Objectives

 

  • Improve physician education

  • Build practices using health analytics

  • Enhance collaboration with other health professionals in integrated health care settings

  • Identify and promote the use of best practices for integrating health care services

  • Provide assistance to Florida’s health care providers in integrating health care

  • Conduct research on how to reduce overall health care costs by integrating health care

 Improve Physician Education

COM Curriculum Assessment

  • Assess the College of Medicine curriculum, including residencies, to determine the extent and types of current training and opportunities to pursue study in integrated health care.
  • Determine additional training needed to prepare physicians for practice in the integrated primary care environment of the future.
  • Become a national leader in physician workforce development in the area of integrated primary care and practice with interprofessional health teams.
  • Ensure that the FSU COM curriculum and residency placements include sufficient training in behavioral health care (e.g., basic concepts of integrated care; integrated care perspective; screening and problem-based assessment for behavioral health disorders; algorithms for mental health conditions; psychopharmacology; chronic disease; geriatric, cognitive and memory disorders; pediatric and obstetrical practice and behavioral health; and communicating with behavioral health professionals.

COM Graduate Surveys

  • Develop and conduct a survey(s) to assess the adequacy of COM training relative to primary care practice; the extent of graduates’ practice in integrated care settings; comfort of graduates in screening, diagnosing and treating behavioral health conditions; graduates’ practice using interprofessional health teams; and graduates’ suggestions for changes in medical education relative to integrated care.

Residencies – Health Team Placements

  • The FSU COM will plan its residencies with its partners to train residents in more efficient and effective care delivery models (e.g., patient-centered medical homes).
  • To accomplish this, FSU will test with other FSU colleges and other universities the placement of residents/intern/students in multi-professional placements in the same settings.
  • For example, primary care residents will be co-located with nursing, social work, pharmacy, students, social workers, and nutrition students in a medical home setting that also employs other team professionals.

FSU Teaching Clinic

The Center will:

  • Establish or affiliate/partner with, or purchase a primary care clinic in Tallahassee
  • Reestablish the clinic as a teaching clinic/center
  • Reengineer the clinic so that it serves as a primary care teaching facility (e.g. organization, staffing, residencies, programming, services)
  • Assign FSU COM faculty to work with the teaching facility
     

 

Build Practices Using Health Analytics

An ounce of data is worth a thousand pounds of opinion
- Ashish Jha, Harvard

Health Analytics

  • The Center will catalogue primary care and behavioral health practice EHR and software vendors; determine the extent of implementation and use of EHRs and analytics software.
  • The Center will assess local PC/BH/IC practices on their capacities to use data to drive treatment and assess outcomes.
  • The Center will review best analytics platforms and practices for integrated care/primary care/behavioral health care practices.
  • The CIHC will maintain a data warehouse/analytics center.
  • Knowing that data can transform health care delivery and improve outcomes, the Center will identify best practices, best products, and provide assistance in upgrading local agencies’ analytic capabilities.
     

 

Enhance Collaboration with Other Health Professionals in Integrated Health Care Settings

 New Professional Certification Programs

The Center will assess the feasibility of Center-sponsored certification programs:

  • Integrated Health Care/Medical Home Practice Management
  • Care Management
  • Medical/Health Care Services Management
  • Facility Design
  • Patient Centered Medical Homes
  • Health Care IT
  • Health Analytics/HIT
  • Geriatric Care/Management

Residencies – Health Team Placements

  • The FSU COM will plan its residencies with its partners to train residents in more efficient and effective care delivery models (e.g., patient-centered medical homes).
  • To accomplish this, FSU will test with other FSU colleges and other universities the placement of residents/intern/students in multi-professional placements in the same settings.
  • For example, primary care residents will be co-located with nursing, social work, pharmacy, students, social workers, and nutrition students in a medical home setting that also employs other team professionals.


 

 

Identify and Promote the Use of Best Practices for Integrating Health Care Services

Evidence-Based Practices

  • The Center for Integrated Health Care will collect information on evidence-based practices and assess model programs in patient-centered medical homes, behavioral health homes, and the bi-directional integration of behavioral health and primary care in behavioral health and primary care settings.
  • The Center will serve as a center of excellence in the evaluation of programs that integrate behavioral health and primary care services.
  • In its training and selection of residencies, FSU will ensure that evidence-based clinical, self-management and behavior change, collaborative care, disease management, care management and transformational practices are employed.
     

 

Provide Assistance to Florida’s Health Care Providers in Integrating Health Care

Provide Technical Assistance to Community Primary Care Practices

  • The FSU COM technical assistance program will be modeled after other university and private organization models such as Colorado HealthTeamWorks (HealthTeamWorks, the University of Colorado Department of Family Medicine, the Colorado Association of Family Medicine Residencies and the Colorado Institute of Family Medicine have partnered for medical practice transformation and curriculum redesign in Colorado’s 10 family medicine residency programs).
  • It aims to facilitate the transformation of the family medicine residency practices into Patient-Centered Medical Homes (PCMHs) and redesign the residency’s curricula to train physicians in the core competencies of PCMH care delivery. 
  • HealthTeamWorks advocates the PCMH model and has developed programs to establish its framework in medical practices. Its coaching and technology assistance enable local practices to improve operations, incorporate quality approaches and increase patients' satisfaction with their health care.
  • Although the PCMH model has great potential as the future of health care delivery, few practices are positioned to become medical homes. Most lack the time, expertise and resources to transform their care delivery methods. The HealthTeamWorks transformation program enables practices to develop the necessary infrastructure and support systems. Its approach narrows the gap between today’s fragmented health care system and tomorrow’s integrated approach
  • HealthTeamWorks' “Coach University” imparts the knowledge that its experts have accumulated over years of in-practice training. As patient-centered medical homes (PCMHs) and medical neighborhoods grow in relevance, the roles of all practice members are evolving. By training in-practice facilitators — quality improvement coaches — HealthTeamWorks prepares local practice staff to guide practices through the transformation to the PCMH.
  • Coach University is the ideal solution for those interested in a structured, hands-on training program.
  • HealthTeamWorks has consolidated its expertise into an experiential training program unlike any other in the country. A combination of didactic, online, simulation and in-office training maximizes the chances for success once a coach begins work in the field.

HealthTeamWorks’ Coach University covers:

  • The model for improvement
  • The chronic-care model
  • Evidence-based guidelines
  • Leadership development and the dynamics of the team approach to care
  • Adaptive change-management methodologies to set goals and expectations
  • Quality measures and population management
  • Patient engagement and self-management support
  • Motivational interviewing
  • Using technology to support the delivery of patient care

The Triple AIM

Key Objectives HealthTeamWorks Solutions
Improve Outcomes                
  • Team-based care                      
  • Registry Functionality
  • Focus on data
  • Learning Collaborative
  • Engage Patients
  • Planned care for chronic patients
  • Embed Evidence Based Guidlines
  • Coaching to build communities
 Reduction of Cost  
  • Effective management of ambulatory sensitive conditions
  • Improved access
  • Reduction of ER visits
  • Office based care-coordination for high risk/high cost patients
  • Care compact between clinicians
  • Reduction of re-admissions through managing transitions
 Improved Patient Experience  
  • Patient shared decision making          
  • Increased access
  • Prepared care teams means productive visits
  • Accommodate patient needs in one visit
  • Self management goals

 HealthTeamWorks, accessed 5/15

 

 

Conduct Research on How to Reduce Overall Health Care Costs by Integrating Heath Care

Primary Care Facility Design

  • Review the literature on how the physical environment of health care facilities affects patients, staff, and families by impacting patient safety and quality of care and positively or negatively affecting patient experiences.
  • Assess and catalog evidence-based facility design features as they affect patient outcomes, staff outcomes, and treatment outcomes.
  • Assess physical environment features and how they affect spatial relationships, visual and acoustic privacy, physical attractiveness, ambient experience, and information in the environment.
  • Discuss design features with design experts (Center for Health Care Design, California).
  • Review examples of best facility designs.
  • Interview health, architectural, interior design, construction, business, and health management professionals.
  • Develop facility design recommendations and consult with primary care facilities/practices.

FQHC Research

  • Review the FQHC model for integration of primary and behavioral health care
  • Compare treatment outcomes of patients served in integrated care FQHC sites and non-integrated sites
  • Determine factors that affect a FQHC’s decision to integrate
  • Assess the integrated model from a quality and business case standpoint
  • Develop a survey on integration to be administered to a sample of FQHCs – both integrated and not
  • Identify and assess FQHCs that have established patient-centered medical homes

Mapping Project

CIHC will implement an integrated/primary care mapping project – a geographic referencing system

  • Location of integrated primary care sites with site description
  • Distribution of primary care physicians
  • Facilities by type of collaboration
  • Facilities by CMS project status
  • Shortage area designations
  • Primary care and GIS mapping

Survey CMHAs

CIHC will survey community mental health agencies to assess:

  • Co-location and collaboration with primary care providers
  • Level and type of integration with primary care providers
  • Integration either at primary care sites or behavioral health sites
  • The level of information sharing with other primary care/health care providers
  • Comparison of treatment outcomes of integrated vs. non-integrated agencies
  • If integrated, the level of integration accomplished
  • Barriers to integration of primary care and behavioral health care
  • Health care service use of integrated agencies vs. non-integrated agencies