Spotlight on Excellence – Culture, Commitment and Data Drive Successful Process Change for Downtown Family Health Care

November 7, 2018

Downtown Family Health Care, in Charlottesville, VA is being highlighted as an exemplary practice in November’s “Spotlight on Excellence” for implementing a workflow that doubled the number of annual wellness visits for Medicare beneficiaries to 732 in 2017. This allowed them to identify high-risk patients for care management and improve their health outcomes.

Downtown Family Health Care, a Practice Transformation Network (PTN) member with HQI and a participant in a commercial APM, has 10 clinicians (seven full-time equivalent) at its single location in Charlottesville. They focus on allowing staff to balance work/life/family while approaching patient care by treating the whole person regardless of their ability to pay. Many patients are uninsured, but the practice remains financially successful while also keeping costs down for patients and payers. Mission is also a key part of the practice with many clinicians going on mission trips. An extra week of vacation is even granted for those who participate on Mission trips, which the practice ties to overall staff satisfaction.

  1. How do you balance focusing on patient needs while still being financially stable?

Because our approach is to treat the whole person, and because we resist temptation to be a high-volume shop, we have successfully managed the hospitalization rates of our patients and their emergency room visits, which helps the bottom line of our ACO. We are going to do what is in the best interest of the patient. We’ve found it is better to act in the best interest of the patient and help keep patients out of the hospital. This may mean higher level visits but it reduces the likelihood the patient with multi-system issues will end up in the emergency room. By focusing on improving the health of increased-risk patients, we improved our quality measures and reduced patient/payer costs.

  1. What changes were made to make Annual Wellness Visits a better asset to caring for your patients?

We modified the role of our triage nurse to include care planning and care intervention work. The nurse is the one who uses information provided by the insurers about subscriber care gaps and our electronic health record system to identify patients who are hurting the most and get them scheduled for an office visit. Our clinicians continue to do annual wellness visits, rather than RNs or LPNs, because they believe the best way to treat the whole person is to identify their needs and address them in a single visit.

  1. What positive results have you achieved from adjusting your practice processes?

By offering transitional care management services, annual wellness visits, extended office hours and giving patients the choice to see the next available provider or a particular provider, we have seen patient admissions and readmissions decrease. Our practice has received additional revenue through cost-sharing we received in 2018 from a commercial payer and we achieved a high score for the Cost component of MIPS.

  1. How did you retain a focus on patient-centered care while implementing changes that helped better the practice?

We have been a patient-focused high-touch organization from the start, but without a ton of structure. Our PTN, led by HQI, essentially provided the groundwork for how we needed to look at our workflow and account for our processes in a way people who are looking from outside could see value. We did not change the caring behavior of our staff, but only how we recorded and described our clinical care, so it could be more effectively communicated outside of our organization. Specifically, HQI helped us with our biannual practice assessments, which is a part of TCPI. This helped us find areas that needed improvement and to understand where practice transformation is heading.

  1. What advice do you have for others looking to improve their processes?

Make sure you have people who fit your culture. It is also helpful to have providers who thrive in a culture of wanting to do the best for their patients and not their pocketbooks. You also need to have somebody who is analytically- and statistically-oriented high in overseeing changes to workflow. This will allow them to share data with staff that backs up recommendations for process change.

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