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Spotlight on Excellence – TCPi Participation Helps Practice Increase Patient Preventive Health Screenings by Over 1,300

April 9, 2019

Fairview Health Associates, a 2018 winner of the Health Quality Innovator Award for Rural Health, is featured as April’s Spotlight on Excellence provider for their achievements with implementing Transitions of Care Management (TCM) and improving multiple preventive health screening rates. The practice, which is the only general medical office in Summersville, West Virginia, has five doctors, four nurses, one nurse navigator, one laboratory technician, one billing specialist, one practice administrator and three front-desk personnel serving more than 12,000 patients (35% who are Medicare or Medicaid beneficiaries) from five surrounding counties. The closest major hospital is more than 100 miles away. Through the practice’s involvement with Health Quality Innovators’ Transforming Clinical Practice Initiative (TCPi), they focused on patients being affected by obesity, tobacco use and opioid addiction, as well as closing care gaps and reducing unnecessary hospital admissions.

  1. What areas did you look at improving after joining TCPi? – Many of our patients are older so we focused on preventive care related quality measures that would drive better health outcomes. We looked at areas where we could improve performance measures and believed we could focus on pre-intervention tactics, including body mass index (BMI) weight assessments and counseling relating to obesity, colorectal cancer screenings, blood pressure control, tobacco cessation and counseling, and TCM.
  2. What process changes did you make to meet your goals? – We improved the workflow at our practice, which included a thorough process review for each measure we selected through TCPi. We also developed a better understanding of our electronic health record (EHR) system and how evidence-based protocols could be incorporated into patient care delivery. Our team learned how to customize reports and templates and use coding to create a care gap template in real time for each patient during their visit. Customized screen alerts and the care gap reports brought our measure information front of mind and allowed our providers to immediately address these gaps.
  3. What results did you see from these changes? – Improvements included increasing the performance rate in the adult BMI screening measure from a baseline of 21% in 2016 to 99% in 2018, which translates into screening about 1,300 more patients. We also increased tobacco screenings from a baseline of 35% to 97%, increased colorectal cancer screenings from a baseline of 0.7% to 87% and increased breast cancer screenings from a baseline of 0% to 87.5%.
  4. What was key to achieving this impressive increase of preventive health screenings? –  Annual wellness visits were implemented in 2017, which allowed us to focus on prevention and risk stratification among our patient population. Medication management and family history are now a regular part of our doctor/patient conversations, which allows potential issues to be addressed early.
    Our care coordinator nurse ensures that annual wellness visits are scheduled. The nurse’s role also includes scheduling TCM visits for our patients who have been recently discharged from a hospital, hospice or nursing home. Since fully implementing TCM and annual wellness visits, we estimate that we’ve increased our revenue by $33,000.
  5. Aside from the revenue increase, what has been the benefit of TCM? – Transitions of care management is much better because medications are verified, and testing and care gaps are covered immediately after a hospital visit. It’s a seamless process for the patient, and our nurses really enjoy this interaction with the patient. Nurses feel they are helping patients on a higher level, which makes their jobs more satisfying.
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