2011-05-16_14.00_Person_Centered_Health_Homes.doc

You know a health home also has a focus on population

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You know, a health home also has a focus on population health outcome and I think this is a particular area that’s been a challenge for behavioral health. We’re not as used to thinking about population health, we’re not used to thinking about who are the broad range of people that we serve and what are their needs, generally? So what’s the universe within the adult consumers that are enrolled in our program, what’s their level of diabetes, what’s their level of heart disease, who’s getting better and who’s not, how are we measuring that for that entire population and what are our overall goals? Again, a very important component of the healthcare home is that care is tailored to the needs of each patient and that that team is engaged in care coordination and management. And I think Larry’s going to talk a little about this, who are the different kinds of staff that can perform that function. [0:37:32] But again this is a critically important idea that grows out of Wagner’s Chronic Care Model and is embedded in many other successful approaches that individuals need support in managing their whole health, that they can be - they are the most important component of that. The notion of self-activation, of engaging individuals in their own self care is a critical component and that there are team members who assist individuals in that process and also help coordinate their care when needed. Teah (ph) can we go to the next slide? This notion of care management and the function that this team provides is that this care is coordination across multiple providers. So many of you may have had an experience like I’ve had or a parent with multiple chronic conditions and how frustrating it is to bring that person to multiple specialists all with their own ideas about medication dose and changing medication dose or changing intervention and no one is actually in the middle negotiating that process, you know, bringing some perspective to it. And in the health home the care manager, that’s one of their functions is to support individuals across multiple models, synthesize that information and to help individuals manage interactions with multiple specialists. Patients are active participants in this process and most importantly that there is a continuous learning and practice improvement environment, that that practice is looking at their population households, they’re looking at the individual experience of folks participating in that health home, and they trying to always figure out how can they do better, how can they make their care more patient-centered? How can they help people achieve functional or clinical goals that they’ve set for each other? And they’re willing to re-engineer their processes as necessary to achieve that. [0:40:08] Again, if you remember back to an earlier slide, this also has a more viable business model and part of the whole notion of re-engineering care in this country is to make it
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  • Fall '19
  • Center for Integrated Health Solutions, Teah, LARA HOKEN, Mr. Chuck Ingoglia

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