The introduction of the new collaborative will be presented at a VIP press conference schedule for May 17^th 2012 at 10:00 am, at the United Way of the Coastal Empire office located on 428 Bull St. Savannah GA.

The purpose of the project is a to create a community-based approach to improve health outcomes for disease management among uninsured underserved population through better care coordination across volunteer clinics, federal qualified health centers, a level-III medical home associated with a teaching hospital, and a rural health program working with migrant farmers in the onions field of Vidalia, GA using m-health technology.  The elements of CBCDMP are as follows:

• The patient is involved and supported in disease management, with ongoing follow-up and education.
• Services are provided in the community before chronic disease impacts on more complex acute care services.
• Care/service delivery is organized effectively to improve health outcomes.
• Care is appropriate care: the right provider, right time, right place.
• Disease Management is integrated across organizational boundaries.
• Care is evidence-based outcomes driven
• Uses Lay-health promoters to reinforce and modify risk behaviors, and improve self-management
• Key patient data is accessed and transferred through HIPPA compliance information systems using two m-Health systems: Ideal-Life and eMOCHA to case managers
• Convenient to the patients
• Emphasis on patient health literacy and health education

Accountable Care Coalition of Coastal Georgia will serve an estimated 8,000 Medicare beneficiaries in the Savannah Region and is a partnership between SouthCoast Medical Group and Collaborative Health Systems (CHS), a Medicare Advantage Plan.  CHS will provide a range of care coordination, analytics and reporting, technology and other administrative services to enable SouthCoast physicians and other healthcare professionals to deliver quality healthcare efficiently.

This collaboration is designed to achieve the CMS goal of the three part AIM objectives of better overall care, improved health.  It is hoped that these aims will ultimately result in lower per capita costs for Medicare and Medicare beneficiaries.

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

Denmark graduated from Tift College, studied at Mercer University, and taught high school science before she decided to become a doctor. She was the only woman in her graduating class at the Medical College of Georgia in 1928. She moved to Atlanta after graduation and became the first resident at the new Henrietta Egleston Hospital for Children. She admitted the first patient to that hospital, now called Children’s Healthcare of Atlanta. She continued to practice pediatric medicine until she retired at age 103 in 2001 at which time she was the oldest practicing physician in the country.

Denmark received the prestigious Fisher Award for outstanding research in the diagnosis, treatment, and development of an immunization for whooping cough. In 2000, Emory University awarded her with an honorary doctorate to a standing ovation. At that time, there had been only three standing ovations at commencement exercises in the school’s history: for Hank Aaron, the Dalai Lama, and Dr. Denmark. She lived independently until she reached the age 106, when moved to Athens to live with her daughter.

Funeral services are set for tomorrow, Thursday, April 5, at 1 p.m. at Athens’ First United Methodist Church, with burial at Portal Cemetery on Friday at 11 a.m. For more information, visit Dr. Denmark’s website, http://drleiladenmark.com.

Posted form the CMS Medicare FFS Provider e-News for Wednesday April 4, 2012

The recognition was presented by NCQA after it reviewed the clinic’s operations.  To be awarded the practice has to demonstrate that they are a health care setting that facilitates partnerships between individual patients, and the physicians, and when appropriate, the patient’s family. Care must be facilitated by registries, information technology (electronic medical records), health information exchange, improved patient communications, use of evidence medical guidelines, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

This brings the number of medical homes in Georgia to 152.  Memorial Family Practice joins Family Health Center of Statesboro (Dr. Davis and Dr. Riley) and Bohler Family Practice of Brooklet (Dr. Boltri) as being this area’s only certified medical homes.

There are other clinics in the area that are preparing for the NCQA recognition and we hope to see more names on the list in the near future.

Here are there main policy implications.

1. Community leadership – 5.6
2. Community support – 1.8
3. Measure performance – 7.3
4. Report performance – 3.8
5. Align financial incentives – 3.0
6. Health information technology – 0.0
7. Engage the patient – 2.6

Commissioners Stone, Holmes, Shay, Liakakis, Odell, Gellatly and Thomas all voted for the Ordinance.  Commissioner Dean Kicklighter voted against it.  Commissioner Pat Farrell was not in the room for the vote.

This ordinance is the work of Healthy Savannah’s Breath Easy Committee, headed by Amy Hughes.  Healthy Savannah is a coalition of individuals and groups who want to make our community a healthy place to live work and play.  They all came to this group for a variety of reasons – school nutrition, bike paths, smoke-free public policy, childhood obesity, neighborhood gardens, road races, and many other reasons but they all share the common denominator; They want Savannah to be healthier.

Since 2009, smoke-free public policy advocacy has been on Healthy Savannah’s “To Do” list.  Thanks to a group effort and a lot of hard work, Healthy Savannah was successful in getting the City of Savannah to adopt the most comprehensive smoke-free ordinance in the state of Georgia closing the loopholes in Georgia’s Clean Air Act of 2005.  Encouraged by success, those efforts are in the process of being replicated in other communities including Macon, Augusta and Fulton County.  The state of Georgia is studying Savannah’s experience in hopes of passing statewide legislation.  DeKalb County also attempted to pass an ordinance last year, but the strip clubs effectively lobbied to grandfather all existing bars.  The DeKalb Coalition decided that it would do more harm than good if that ordinance passed so they pulled their support from the legislation.

Very early on, the Breatheasy Savannah Chatham Committee of Healthy Savannah developed the goals that it would progressively pass the ordinance in our community first in Savannah, then the unincorporated area of Chatham County, then the other municipalities, then going to Tybee Island last.  (Passage of the 100% Tobacco-free Schools Policy in the SCCPSS was also a committee priority that we succeeded with last spring.)  Breath Easy carefully reviewed the experiences of other communities across the globe that are smoke free and agreed that the goal was to make all workplaces smokefree.  A list was developed of “deal breakers” – changes to the ordinance that were so unacceptable we agreed to walk away.  Exempting bars from the ordinance is one of the pre-determined deal breakers.

Georgia Hospital Association will be working closely with a national content developer to provide tools and approaches to hospitals.  The improvement model is based on the Institute for Health Improvement (IHI) model. Key will be patient safety leadership & culture of safety.

GHA will introduce the program at the Patient Safety Summit and the GHA Annual Trustees meeting in February and is now kicking off the learning collaborative.  The Care Transition Special Interest Group will be the Advisory Group for the Reducing Readmission learning collaborative.

GHA is recommending the use of the leader action guide and will be determining the interventions and agree upon the measurements.   The interventions will fall into one of the four broad categories: 1) enhanced care and support during transitions; 2) improved patient education and self-management support; 3) multidisciplinary team management; and 4) patient-centered care planning at the end of life.

SBG is proud member of the GHA Advisory Council and is a participant of the Care Transition group.

Deason was first elected to the Board in 1991 and has served continuously since.  He has served as Chairman, President, and a member of the Executive Committee. Deason has participated in many of the Coalition’s most significant projects.

“It is hard to find people willing to volunteer but to have someone volunteer their time for 20 years is truly an accomplishment worthy of recognition,” said Gary Rost, Executive Director of SBG. “I and the Coalition greatly appreciate Deason’ s service and the impact he has had on our mission.”

This new County ordinace, in combination with the City of Savannah smoking regulations, is a big move forward in improving the health profile of our community.

There are some who have viewed this new proposal as a failure. The Commissioners did change some of the recommended language (such as allowing smoking in bars with an over 21 restriction or private clubs) but this is a success.

For Chatham Health Link (CHL), he is now working on using the Mirth Connect Web Services Reader to access the Catalyst Enterprise Master Patient Index (EMPI) data and create a EMPI ID to Provider MRN crosswalk table to be written out to a database table.  This asset will be valuable in reporting provider patient overlap, and enhance encounter tracking over time and across providers. CCSNPC is also working on using a Mirth Appliance to set up parallel message processing.  This will allow them to continue the Orion pilot solution and simultaneously begin implementing the next phase with an independent EMPI solution in a more secure and resilient hosting facility.

CCSNPC would also like to congratulate Jamey Smith, CHL’s hardware manager and Coastal Health District IT staff on attending and completing the training along with Cory.