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Link to refined objectives (xxxx)

Original "Brainstorming" Session including Ideas to Close the From-To GAP for AL - Franklin Primary Health Center

FROM (Current State)

TO (Desired State)

1. Clinic providers are unable to monitor patient profiles across the continuum of care (i.e. transition of care with hospital, pharmacy) through the EMR.
1. Clinic providers are able to monitor patient profiles across continuum of care through the EMR.
Ideas to close this From-To Gap: (Example - Ideas of how to get to the desired state):
  • Create interfaces/modules with immunization registeries, pharmacy, and HIV care within the EMR to access other patient health data
  • Optimize connection/relationship with the state HIT REC
  • Need to identify what is in what - Success EHS and NextGen on transitions of care component
  • Start with specific use case for the HIE interventions
2. The number of BH providers is insufficient.
2. Sufficient number of BH providers to meet patient need.
Ideas to close this From-To Gap:
  • Connect GRHOP MBH partner with clinic operator.
  • Explore Altapointe and FQHC relationship for possibility of integration for referral services.
  • Explore current state of MBH screenings onsite - identify possible needs for staff training and protocol redevelopment
3. The number of Occ. Med providers is insufficient.
3. Sufficient number of occ med providers to meet patient need.
Ideas to close this From-To Gap:
  • Connect GRHOP Occ Med partner with clinic operator.
  • Identify other local and national resources to assist RN (currently trained but not certified) in providing assessments and services
  • Achieving certification
4. Patients have to make their own appointments with Alta Pointe, the regional BH provider and clinic staff cannot.
4. Clinic staff can make appointments for patients with Alta Pointe.
Ideas to close this From-To Gap:
  • Explore Altapointe and FQHC relationship for possibility of integration for referral services.
5. The clinic does not have assigned clinical care teams.
5. The clinic assigns and utilizes clinical care teams.
Ideas to close this From-To Gap:
  • Implement overall PCMH plan and TA to include clinical care teams.
  • Provide onsite coaching for clinical care teams - PCDC?
  • Tour certified PCMH clini in New Orleans.
6. The clinic doesn't have an open schedule, but would like one.
6. Clinic implements open access.
Ideas to close this From-To Gap:
  • Implement PCMH model and provide TA specific to offering open access schedules.
  • Provide front office EMR training for scheduling and to reduce no show rate.
  • Explore current state of appointment scheduling, design, and policies and protocols.
7. Patients are insufficiently motivated to participate in their own health care.
7. Patients are actively participating in managing his/her care.
Ideas to close this From-To Gap:
  • Identify reasons for lack of motivation by individual.
  • Establish patient portal.
8. Patients are not able to be informed or connect to the clinic during emergency events.
8. During an emergency, patients are able to access their patient information and all related services.
Ideas to close this From-To Gap:
  • Proactively get emergency planning information to patients
  • Create a clinic website with emergency planning information
  • Create a patient portal website
  • Utilize texting through EMR system during emergencies
9. Topic 9
9. Topic 9
Ideas to close this From-To Gap:
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  • Idea
  • Idea
  • Idea
10. Topic 10
10. Topic 10
Ideas to close this From-To Gap:
  • Idea
  • Idea
  • Idea
  • Idea