Spotlight on Excellence – Health and Wellness Center of Louisa Focuses on Treating the Whole Patient

May 7, 2019

Health and Wellness Center of Louisa’s approach to treating the whole patient, regardless of ability to pay for health care, is one of many factors making them Health Quality Innovators’ (HQI) “Spotlight on Excellence” featured practice for May. The Federally Qualified Health Center (FQHC) located in Louisa, VA serves a rural area of 35,236 residents with a median income of $29,519. Health and Wellness operates under Central Virginia Health Services (CVHS) FQHC network, providing comprehensive care that includes medical, dental, obstetrics and gynecology, as well as behavioral health. A member of HQI’s Practice Transformation Network (PTN), Health and Wellness Center of Louisa incorporates uniformity across payment arrangements whether a patient is insured or not, which helps build trust and sends a message that the practice is there to meet the health care needs of its community.

  1. What is the practice’s approach to effectively treating residents in the Louisa region?
    We aim to be patient-centered and continuously work on improving the quality of care we provide. Our office is a patient-centered medical home (PCMH) recognized by the National Committee for Quality Assurance (NCQA), which is a model of care that places patients at the forefront and builds better relationships. Time is allocated for staff to ensure patients receive the services and support they need, such as timely visits for those with chronic conditions. Our team meets weekly to discuss care gaps, quality measures and opportunities to improve, and we also use the Plan-Do-Study-Act (PDSA) methodology to test change and adjust our strategy. Our nurses are at the heart of keeping communication lines open with patients. They frequently review Uniform Data System (UDS) measures and work on connecting with patients to get them back into the practice.
  2. What makes the staff at Health and Wellness Center of Louisa efficient?
    It takes the entire practice to care for our patients and each team member must work at the top of their license. Roles and responsibilities are clearly defined for each staff member. To ensure the best care possible, we conduct pre-visit planning that includes communicating with our patients before their visit. Ancillary staff is trained to capture important information to enter in our electronic health record (EHR) system to satisfy clinical decision support alerts. Our care team huddles periodically throughout the day as new patients arrive and we review our huddle checklist, which includes information such as chronic illness (diabetes, hypertension and depression), lab work, immunization, procedure/screening and whether a behavioral consultation is necessary. We also make sure we have standing orders for patients with diabetes, hypertension, chronic obstructive pulmonary disease (COPD), asthma, as well as screenings and immunizations.
  3. As part of addressing the whole patient, the practice focuses on addressing social determinants of health. Please share your approach.
    We participate in Mobilizing for Action through Planning and Partnerships (MAPP), which not only connects us with organizations to share community resources with our patients but also allows us to educate the community about the services available through our practice. MAPP has outlined priorities that we continuously meet, such as promoting healthy eating, active living, addressing mental health and substance abuse, reducing health disparities and improving access to care and fostering a healthy and connected community for people of all ages. A social determinant smart tool called the protocol for responding to and assessing patients’ assets, risks and experiences (PRAPRE) helps us assess patients’ assets, risk, and experiences, and connects patients in need with external care and resources. We also offer same-day appointments and evening hours once per week. This has increased the average number of patients we see each day by 66%.


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