewide
  • Safety net clinic information technology support

Health Information Technology Landscape in 2001
  • There was no market for EHR systems for
    safety-net providers.
  • Safety-net providers have unique characteristics
    and needs.
  • Most commercial systems had high up-front and
    maintenance costs.
  • Not many options for a system that could be
    shared across multiple, independent
  • Open Source technology had become a more stable,
    sophisticated option.
  • Montgomery County safety-net clinics had these
  • Severely limited computer resources, equipment,
    expertise, and staff
  • At best small, obsolete, volunteer-contributed
    data collection systems
  • Few resources or time to explore the benefits of
    EHRs in their clinics.

CHLCare Safety-Net EHR Objectives
  • CHLCare Objectives
  • Basic Electronic Health Record capability
  • Appointment management
  • Reporting capability
  • Position for regional linkage hospitals,
    specialty providers
  • Position for new clinical care tools chronic
    disease management, continuity of care, decision
  • Referral management
  • Electronic receipt of laboratory results
  • Integrating Community Pharmacy point-of-service
    medication management
  • Ease of use in settings with multiple volunteer
  • Shared information across providers for a mobile
    patient population
  • Shared medical data with mainstream providers
  • Public health and community care planning

Web-Based Shared EHR Architecture
A web-based, secure-access application
CHLCare (HER) Current Capabilities
  • Developed collaboratively with safety-net clinics
    to meet their needs
  • CHLCare in production since July 03
  • Deployed by 15 clinic organizations at over 35
    clinic locations
  • Montgomery and Prince Georges Counties, DC,
    Northern Virginia
  • Prior electronic data converted and added to
  • Shared database with 250,000 visit records for
    80,000 patients
  • Content includes
  • Patient demographics
  • Encounter data, including ICD9 and CPT codes
  • Patient appointment scheduling
  • Specialty referrals
  • Picture ID cards
  • Visit planner
  • Extensive patient clinical reports and clinic
    management reports
  • Clinical quality assurance data, e.g. diabetes
    quality measures
  • Additional clinical data at the option of
    individual clinics, e.g. allergies, labs

Patient Dashboard
Patient Encounter
Encounter Objective
Stream-line Medical Record Decision Support
Lessons Learned/Positive Outcomes
  • Clinics are becoming more eager to move to
    real-time data entry
  • Clinics see the benefits of additional
  • Clinics are using data for improving clinical
    outcomes and operational efficiencies, clear
    evidence of a more quantitative approach
  • Clinic staff and volunteers are increasingly
    knowledgeable about EHRs.
  • More and better information enhances County
    Public Health planning.
  • Shared information supports a system of care for
    low-income uninsured patients.
  • Clinics are better positioned in seeking grant
    and contract support for clinical quality
    improvement interventions.
  • Technology supports safety-net specific features
    not in commercial systems.
  • Technology facilitates innovative care models
    Chronic care model planned care Triple Aim
    care team.
  • Low cost of entry allows participation for
    financially limited safety-net clinics.

Metro DC Health Information Exchange (MeDHIX)
  • Rationale
  • Secure, private, timely exchange of health
    information to improve health care quality,
    prevent medical errors, and reduce costs by
    promoting care continuity
  • Initial focus
  • Safety-net providers and hospitals in the Metro
    DC area (Montgomery County, P. G. County, DC, No.
  • Current focus
  • Montgomery County safety-net clinics and
  • Demonstration project
  • Exchange CHLCare data with Montgomery General
    Hospital ER Proyecto Salud collaboration
  • Expand to other providers and organizations

Metro DC Health Information Exchange History
2004 Primary Care Coalition awarded a one-year
Regional Health Information Exchange planning
grant from the Agency for Healthcare Research and
Quality 2005 PCC awarded a-three year
implementation grant to design and build a Safety
Net Regional Health Information Exchange

Current MeDHIX Model
Proxy Server
Sub Network Organization
MeDHIX is an Information Bridge
Health Information Exchange
Hospital Emergency Depts
Safety Net Clinics
Montgomery County, MD
Laboratory Provider
SCC Langley Park Adults
Hospital A
SCC Langley Park Peds
Hospital B
  • MeDHIX Exchange
  • Enterprise Service Bus
  • Routing and Transformation
  • Data Storage (edge servers

Proyecto Salud
Mobile Med
Hospital C
  • A Health Information Exchange to link Safety Net
    clinics to mainstream healthcare
  • Using CHLCare to make a single connection to
    MeDHIX, simplifying data exchange
  • Linking to Quest Diagnostics for Lab Results

Peoples Comm Wellness
District of Columbia
SCC DC Medical
Virginia Counties
Arlington Free Clinic
MeDHIX Care Continuity Goals, Phase One
  • Enhance patient safety, quality, and efficiency
    of care
  • Share safety net clinic data with hospital
    emergency departments
  • (ED-MC Connect)
  • Continuity of care identify a patients medical
  • System design that protects patient privacy
  • Conform to multijurisdictional privacy
  • Easy to use, web-based access
  • Pertinent information to facilitate care

Specific Phase One MeDHIX Capabilities
  • eChart
  • Synopsis of patients medical record
  • Web accessible
  • Picture ID card
  • Quest electronic laboratory result link

ED-MC Connect Schematic
ID Card Design
Identifies Safety Net Community
Issued Date
Medical Home and Contact Number
Sex and Date of Birth
Magnetic Swipe contains CHLCare ID
Patient Information
CHLCare ID and Indication of Membership in the
Health Information Exchange
Disclaimer to insure no misunderstandings' as to
the intent of the card occurs
Return to Address
MeDHIX eChart
Montgomery County Health Information Exchange

Maryland State goals Promote the adoption of
EHRs Develop a statewide health information
exchange Phase 1 Maryland Governors Task
Force to Study Electronic Medical
Records Address EHRs, HIE, school health
records 26 members appointed by the legislature
and Governor PCC asked to represent safety-net
clinic perspectives Report submitted to the
Governor and General Assembly December 31, 2007
Montgomery County Health Information Exchange
  • Phase 2 RFA for a Citizen-Centric HIE for
  • Issued by MHCC, funded by HSCRC
  • Two awards Montgomery County HIE
  • CRISP Health Consortium led by Erickson
    Retirement Communities with Johns Hopkins,
    MedStar, U. of MD
  • Plans and Requirements
  • Recommendations to the State addressing the broad
    range of policies, principles, and practices
    necessary for the successful adoption of
    statewide health information exchange in Maryland
  • Recommendations for statewide implementation
    strategies to MHCC/HSCRC, Feb. 20, 2009
  • Reports submitted to be submitted to the Governor
    and General Assembly, Feb. 27, 2009
  • Demonstration project to test principles and gain
    local experience

Montgomery County Health Information Exchange
  • Project participants
  • MCHIE led by Dr. Roger Leonard, VP, Medical
    Affairs, Montgomery General Hospital
  • all county hospitals
  • DHHS
  • PCC
  • Regional charitable organizations and funders
  • Prince Georges County Health Department
  • Demonstration project
  • MGH Emergency Department
  • Proyecto Salud
  • CHLCare MeDHIX eChart data exchange (ED-MC

Regional Health Information Technology Activities
  • DC Primary Care Association EHR Project
  • National Capital Area RHIO (DC RHIO)
  • Pediatric Regional Health Information Network
  • DC Medicaid Transformation Grant
  • INOVA EHR activities and regional implications
  • Northern Virginia RHIO
  • NOVA Scripts Central

Regional Health Information Technology Activities
  • Maryland Governors HIT Advisory Committee
  • Citizen-Centric Health Information Exchange for
    Maryland Grant received for Montgomery County
  • Maryland Statewide HIE plan
  • PCC AHRQ-funded MeDHIX Project
  • Maryland Community Health Centers EHR plans
  • PCC Montgomery County EHR Assessment Activities

Health Information Technology Challenges and
  • Maintaining congruency among
  • Technology evolution
  • Safety-net clinic needs, characteristics, and
    patient populations
  • Reliance on volunteer providers pros and cons
  • Links to mainstream health care resources and
  • Population health
  • Cost
  • Importance of evolutionary curves
  • Finding the proper curve and evolving
    functionally and cost effectively
  • Determining when to jump to the next curve

Funding Sources and Collaborators
  • Major development funding and sustainability
  • U.S. Health Resources and Services Administration
  • CAP grant ( 3 million, with 25 for health IT R
  • National Library of Medicine
  • Connecting Communities for Health Information
    Technology (125,000)
  • Kaiser Permanente
  • Multiple modest grants for safety net care
    quality improvement (100,000)
  • CareFirst Blue Cross/Blue Shield
  • Multiple grants to add clinically oriented
    capabilities (100,000)
  • U.S. Agency for Health Care Research and Quality
  • Transforming HealthCare Quality through Health
    Information Technology
  • 1.5 million with 11 matching requirement)
  • Maryland Health Care Commission/Health Services
    Cost Review Commission
  • Montgomery County health information exchange
  • Montgomery County DHHS
  • Montgomery Cares

Center for Health Improvement
  • To improve the health status of adults and
    children being served through Montgomery Cares
    and Care for Kids

Center for Health Improvement Goals
  • Improve overall quality, safety, and
    effectiveness of care through measures of health
    outcomes and system-wide performance.
  • Foster a culture of quality improvement in the
    provision of care.
  • Build an environment of shared learning,
    collaboration, and best practices in areas of
    access, efficiency, and the delivery of planned
    care in the clinics and system-wide.
  • Engage patients in improving their own health and
    preventing complications of diseases.
  • Develop a research infrastructure to attract
    academic partners and health care leaders to
    foster innovative approaches that reduce health

  • Transforming health care deliveryBuilding the
    foundation and infrastructure for quality
  • Infusing planned care into Montgomery Cares
  • Develop measurement system for quality,
    access, efficiency
  • IHI Collaboratives Office Practice Redesign
    Triple Aim
  • Patient activation and community partnership
    initiatives   7331 Healthy Families Having Fun 
    Diabetes self-management education
  • Community-based cancer prevention projects
  • Research
  • Community-Based Participatory Research NIH
  • Health literacy NIH
  • IP-RISP NIH/Georgetown University
  • Emergency Department utilization HSCRC
  • Komen Community-Academic Partnership Research

The Model of Planned Care
  • A design for delivery of primary care for all
    patientsmust support quality, effective,
    patient-centered care
  • PCC adopts Institute for HealthCare Improvement
    (IHI) model of Planned Care, the notion that
    every patient should have a plan of care.
  • Planned Care model is used across the nation to
    improve care by creating a reliable and lean
    system for all patients.
  • Model calls to support four elements of service
  • Care Team Clinical Information System
  • Patient Activation Leadership


IHIs Planned Care Model


Building the Foundation for Quality Improvement
Infrastructure building Began with IT
Streamline Enhance EHR Planned
Care Metrics/ Performance Dashboard
Fostering Learning Environment Knowledge
Transfer Learning sessions Newsletters Quality
Visits QHIC/MD Mtgs
Practice Redesign Office Practice IHI
Collaborative FY08 2 Clinics FYO9 3 Clinics

Transforming System Culture Triple Aim
Building IT infrastructure The Process
  • Created CHLCare (EHR) and Diabetes Registry
  • Embedded functionality into CHLCare to support
  • Planned Care
  • Diabetes Registry
  • Developed metrics for Quality
  • Medical Directors approved nationally recognized
    diabetes, hypertension and chronic disease
    preventive measures
  • Developed Performance Dashboard
  • Hired a Data Manager
  • Established annual and quarterly reports to
    assess performance

Streamline Medical Record/Decision Support
Foster a Learning Environment Activities to
promote knowledge transfer and spread
  • Periodic Learning Sessions
  • Quality Health Improvement Committee
  • Medical Directors meet quarterly
  • Review and approve metrics
  • Share knowledge and best practices
  • Quality Subcommittee Working group
  • Quarterly and Annual Reports
  • Performance Dashboard
  • Planned Care Tipsmonthly e-bulletin
  • Online Continuing Medical Education (CME)
  • The Role of Culture in Breast Health Care (funded
    through Komen)
  • www.primarycarecoalition.org/cme/welcome

QI Tool used to Accelerate Change Model for
What are we trying to accomplish?
AIM Statement Demings PDSA
Performance Dashboard
  • Promote Quality Improvement by sharing best
    practices to improve
  • Access
  • Efficiency
  • Patient Experience
  • Compare performance over time and with other
    industry benchmarks. Reported quarterly and
  • Diabetes
  • Hypertension
  • Cancer Prevention
  • Adult Vaccination

Diabetes patients with controlled blood pressure
lt 140/90
Diabetes Process Measures for Clinic E over time
Patient Activation and Community Partnership
  • Child Health Improvement Initiative (Kaiser
  • Promote assessment and treatment of childhood
    obesity consistent with evidence-based guidelines
  • Facilitate referral to 7331 Healthy Families
    Having Fun and other appropriate support
  • 7331 Healthy Families Having Fun
    Family-centered, culturally relevant healthy
    lifestyle program for overweight and obese
  • To date 105 pediatric provider-referred children
    with families
  • Documented improvements in nutrition and physical
    activity behaviors
  • Diabetes Self-Management Education
  • Standardized support to low-income diabetic
    patients to engage self-management of this
    chronic disease

Community-Based Cancer Prevention Projects
Komen I Patient Navigation Project
  • 3 Montgomery Cares clinics selected to
    participate in Breast Health Patient Navigation
  • 2 Clinics began project 9/07
  • 1 Clinic began project 1/08
  • All 3 participating clinics provide culturally
    competent patient
  • navigation at clinic site
  • Measures include
  • Mammogram Referral Rate
  • Mammogram Screening Rate

Komen 2 Process Improvement Three Phases
  • PHASE I Setting Priorities and Kick-Off
  • PCC and WCCP use PDSA tests of change
  • to improve efficiencies and reduce waste.
  • PHASE II Measure Impact of PDSA
  • Reduction in cycle time from clinic referral to
    WCCP receipt of patient application.
  • Reduction in cycle time from WCCP receipt of
    patient application to voucher sent to patient.
  • PHASE III Scaling Up and Sustainability
  • The final phase of the project will focus on
  • developing QI initiatives in other breast
  • cancer screening programs including
  • Holy Cross Hospital MAPS 2
  • Adventist Healthcare
  • (Washington Adventist and Shady Grove Adventist)

Prevent Cancer Foundation Goals
  • Goal 1
  • To increase the scope of cancer screening patient
    navigation at the
  • participating CHL clinics to include colorectal
    cancer screening.
  • Colorectal chart abstraction of all women gt 50
    years of age
  • Build on current patient navigation model to
    expand clinic cancer prevention services
  • Utilization of CHLCare to track colorectal cancer
    screening and coordinate patient care.
  • Goal 2
  • To test direct-referral pilot designed to address
    barriers to access and
  • improve efficiency from referral to completion in
    mammography screening.
  • i.e. Holy Cross Hospital MAPS 2 and Adventist

Institute for Healthcare Improvement
  • The Institute for Healthcare Improvement (IHI) is
    an independent not-for-profit organization
    helping to lead the improvement of health care
    throughout the world. 
  • IHI works to accelerate improvement by building
    the will for change, cultivating promising
    concepts for improving patient care, and helping
    health care systems put those ideas into action  

IHI homepage www.ihi.org/ 9-24-08
Sustainable Changes Rely on Linking Clinical
Quality Improvement and Business Improvements
  • Improving Efficiency
  • Improving Team Productivity
  • Efficient Facility Design and Standardization
  • Availability of Key Resources
  • Team-based care
  • Optimizing utilization of staff
  • Cross-training staff in a team-based model
  • Generating Revenue
  • Reducing Expenses

Roger Chaufournier, CSI Solutions
Institute for Healthcare Improvement
  • IMPACT Community Office Practice Redesign
  • PCC Sponsored Clinics
  • The Peoples Community Wellness Clinic 9/07-9/08
  • Spanish Catholic Charities 9/07-9/09
  • Proyecto Salud 9/08-9/09
  • Muslim Community Center Medical Clinic 9/08-9/09
  • 15 - 60 organizations working together to achieve
    significant improvements within learning
    collaborative model
  • Community brings together known improvements in
    the areas of access efficiency and delivery of
    planned care
  • Triple Aim Learning Collaborative
  • PCC invited to join 15 other organizations
    globally to work together to test models and
    methods to transform health care delivery systems
  • Completed Phase I April 2008
  • One of nearly 40 organizations participating in
    Phase II
  • Project ED-MC Connect

The Spanish Catholic Charities Experience
Small PDSAs, Big Improvements
Langley Park Shows a Decrease in Cycle Time
Patients Safety Report
QI Opportunities Reports
Better Design Forms at DC Medical
Huddles and Meeting
Better No Show Rate with an Innovative Scheduling
System at Montgomery Dental
Phone System Coordination
Data Collection Improvement
Office Redesign
Less Time to Have an Appointment at DC Clinic
Our Clinics Score High in Patient Satisfaction
IMPACT Office Practice Redesign results
  • Quality and Process Improvement Mind-shift
  • Utilizing QI Tools Ideas into Action/Results
  • Collecting and utilizing data
  • Overcoming resistance
  • Empowerment of staff to make quality changes
  • Improved workflow and efficiency
  • Improved communication
  • Exam room standardization
  • Spread of knowledge to all CHL Clinics

The Triple Aim
Population Health
  • Optimizing health care by balancing three
    health care delivery dimensions
  • Improve the health of the population
  • Enhance the patient experience (quality, access,
  • Reduce, or at least control costs of care

Experience of Care
Per Capita Cost
Organizations in Triple Aim Phase II
Hospital-Based Systems Bellin Health
(WI) Cincinnati Childrens Hospital Medical
Center (OH) Genesys Health (MI)
(Ascension) ThedaCare (WI) Health Plans Blue
Cross Blue Shield of Michigan (MI) CareOregon
(OR) New York-Presbyterian System SelectHealth
(NY) UPMC Health Plan (PA) Independent Health
(NY) Integrated Health Systems Group Health
(WA) HealthPartners (MN) Kaiser Permanente (CO,
MD) Alaska Native Medical Center (AK) Veterans
Health System (OH, OR, NE) Health Department
King County (WA)
State Initiative Vermont Blueprint for Health
(VT) Safety Net Colorado Access (CO) Contra
Costa Health Services (CA) North Colorado Health
Alliance (CO) Primary Care Coalition Montgomery
County (MD) Queens Health Network
(NY) Employers/Businesses General Mills
(MN) QuadGraphics/QuadMed (WI) International Blac
kburn With Darwen Primary Care Trust (UK) Bolton
Primary Care Trust (UK) Central East Local
Health Integration Network (Canada) East
Lancashire Teaching Primary Care Trust
(UK) Eastern and Coastal Kent Primary Care Trust
(UK) Forth Valley (Scotland) IMPACT BC
(Canada) Jönköping (Sweden) Saskatchewan
Ministry of Health (Canada) Tayside
(Scotland) Social Services Common Ground (NY)
Triple Aim System Components
  • Redesign primary care services and structures
  • System integration and execution
  • Focus on individuals and families
  • Population health management
  • Cost control platform

Strategy Segment the population, plan the
  • Domains
  • 1. Income deprivation
  • 2. Employment deprivation
  • 3. Health deprivation, disability
  • 4. Education, skills, training deprivation
  • 5. Barriers to Housing and Services
  • 6. Living environment deprivation
  • 7. Crime

Next steps for PCC in the health improvement arena
  • Dissemination of quality improvement activities,
    knowledge among clinics and partners
  • Population-Based EMR that supports the care team
    to provide the right care at the right time for
    every patient, assist with implementation of
    MedHIX to exchange patient information with
  • Change culture of the MontgomeryCares to focus on
    quality and efficiency within a caring
    environment apply Triple Aim principles to move
    toward family centered care
  • Community-based Wellness Collaborative
  • Community Engagement
  • Continue learning from Triple Aim model and
    promoting systems redesign
  • Data analysis (including GIS) to examine links
    between clinic utilization and reductions in
    emergency department visits, patterns of clinic
    utilization, and areas of need
  • Development of coordinated, patient centered
    cancer control plan

Funding resources for two years 2.4M
  • Consumer Health Foundation 7331, IT
    Mini-technology grant, Geo-mapping
  • Trawick Foundation 7331
  • Morris Gwendolyn Cafritz Foundation 7331
  • CareFirst I CareFirst II Planned Care/
  • Susan G. Komen Foundation I II Community-based
    Cancer Prevention Projects Breast Cancer
  • Prevent Cancer Foundation Colorectal Navigation
  • Healthcare Initiative Foundation Triple Aim,
    Community Wellness Collaborative
  • DHHS Diabetes Education/IHI Practice Redesign
  • Eagle Bank Breast Cancer Initiatives
  • BBT 7331

CBPR Research Project Goals
  • To determine major barriers to health care
    access among uninsured persons in Montgomery
  • To implement and test community-suggested
    strategiesvia a CBPR processto increase access
    to care
  • _________________________________________________
  • Overall To use Community-based Participatory
    Research to build health care infrastructure

What is community-based participatory research)?
CBPR is a collaborative research approach
that is designed to ensure and establish
structures for participation by communities
affected by the issue being studied,
representatives of organizations, and researchers
in all aspects of the research process to
improve health and well-being through taking
action, including social change. Viswanathan
et al., 2004 CBPR Assessing the Evidence AHRQ
Relevance of community engagement
  • Essential to the understanding of barriers and
  • (use of preventive measures, primary care, and
    to improve health)
  • Critical to identifying community perceptions and
    attitudes as well as identifying cultural issues
    and opportunities.
  • Secures the use of appropriate related
    terminology and language to reach, particularly
    those community members who need services the
  • Includes active community-wide opportunities for
    discussion, dissemination, advocacy and idea
    generation (local forums and trainings regarding
    lessons learned and needs identified).
  • Promotes documentation of needs and baseline
    information based on evidence-based practices.
  • Encourages community exchange that leads to
    development and implementation of best practices
    that are culturally appropriate to our community
    (ownership and promotion) .

Working with different communities
Chinese Community Health Fair
African-American Heart Health Symposium
Latino Health Fair (2006)
Cambodian Community Health Fair
Community Recommendations for Increasing Access
to Care
  • Support and increase patient navigation and
    health promotion efforts targeted toand tailored
    forparticular communities.
  • Increase and support efforts to improve
    staff/provider sensitivity, professionalism, and
    cultural competence.
  • Assure mechanisms for lay involvement and input
    in county health programs and initiatives.
  • Increase community outreach initiatives through
    media regarding services available for the
    uninsured, as well as health promotion
  • Increase flexibility in documentation
    requirements for service eligibility.
  • Support preventive health efforts like community
    health fairs that provide health screenings and
    education as a means to increase access.
  • Increase language-appropriateness of available

Partnerships and Acknowledgments
  • County Partnerships African American Health
    Program, Asian American Health Initiative,
    Latino Health Initiative, Office of Health
    Promotion Substance Abuse Prevention
    (G.O.S.P.E.L. Program), MC Cancer and
    Tobacco Initiatives, Up-County Multicultural
    Health Promoter Program
  • Montgomery Cares Clinics Proyecto Salud,
    Spanish Catholic Center, Pan Asian Volunteer
    Health Clinic, Mobile Med, Community Clinic Inc.,
    Holy Cross, Mercy Health Clinic, The Peoples
    Community Wellness Center
  • Hospitals Holy Cross, Suburban, Montgomery
    General, Adventist H.C.
  • Academic Partners Georgetown University,
    George Washington University, Uniformed
    Services University Ctr. for Health Disparities,
    University of Maryland -- Anthropology
    Public Health
  • Community-Based African Immigrant and Refugee
    Found., African Womens partners Cancer
    Awareness Assoc., Chinese Culture and Community
    Svs. Center (CCACC), Cambodian Buddhist
    Society Inc., Community Ministries of
    Rockville, CASA Maryland, Inc., Maryland
    Vietnamese Mutual Association (MVMA)
  • More partners Capital Technology
    Information Services Inc. (CTIS), National
    Kidney Foundation of the National Capital
    Area, ENACCT, Summit Health Institute for
    Research and Education, Inc.

Thank you for your for being part of our
Primary Care Coalition Senior Staff
  • Steve Galen, President and CEO
  • Bill Bletzinger, Chief Operating Officer
  • Sharon Zalewski, Director, Center for Health Care
  • Rosemary Botchway, Director, Center for Medicine
  • Tom Lewis, Chief Information Officer
  • Maria Triantis, Director, Center for Health
  • Maria Rosa Watson, Research Director
  • Diane Briggs, Director, External Affairs
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