Download HRSA Presentation March 2008 - NYS Care Management Coalition

Care Coordination and Technology to
Support Physical and Behavioral Health
Michaela Frazier, LMSW
Director of Community Benefit Programs
Institute for Family Health
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The Institute for Family
Health
• Large FQHC network
• Primary care, behavioral health , dental and
community programs
• 100,000 patients with over 500,000 visits
• Rural and urban centers
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Our Service Area
Behavioral Health and
EMR
• EMR implementation in 2002
• All behavioral health and community programs on
EMR since implementation
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Collaborative
Documentation
• Helping consumers embrace use of computer and
technology in session
• Changing room set up
• Using tools and graphs in session
• Quoting patients
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Use of the EMR
in Care
Coordination
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Review progress with
patients
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Shared Care Plan
Safety Planning
Care Team Management
• Patient Documentation Management
o Assessments due
o Care plans
o Upcoming appointments
• Gaps Lists
o Annual wellness visits
o Eye exams etc.
• Emergency Visit Notifications
o Information pushed into the record through the RHIO
o Supports Transitions of Care
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It Takes a Village…..
• Community or physician portal
• Ability to improve intake and expedite referral
services
• Ability to get information on patients In an
emergency
• Longitudinal care planning
• Continuity
• Real time provider communication
• Agencies no longer keeping health records
• Institute Link!!!
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DIRECT SCHEDULING
Patient Snap Shot
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Chart Review
MEDICATIONS
(Current/Past)
Document Upload
Patient Portal Classes
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My Goals and Plans
You have a diagnosis of DIABETES.
Here are your personal treatment goals:
High A1C (average sugar level). Your goal is less than 7%.
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Contact Information:
Michaela Frazier, LMSW
email: [email protected]
cell: 917-831-0334
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