Cleveland Clinic Lakewood Family Health Center. Jenny Evans James Hekman, MD FACP Judy Welsh, MD FAAEM

Transcription

1 Cleveland Clinic Lakewood Family Health Center Jenny Evans James Hekman, MD FACP Judy Welsh, MD FAAEM

2 Our Vision To be a reliable partner in an integrated and coordinated approach to health and wellness which is inclusive of health systems and community organizations and that removes barriers to healthy living for all of Lakewood s people. Within 5 years, it is our hope that a Lakewood community member will be able to say that through the Lakewood Family Health Center s focus on population medicine and efforts of others in the community my family and those I care about are healthier and have a better quality of life

3 Objectives 1. Update this task force on the progress of the new Lakewood Family Health Center 2. Give a broad overview of the current initiatives our teams are working on in Lakewood. 3. Introduce current and future collaborations with community partners to improve health and wellness through population health

4 Population Health Many progressive health care organizations are doing cutting edge population health management, but are also working with other partners on total population health across geographic [geopolitical] populations. In such cases, it would be appropriate to label these efforts as population medicine expanding into total population health. David Kindig April 6, 2015

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7 Lakewood FHC Lakewood ARB approved Design

8 Third Floor Draw Lab Internal Med Ctr. for LGBT Diabetes/Endo Allergy Pulmonology Chronic Care Geriatrics Neurology Nephrology Urology Behavioral Health Cardiology General Surgery Dermatology

9 Patient Centered Exam Room

10 The Center for Family Medicine

11 Faculty Physicians Sandy Snyder, DO Program Director, Director of Osteopathic Education Fred Jorgensen, MD Chairman, Associate Program Director, Medical Director Kelly Raj, DO Associate Program Director/Curriculum Director Dave Eberlein, MD OB/GYN & Medical Student Director Carl Tyler, MD, MSc Geriatrics & Research Director Robert Kelly, MD Integrative Medicine /Conference Director John Hanicak, MD Faculty

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13 School Based Health Care

14 School Based Health Careitiative Description Clinic located within Lakewood HS providing services for the Lakewood school district 2 exam rooms, conference room, & office space for: Telehealth Behavioral health consults Shared medical appointment space APP provider to serve students and school faculty and staff Dedicated clinical time to Teen Health mission.

15 Navigation Center Purpose Community outreach Financial Service Clinical Outreach and Education; Health Screenings Linkage to external Social service agencies Patient Qualifications for insurance Assist with medical applications Coordinate the service needs of patients including: housing, food stamps, clothing, transportation, etc Care coordination for Chronic disease management, Behavioral health and primary care

16 Patient Navigation Model The Patient Navigation Model at STJHC aims to increase coordination across the continuum of care, from outreach to rehabilitation, using both clinical and lay navigators. Patient Navigation Community Outreach: -Identifies patients in need of HC Services. -Represents Cleveland Clinic in the Communityifies patients needing HC services Promotes CCHS brand in community through events Patient Navigation Services Barrier identification / assessment Helps patient in navigating non clinical elements of care First point of contact Maintains relationships with community groups Patient Navigation Provides health and wellness programming to patients and community Navigator Barrier Navigator Financial Counselor(s) -Insurance Assistance -Payment Plans Assistance Payment Plans SociSocial Worker(s) -Psychosocial assessment and intervention External Resources -Community Resources -Social Resources Social Resources Navigator Barrier Clinical Clincal Coordinators -Chronic Disease Management(DM, CKD)oordinators Chronic disease management clinics (diabetes, CKD) Navigator Cliniciansicians -Physicians Navigator -Physical Therapists - Pharmacyherapy Pharmacy Types of Barriers Cultural Logistical Financial Clinical

17 Social Determinants of LGBT Health 56% of Lesbian, Gay, Bisexual patients have experienced some form of discrimination in healthcare. 70% of transgender individuals have experienced discrimination [HRC HEI 2014]. LGBT individuals face discrimination in access to health insurance, employment, housing. Shortage of health care providers who are knowledgeable and culturally competent in LGBT health [Healthy People 2020]

18 Certifications, recommendations, etc. Required for certification as a Healthcare Equality Leader by Human Rights Campaign Does your organization have an official plan, strategy or goals for reducing health care disparities and/or providing culturally appropriate services to your patient population? Does this plan specifically include LGBT patients in addition to race, ethnicity and linguistic concerns? ACP Health and Public Policy Recommends that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would other beneficiaries. Recommends that the definition of family be inclusive of those who maintain an ongoing emotional relationship with a person, regardless of their legal or biological relationship. The Joint Commission: Field Guide Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Urges U.S. hospitals to create a more welcoming, safe, and inclusive environment for LGBT patients and their families. Department of Health and Human Services: Will encourage new and existing health profession training programs, including behavioral health (e.g. mental health, substance abuse, and HIV) programs, to include LGBT cultural competency curricula. 1 8

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20 HIV incidence

21 Patient Care

22 Mental Health Care Adult psychiatry, MD s and APP Child and adolescent psychiatry Psychotherapy Colocation of mental health teams with primary and specialty medical care. Mental health faculty Behavioral health resource school based clinic. Community mental health center partnercomprehensive mental health services.

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