Spotlight on Excellence – Falls Church Practice Focuses on Person and Family Engagement for Mostly Older Vietnamese Patients

July 17, 2019

July’s Spotlight on Excellence features Sang Van Tran, MD, an independent, solo practice located in Falls Church, Va., which provides care to about 2,000 patients per year with the majority being Vietnamese and only 6% who speak English as their primary language. The practice is built on strong values and understands the expectations of the population they serve. In many Asian cultures, multiple generations cohabitate to take care of each other, and many of Dr. Van Tran’s patients are Medicare-eligible and live with their children and grandchildren. Person and family engagement is critical to successful health outcomes for their patients. Sang Van Tran’s practice is a member of Health Quality Innovators’ (HQI) Practice Transformation Network (PTN) in the Transforming Clinical Practice Initiative (TCPi).

  1. How do you approach maintaining the health of your older population?
    We focus on preventive care by using annual wellness visits and care coordination for our patients and community. Our protocols and guidelines that are incorporated in our electronic health record (EHR) system help us deliver better patient care. Support tools such as clinical decision alerts for services that are due, care gap reports and condition-specific pathways enhance our screenings for blood pressure, diabetes and cancer. We’ve also focused on referral follow-ups and documentation in the EHR, which has improved our patient referral management and care management.
  2. How has the implementation of annual wellness visits benefited your patients and your practice?
    We began annual wellness visits in 2016 and now average over 600 visits. Our patients and Dr. Van Tran develop a personalized prevention plan that helps prevent illness based on patients’ current health conditions and risk factors. Our care team and patients discuss health issues, barriers to care and the need for preventive care, which is particularly important with our older population. The annual wellness visits have led to better care coordination and helped us improve health literacy, shared decision making with patients and their family, better medication management, and improved management of complex conditions such as diabetes and hypertension. The practice has also benefited because additional revenue from the visits has allowed us to invest in practice transformation.
  3. How were you able to successfully implement changes when you joined HQI’s PTN?
    Dr. Van Tran is very engaged with our PTN efforts. He openly shares information with the team about our vision for improvement, aims, progress and updates about our performance. Everyone bought in to improving the quality of our work in all aspects of the practice and we have been able to continually demonstrate data-driven quality improvement and helps our patients live healthier lives.
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