Pilot Program and Possible Expansion

Hey, everyone!  Happy Tuesday!  As you have likely already heard from your Department Leader, we are working on some super exciting things SO make sure you read this entire post so that you are well informed.

First, we are starting a pilot program that will move our health centers forward in our efforts to progress in our vision to transform healthcare delivery to genuinely BUILD HEALTHY PEOPLE.  We have been working on a new care delivery model that will take our ability to care for our patients to the next level.  A few key components of the program include adding an RN Care Manager, a Licensed Clinical Social Worker, two Patient Navigators and two Patient Advocates to a two-provider medical pod.  The following is a general summary of their roles within the pods and the positions are posted on our careers page.

·       RN Care Manager – This position will be responsible for medical case management, creating care plans for moderate and high-risk patients, performing annual wellness visits and leading the chronic care program.

·       Licensed Clinical Social Worker (LCSW) – This position will be responsible for behavioral health assessments and screenings, interventions, case management, crisis interventions, care planning and behavioral health referrals for further counseling and/or treatment.

·       Patient Navigators – These positions will be the patient’s go-to person and will be responsible for administering health risk and social assessments, patient intake and eligibility services, community, and social service referrals as well as medical referrals and pre-authorizations and aiding patients in navigating the healthcare system.  There will be one Patient Navigator per provider.

·       Patient Advocates – These are two call center Patient Advocate positions who will each be assigned to a single provider to manage that assigned provider’s schedule within the pod setting to better understand the daily workflow of that individual care team and to provide administrative support as needed for the pod.

The pilot program target go-live date will be October 31st.  The pilot program will begin with one provider pod at the Walnut location and Dr. Carnahan and Gina have graciously agreed to be the guinea pigs for the project.  The plan is to use the pilot to work out any kinks in the delivery model before implementing these new workflows across the entire organization.  The pilot will likely run about 6 months before we take steps to be able to successfully implement it further into the health center.

We have also hired a part-time psychiatrist who will join the team and be part of the pilot as well as lead the Integrated Behavioral Health Program and team.  Dr. JaHannah Jamelarin, MD will join the team in late October as the Chief Integrated Health Officer (CIHO).  She and Gina will share an office.

Below you will find the anticipated timeline for implementation with some of the generalized steps for each month prior to implementation.  As with all pilot programs, there will be changes and shifts along the way as we learn what works and what doesn’t.  We are confident that this new program is a game-changer that will benefit our patients in ways that we have dreamt about for years.  We will do our very best to keep you informed about our progress along the way and the changes that may impact your department.

August:

·       Establish pilot program taskforce to lead the project through implementation and evaluation

·       Establish initial job descriptions for each role in the pilot program

·       Interview new positions needed for the pilot project:

o   RN Care Manager – will office in the exam room nearest Dr. Carnahan

o   Licensed Clinical Social Worker – will office in the exam room nearest Gina/Dr. JaHannah’s office

o   Patient Navigator – 2 – will each have a workstation in the nurse’s window box

·       Swap Tamra and Gina’s pods and finalize workstation needs

·       Choose two call center Patient Advocates to participate in pilot program

·       Review and refine draft workflows for pilot program with taskforce

·       Set-up CCM and AWV in Athena

·       Set-up RN and LCSW workstations

·       Credential Dr. JaHannah

·       Request health center Change in Scope to add additional Behavioral Health Services

·       Establish goals, benchmarks, and score cards to evaluate program effectiveness and progress

September:

·       Onboard and train Patient Navigators, RN Care Manager, LCSW in their roles and the clinical workflows of the team and GSCC operations

·       PN, RN and LCSW shadow the following departments:

o   Patient Access

o   Behavioral Health

o   Nursing Teams

o   Referral Team

·       Set up billing codes as needed

·       Credential clinical team as needed

·       Refine pilot workflows as necessary to function effectively within the clinical setting

·       Transition LPN and MA workstations to center pod workstations

·       Set-up Patient Navigator and Patient Advocate workstations in window box workstations

·       Restructure incoming call instructions and scheduling practices in the call center to accommodate pilot structure

·       Identify and review attributed patients who qualify for AWVs

·       Identify and review high risk patients, frequent ED users

·       Train appropriate personnel on Azara

·       Determine appropriate and effective documentation methods for PN, LCSW and RN Care Manager

·       Meet with taskforce weekly to review progress and clarify next steps

·       Layout daily huddle format and assign responsibilities

October:

·       Transition 2 Patient Advocates to pod

·       Work with Dr. JaHannah on a risk stratification assessment and workflow

·       Work with Dr. JaHannah on a behavioral health strategy for the pilot and for the health center

·       Introduce Dr. JaHannah to providers and do an in-service to share behavioral health strategy, workflows, treatment planning process, crisis response, and risk assessment / stratification process

·       Target go-live date – October 31st

·       Continue meeting with taskforce weekly

Second, an opportunity came to us last week that will expand access to serve more patients.  We have been offered the opportunity to potentially purchase a medical practice in Healdton to be our fourth healthcare delivery site. This would expand our reach into western Carter County which is super cool!!

As a next step in the process to determine if this is an opportunity that both parties should further consider, we invited the physician who owns the practice, Dr. Mark Newey, DO and his office manager, Julie to tour and visit the Walnut health center on Wednesday around 11a and if there is time, they will also visit Bloom and 12th Street.  It is our hope that their visit will help them see who we are and what we do as a community health center.

Should this opportunity move forward, and we purchase his practice, it will be about six-month process to transition his practice into a GSCC site.

I know that all of this at once is a lot to digest and for some of you it could be quite overwhelming.  I am certain that you have lots of questions and likely some concerns about how we will manage it all at once!  My answer…we have an amazing team that shines through these challenges no matter how difficult or overwhelming they may seem because our patients deserve our best, this organization deserves our best and our team deserves our best.  If we are all truly about the mission and vision of the Good Shepherd to transform healthcare delivery for all the patients who count on us every day to be there for them…these opportunities are the next right steps in reaching our goals!  I hope that at least some part of you is excited about all that is in front of us as a team and as an organization!