Timothy Borzilleri, RN, discusses the benefits of new spirometer equipment with Kristy L. Lauer, LCSW-R, Chief Clinical Officer. (A spirometer is an apparatus for measuring the volume of air inspired and expired by the lungs.)

By Anthony J. Billittier IV, MD, Chief Medical Officer and Janet Stoeckl, Clinical Director

Our Asthma and Chronic Obstructive Pulmonary Disease (COPD) Medical Neighborhood Pilot program has entered the “go live” phase with The Chautauqua Center (TCC) recently beginning a six-month implementation process.

The Chautauqua Center is a Federal Qualified Health Center providing family medicine and wellness outpatient services to individuals of all ages with offices in Dunkirk and Jamestown, NY.

The key objectives for TCC – and pilot programs — is to improve quality of life by applying patient-centric care and implementing clinical guideline workflow into practices.

The strategies range from prevention thru early warning to high utilization. We anticipate seeing improvement in:
– Patient experience of care
– Health of population being care for with asthma and COPD
– Reduction in Inpatient admission, ED visits, and Re-admissions
– Provider/Office enhanced satisfaction

Implementing evidence-based medicine into a practice will promote consistency of treatment and optimal outcomes.  The established national guidelines of patient care for asthma are The GINA Guidelines and GOLD Guidelines for COPD.

 

TCC Team: Rachel Ritter, LPN; Kristy Lauer, CCO; Zoraida Nieves, MA; Amani Seymore, MA; Timothy Borzilleri, RN; Michele Reynolds, RN

To date, The Chautauqua Center (TCC) has instituted a Quality Improvement Team to implement the program requirements based on the National Guidelines,  in addition to implementing a standardized approach for pre-visit planning and at the patient point of contact. TCC has also begun to address areas of weakness in their Medical Neighborhood.(Medical-N). Opportunities for timely care, coordination and communication with pulmonologist support is underway. Identifying DME vendors that have respiratory therapy support for at risk patients in their home, and to continue to build upon the relationships with community based organizations that addressed the social determinates of health to support patient’s stability in their home environment.

MCC will work closely with TCC QI and key staff to implement the following Asthma COPD program elements

Months 1-2
– Registry management (Gaps in Care)
– Support the development of key work flows

Months 3-4
– Registry management continues
– Implementation of validated Asthma and COPD screening tools. (SDOH, Medication Adherence, Symptom Assessment tools)

Months 4-6
– Registry management continues
– Practice continues with implementation of validated Asthma and COPD screening tools. (SDOH, Medication Adherence, Symptom Assessment tools
– MCC will assist with development of workflows for patients discharged from ED/Inpatient to primary care follow up (guideline driven)

For an overview of the entire 6-month COPD Population Health/Medical Neighborhood Pilot implementation process, please click here:

Millennium looks forward to continuing to work with TCC in the months ahead on the COPD/Asthma Pilot; and to gaining feedback on expected benefits to TCC.

(The Chautauqua Center is also supported by Millennium Primary Care Support team member Amy Pease, RN MA. In addition to advising on best practices and supporting the completion of deliverables; Amy also provides independent contractual support for TCC’s QA/Risk Management/Special Projects. )

For further information on implementing COPD Population Health/Medical Neighborhood Pilot, please contact Janet Stoeckl, Clinical Director t: +1 716-898-6428 e: jstoeckl@millenniumcc.org

 

Click here to view additional photos: VISIT TO THE CHAUTAUQUA CENTER

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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

Millennium Collaborative Care

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www.millenniumcc.org

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