Posted by: Primary Care Coalition
Silver Spring, MD, US
About The Primary Care Coalition of Montgomery County, Maryland
The Primary Care Coalition of Montgomery County, Maryland was founded in 1993 when a group of physicians and health care officials imagined a Montgomery County where every resident had access to high-quality health services. They envisioned a dependable source of primary care for low-income, uninsured individuals in our community and created a framework that shared the responsibility for providing that care across the public and private sectors. The Primary Care Coalition (PCC) was formed to help make their vision a reality.
The PCC, a mid-sized regional non-profit, is deeply connected to the continuum of care for low-income uninsured, ethnically diverse residents of Montgomery County who frequently lead medically and socially complex lives. The PCC strives to provide a coordinated network of high-quality care for vulnerable residents of Montgomery County. The PCC works with the Montgomery County Department of Health and Human Services (DHHS), 12 independent safety-net clinics, six hospitals, and a number of other community partners to help patients’ access the full range of care they need.
The mission of PCC is to be the catalyst for developing and coordinating a community-based healthcare system that strives for universal access and health equity for underserved community members. The vision of PCC is that all community members have the opportunity to live healthy lives, and that Montgomery County will be the healthiest community in the nation and a model for providing access to high quality and efficient care for all. To learn more please visit www.primarycarecoalition.org.
The Director, Outcomes Improvement (OI) is responsible for development of outcome metrics, overseeing data acquisition and analysis for measures, facilitating a learning collaborative among local organizations providing care transitions and care coordination, and supporting improvement activities. The Director OI supports the Nexus Montgomery Regional Partnership (NMRP), a $7.6M collaborative effort among the six hospitals operating in Montgomery County and a network of community-based organizations, with the goal of reducing unnecessary hospital use by connecting people to community services that can help keep them healthy.
PCC serves as the management and implementation infrastructure for the NMRP under the direction of the governing NMRP Board of Managers (representing the six member hospitals), the NMRP Finance Committee (responsible for assessing programs’ return on investment) and the Partnership Program Interventions Committee (P-PIC: responsible for review of programs’ outcomes and recommendations for programs’ expansion or contraction). Specific to NMRP care coordination programs, outcomes include: reduced hospital cost, admissions, readmissions and ED visits and reductions in total cost of care not limited to hospital costs. The initial four programs of the NMRP are described below; the learning collaborative primarily involves the first two program areas.
- Wellness and Independence for Seniors at Home (WISH: a pre-emptive care coordination service for Medicare Seniors living independently in community; implemented by The Coordinating Center; goal: to reduce avoidable hospital utilization),
- Hospital Care Transitions (HCT: 30-90 day programs implemented uniquely by each of the six NMRP member hospitals; goal; to reduce readmissions),
- Community capacity expansion and system improvement for the Severely Mentally Ill (SMI; goal to reduce hospital utilization), and
- Specialty care for ineligible-uninsured; goal to reduce hospital utilization and readmissions.
Reporting to the NMRP Partnership Director/VP Population Health (PD/VP), the Director OI is supported, directly and through matrix relationships, by process improvement and data management and analytics staff. The Director OI is the primary staff liaison to the P-PIC, providing staff support and facilitating P-PIC review of Nexus Montgomery programs for recommendations to the NMRP governing Board.
The P-PIC meets monthly to establish and monitor key Nexus Montgomery performance and outcome metrics, monitor needed quality improvement initiatives, evaluate and recommend proposed projects, and ensure that the Board has the information needed for informed decision-making.
- Support P-PIC in the development of performance and outcome measures for all NMRP programs. Refine the metrics’ technical specifications, assess availability and timeliness of relevant data. Reconcile outcomes metrics required by HSCRC with measures tracked by P-PIC. Educate P-PIC and Partnership Director on assumptions and relationship between P-PIC measures and HSCRC measures.
- Work with CRISP, HSCRC, VHQC, member hospitals, and others to obtain access to data needed for measures.
- With data management and analytics staff, gather measures data from multiple sources; assure data integrity, privacy and security. Implement procedures for regular updates to measures. Perform or interpret quantitative analyses. Prepare routine and ad hoc reports for internal and external stakeholders.
- Assist P-PIC in interpretation of measures and in creating recommendations to the NMRP Board for program investments. At least annually, provide P-PIC with a summary of literature review on programs with evidence of positive impact on hospital or total cost of care.
- Serve as primary staff liaison to P-PIC. Plan meeting agendas with P-PIC Chair. Ensure meeting materials are distributed, minutes are maintained, PD/VP is informed of actions or recommendations, and staff follow-up activities are completed.
Care Coordination Outcomes Improvement
Facilitate regular meetings and quality and process improvement activities among participating care transition, care coordination programs and other stakeholders to achieve reductions in avoidable hospital admissions/readmissions and ED use. Maintain minutes and insure follow-up of issues to completion.
- Plan, coordinate and facilitate regular collaborative learning activities among the six hospital care transition programs, including WISH program as appropriate.
- # Promote the sharing of challenges, lessons learned, best practices or other models from regional or national care coordination programs that serve to maximize the effectiveness and efficiency of individual care transition programs. Provide process improvement technical assistance and consultation when requested by individual hospitals.
- # Facilitate resolution to intra-program inefficiencies among the many patients shared across hospital care transition programs (and WISH).
- # When appropriate, encourage development of common solutions or programs, promoting innovative design of community ‘utilities’ for care coordination, care transitions, chronic care management, that address clinical and social determinants of health.
- Draft approach and resource plans to address challenges that require the engagement of community stakeholders beyond the HCT and WISH teams. With PD/VP, assess staff capacity and budgets to implement plans. Provide leadership for improvement effort and technical assistance as directed.
- Provide oversight of the subcontracted WISH program, working with subcontractor’s WISH Program Director. Ensure program retains focus on outcomes; provide insights to subcontractor on program design challenges and changes. Serve as communications liaison from WISH subcontractor to PD/VP and P-PIC regarding program successes, challenges and requests for changes in scope of work or design.
- Support PD/VP in communications to the NMRP Board, HSCRC and other external stakeholders on programs performance, outcomes and recommendations; address impact on short-term and longer term population health goals and opportunities. As delegated by PD/VP, represent Nexus Montgomery Regional Partnership to external agencies and organizations.
- Identify and build opportunities for collaboration with local, State and Federal organizations, academic centers involved in health care management and quality improvement efforts, and others to further regional reductions in hospital and total cost of care, ensure positive patient experience, and improve population health.
- As time permits, engage with the PCC Director of Quality and Improvement to serve as peer mentors to staff to further develop PCC’s culture of quality and improvement. Participate in other PCC collaborative improvement programs, such as the Safety-Net Medical Directors’ clinical quality/HEDIS measures.
- Perform other duties as assigned.
- Professional Licensed Clinical Experience (e.g. Physician, Physician Assistant, Nurse Practitioner, Registered Nurse) or equivalent; must have knowledge and clinical experience to engage in improvement discussions involving specific clinical diagnoses.
- Demonstrated experience in process improvement with ability to work as a consultant, facilitator and colleague with multidisciplinary healthcare professionals.
- Demonstrated advanced communication skills. Ability to communicate effectively and persuasively, both orally and in writing to a broad range of stakeholders, including clients, clinicians, hospital administrators, and public health officials. Prepare and deliver effective presentations. Listen actively, build rapport easily, identify conflict and tension and facilitate constructive resolution, inspire and build trust.
- Demonstrated advanced analytical skills. Experienced in definition of outcomes and process measures and reporting. Familiarity with data collection/data analysis and relational data base functionality sufficient to direct data management and data analysis staff.
- Public Health or Hospital Quality Improvement experience preferred.
- Care Coordination/Care Transitions experience preferred.
- Ability to organize, develop, implement, monitor and evaluate professional work plan goals and performance objectives. Must have superb organizational skills and attention to detail.
- Ability to lead, facilitate and work with diverse groups. Experienced in creating engaging, non-judgmental meeting environments that encourage sharing of challenges and failures and supportive peer-to-peer learning.
- Computer literacy with proficiency and expertise in Microsoft Office, including WORD, EXCEL, and PowerPoint.
- Self-motivated individual with the ability to work independently and with minimal supervision.
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