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Spotlight on Excellence – Strategic Planning Takes Maryland Provider to Next-Level Care

September 16, 2019
Health Quality Innovators’ September “Spotlight on Excellence” features Greater Baden Medical Services (GBMS), a Federally Qualified Health Center (FQHC) with six Maryland locations across Prince George’s County, Charles County and St. Mary’s County. The multi-practice, non-profit organization cares for over 16,000 patients annually and employs 17 medical providers and 150 staff members to provide a range of care including pediatric and adult primary care, behavioral health, eye care, veteran’s care and an array of health education, outreach and links to public health and social services. They also provide a medical safety net for diverse and traditionally medically underserved communities to eliminate health disparities.
  1. What are some changes you have made to continue providing high-quality primary care?
    We adopted the Patient-Centered Medical Home (PCMH) model in 2016 to better serve our patients. This model assures we are coordinating our patients’ treatment through their care team, and that they receive appropriate care at the right time in a manner they can understand. We went through a rigorous process to be recognized and maintain our status as a level 3, the highest level of PCMH by the National Committee for Quality Assurance (NCQA) at our Brandywine location that provides adult, pediatric and dental care. We also achieved Joint Commission Status for complying with national performance standards that promote quality health care delivery. We provide nutrition and wellness services through the Women, Infant, & Children (WIC) program at three of our sites, as well as complimentary transportation for those who need it. We also are planning to spread the PCMH model to our other locations by 2020. Our quality improvement team and staff meet regularly to address challenges, process patient feedback, and monitor quality measures and the uniform data set (UDS) for improvement.
  2. How do you approach reducing unnecessary hospitalizations and improving health outcomes?
    To be more patient centered, we implemented i2i, a population health management tool, which established effective care management of our patients with chronic conditions. The tool, in combination with our electronic health record (EHR), helped us stratify risk level and better manage our high-risk patients. Another element we incorporated was our dynamic care coordination model. Complex care nurses (CCNs) were hired to be part of the clinical care team. The CCNs use Maryland’s health information exchange (HIE), Chesapeake Regional Information System for our Patients (CRISP), to coordinate care for patients who were high utilizers of the emergency department (ED) and hospital. We use gap reports to identify and contact patients who should come in for preventive or chronic care. One service we use to get patients in the office that helps identify those who need care management is Medicare’s Annual Wellness Visits. Since incorporating CCNs, we have seen an additional 70 Medicare patients, and that number continues to increase each quarter. These reimbursable visits allow us to establish a patient-provider relationship as we formulate and maintain a personal prevention plan that addresses their risk factors, conditions and recommended treatments.
  3. What has been key to GBMS’ success?
    We strongly believe in creating a sound strategic plan that is aimed at identifying goals to guide the organization. Our plan in place for 2015-2020 assists with focusing on reaching measurable outcomes and providing a timeline that spans across all areas of our organization from clinical/quality to operations. It helps identify programs and initiatives, such as the Transforming Clinical Practice Initiative (TCPi), which aligns with our goals to incorporate our staff to a greater degree in our quality improvement. Our value is demonstrated by the quality, respect, professionalism, teamwork and commitment we embody as a staff, and we will continue to strive to support our patients’ health and well-being.
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