• Very large and rapid growth in the population served by Alameda Health Consortium inspired them to focus on digital transformation in order to manage and effectively respond to health service needs.
  • Heard from Rubicon MD health consultants Dr Nwando Olayiwola (Chief Clinical Transformation Officer) and CandyMagana (Practice Manager) about their work advocating for high quality healthcare for all in their community; bringing a social determinants approach to health care.
  • The Alameda Health Consortium’s PHASE Hypertension Management Project improves health outcomes—its key elements include a patient registry, clinical guidelines, team-based care, patient engagement, and performance metrics and benchmarking.
  • Data are used at Alameda Health Consortium to identify actionable opportunities for quality improvement: some great examples—and even better, it’s really timely data!
  • The Consortium demonstrated the value of care facilitation/coordination for complex chronic care patients. Its embedded role in the primary care team is a key element.
  • Some data tips: invest in analytics and data stewards; relentless incrementalism is better than ‘big bang’; and the most important elements of data are relationships and communication.
  • The Electronic Consult program by Rubicon_MD at the Consortium has reduced appointment wait times, and provided quicker access to care. The E-consult program is linked to the patient’s electronic health record.
  • Some outcomes from the Consortium’s Care Neighborhoods and Community Health Care Worker program: reduced in-patient admissions and ED presentations; but increased specialty visits (because access is better coordinated).
  • The Alameda Health Consortium’s Lifelong Medical Care program has worked with patient-centred scheduling (Open Access). These are Lean processes in action in primary healthcare.
  • ‘We thought moving from an ED of 14 beds to 59 beds was going to solve our problems—they actually got worse!’—lessons from San Francisco to Sydney. A new approach is needed, requiring investment outside the hospitals.
  • ‘Many thanks to the unstoppable Dr Nwando, the Rubicon MD team, the Community Health Centres Network & San Francisco General Hospital for a powerful last day of the US Primary Care Tour. Great program, and great group and friends!’—Walter Kmet (WentWest) (participant).
Tags: 
US Study Tour 2018
US Study Tour
Patient-Centred Medical Homes