^{22nd World Nutrition & Pediatrics Healthcare Conference}

Statement of the Problem: Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. Although the need for care coordination is clear, there are obstacles within the American health care system that must be overcome to provide this type of care. El Centro Regional Medical Center (ECRMC) is located in El Centro, California and stands as the principal city of the County of Imperial. ECRMC patients face many healthcare disparities, including our rural geographic location, an ethnic community makeup, low socio-economic status and literacy rates, limited access to public transportation and high levels of air pollution. Access to care has long proven to be a major challenge for the community and its citizens. In 2012-13, there was one primary-care physician for every 4,170 Imperial County residents, compared to one for every 1,341 residents statewide. The Imperial Valley’s geographic location and high summer temperatures (120 °F) make it difficult to recruit and retain qualified providers for both primary and specialty care.

Method: The overarching goal is to improve access to care for our patients by providing culturally competent, evidencebased and person-centered care. We are moving towards a population health management model across the continuum of care. Three initiatives were deployed:

(1) Ambulatory Care Redesign: Primary care, obesity prevention & healthier;

(2) Foods initiative;

(3) Resource Stewardship: High-cost imaging. Metrics were established to determine effectiveness of interventions and coordinating care.

Findings: The initial findings are short of meeting the targets. It was found providers were not consistently utilizing standardized criteria in treating low back pain to manage resource stewardship. Physician documentation was missing from the patient progress notes because the service was not rendered, or the documentation is not inputted as structured data, so it is not being picked up by coding or our mapped reports. Due to a lack of interconnectivity between the current EMR systems throughout the hospital, this initially posed a challenge for applying a standardized algorithm to capture the target population nearly impossible.

Conclusion & Recommendation: It was vital to enhance patient engagement and various types of touches (outreach and in-reach), to include new campaigns and non-traditional services (such as telemedicine and phone visits). Also, equally as important was to collaborate on improving coordination of strategies with the hospital internal resources such as quality, risk staff and enhancing the external partnerships to improve performance and patient care. External partners included insurance providers, disease support groups and the hospital resources to ensure mutual attainment of goals. Created standardized templates such as for the tobacco cessation and screening, BMI-Nutrition counseling for primary care to ensure consistency and easy to document structure. In addition, establish the screening criteria to assist providers to utilize the “Red Flags,” criteria in prompting ED physicians to document the reasoning for ordering an imaging study for uncomplicated low back pain. Lastly, induce accountability by including the PRIME/HEDIS metrics to the physicians OPPE, it will provide a sense of accountability to provide quality care.