Video chats, case tracking among key tools

NASHVILLE, TN – Last year, the Centers for Medicare & Medicaid Services provided grants to 500 Federally Qualified Health Centers (FQHCs) for a demonstration project to showcase how the Patient-Centered Medical Home (PCMH) model can improve care and lower costs.

The FQHCs are reporting teamwork has improved greatly – and IT is playing a major role in making that happen.

“There have been times when I’ve been awestruck by the feeling of support and camaraderie among our team members,” said Mary Szecsey, executive director of West County Health Centers, which serves 12,000 patients in three communities in western Sonoma County in California. “Technically, our biggest challenge has been getting the self-management systems in place,” she said. “Overall, it has been a huge investment in redefining roles, staff training, and workflow redesign. But we’re getting pretty good at change management here.”

West County’s IT system has been a work in progress. “We already had an EHR in place, but we needed to add better data analytics tools,” said Jason Cunningham, DO, West County’s medical director. “Now I can easily analyze data at a core team level to monitor how we’re managing our diabetes, HIV and hepatitis C populations.”

Cunningham adds that technology is improving communication among all West County’s care teams, which include behavioral health, a teen clinic and even one health coach.

“Our health coach spends an hour with a patient, then does a video chat with the provider,” said Cunningham. “The coach is specially trained in motivational interviewing and active listening, and she’s really helping our patients with setting realistic health goals and sticking to them. In similar fashion, our nurses take iPads when they make home visits so they can video chat with the physician at the point of care.”

“Most of our work so far has been in team development,” said Mary Bufwack, CEO of United Neighborhood, which operates nine freestanding community clinics in Nashville, Tenn. “We’ve implemented a ‘morning huddle’ that includes not just the provider and medical assistant, but the behavioral health and customer service people as well.”

As part of the PCMH demo, United Neighborhood received $35,000 in federal funds from the Bureau of Primary Health Care.

“We used that money to begin implementing a robust reporting and case management tool,” said Bufwack. “It will sit on top of the patient’s electronic health record and pulls data from it. We’re planning to go live in June, and we anticipate that it will greatly improve our case management tracking. EHRs are really good at documenting, but the reporting features aren’t always the best. This new tool will help us manage our diabetes cases more effectively.”

United Neighborhood is also taking part in a Medicare PCMH initiative. “CMS chose our Cayce Family Clinic in east Nashville because over 200 Medicare patients use that facility for primary care,” said Bufwack. “This initiative provides an extra management fee – $6 per member per month – to help us improve quality and engagement with our Medicare population.”

Both West County and United Neighborhood have taken steps to make their front office team more service-oriented. “We’re planning to centralize our appointment system so that our front desk people will have more time to deliver real customer service,” said Bufwack.