Supporting a population health approach in primary care

Background: The Thames Valley Mental Health and Addiction Collaborative Care Network is a proof-of-concept initiative between psychiatry, primary care, and community mental health to create an integrated care network. Grounded in practice-based population health management, we have been working to leverage primary care electronic health records (EHRs) as point of care registries. Audience: Health system leaders, designers, planners and clinicians, especially in the areas of primary care, mental health and digital health. Approach: The Thames Valley Mental Health and Addiction Collaborative Care Network is a proof-of-concept initiative between psychiatry, primary care, and community mental health and addictions in the London, Ontario region to create an integrated care delivery network, within existing resources. Our unique model of collaborative mental health care incorporates the key collaborative care elements (based on the University of Washington AIMS Centre), with a strong population health focus, delivered within a team-based primary care setting. Practice-based population health management (PB-PHM) has been identified as an important component for the management of chronic disease within primary care. A key enabler of PB-PHM is a patient registry which can support the identification of patients within a target population, provide prompts and reminders about preventative health care, and inform quality improvement practices. However, there is limited information available about how to implement such registries and current primary care EHRs have limited functionality in this regard. This workshop will introduce the audience to population health management, describe the elements of a point-of-care registry and describe our journey of co-designing a point-of-care registry using primary care EHRs. This interactive workshop will introduce participants to the concepts of population health management and the role of patient registries in supporting an equity driven quadruple aim. Through the use of design thinking tools, participants will explore the jobs to be done in practice-based population health management and discuss the ways in which existing electronic health records can support patient segmentation, preventative care, chronic disease management and patient engagement in a team-based primary care setting. The presenters will review limitations of the currently available tools, the primary care practice environment and opportunities for future development. Outline for 60 minute workshop- 5 minutes Introduction- 5 minutes describing the collaborative care model, principles of population health management, and elements of a patient registry- 30 minutes - through the use of design thinking tools, participants will explore the jobs to be opportunities and challenges implementing PB-PHM and discuss the ways in which existing electronic health records can be developed as registries- 0 minutes - summary of lessons learned and take-awaysOutcomes: Following this presentation, participants will be able to: Understand the components of population health management in the context of integrated health systems Describe how practice-based population health management and patient registries can enhance chronic disease management within a primary care setting using the example of collaborative mental health care Identify the ways that existing primary care electronic health records (EHRs) can support practice-based population health management Describe the challenges and opportunities with current primary care EHRs and practice context in designing patient care digital registries

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