Explain how this case can be applied to the goals of the Kingdom of Saudia Arabia Vision 2030.Union Health Center (UHC) embraced the patient-centered care team model very early on, which helped ease the transition to new workfl ows, processes, and features that are critical to change management and quality improvement.
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CASE 1: REGISTRIES AND DISEASE MANAGEMENT
UHC’s Care Team Model
Union Health Center (UHC) embraced the patient-centered care team model very early on, which helped ease the transition to new workfl ows, processes, and features that are critical to change management and quality improvement. UHC clinicians and staff members are assigned to clinical care teams, composed of physicians, nurse practitioners, physician assistants, nurses, medical assistants, and administrative staff members. The practice uses a full capitation model with standard fee-for-service and a fee-for-service plus care management payment model. Ten years ago, UHC instituted the California Health Care Foundation’s Ambulatory Intensive Caring Unit (AICU) model, which emphasizes intensive education and self-management strategies for chronic disease patients. The model relies heavily on the role of medical assistants (called patient care assistants or PCAs) and health coaches. Working closely with other members of the care team, PCAs and health coaches review and update patient information in the record, conducting personal outreach and self-management support, and providing certain clinical tasks. For instance, all PCAs have been trained to review measures (e.g., HgbA1C, blood pressure, and LDL cholesterol), provide disease education, and set and review patient health goals. A subset of higher- trained health coaches works more intensely with recently diagnosed diabetic patients or those patients whose condition is not well managed.
UHC’s eHealth Strategies
Patient registries. UHC uses patient registries to identify patients with specific conditions to ensure that those patients receive the right care, in the right place, at the right time. In some instances, they use registries to target cases for chart reviews and assess disease management strategies. For example, patients with uncontrolled hypertension are reviewed to help identify treatment patterns, reveal any need for more provider engagement, and may indicate the need for care team workflow changes. In the future, UHC would like to construct queries that combine diagnosis groups with control groups and stratify patients by risk group. For example, care teams could pull a report of all patients over the age of sixty-five with multiple chronic conditions or recent emergency room admissions.
Maximizing time and expertise. UHC uses technology such as custom EHR templates to support PCAs and free up clinicians for more specialized tasks and complex patients. For example, a PCA or health coach taking the blood pressure of a high-risk diabetic patient has been trained to determine whether or not BP is controlled. If it is not controlled, the health coach checks the electronic chart for standard instructions on how to proceed and may carry out instructions noted in the record. Or, if no information is available he or she will consult with another provider to adjust and complete the note. Following all visits with PCAs or health coaches, the patient’s record is electronically flagged for review and signed by the primary care physician.
Working with medical neighbors. The teams also collaborate with on-site specialists, pharmacists, social workers, physical therapists, psychologists, and nutritionists to enhance care coordination and whole-patient care. UHC has also adopted curbside consultations and e-consults to reduce specialty office visits. For example, if a hypertensive patient has uncontrolled blood pressure, the record is flagged by the PCA for further follow-up with a physician or nurse practitioner, who may opt for an e-consult with the nephrologist to discuss recommendations. UHC also has a specialty coordination team—composed of two primary care physicians, one registered nurse, one PCA, and one health coach—which functions as a liaison between primary and specialty providers.
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