Spotlight on Excellence

Spotlight on Excellence – Enhanced Teamwork, Process Change Positions Clinician Office for Success in Value-Based Care

October 9, 2018


Photo of New Horizons Healthcare team

Thanks to money granted to New Horizons Healthcare (NHH) from the Virginia Healthcare Foundation, many lives are being impacted in a positive way. Through New Horizons Healthcare’s “Hope, Health and Healing” initiative, patients with diabetes and depression are becoming healthier by lowering their A1Cs through diet and exercise. They also are forming friendships within therapy sessions, support groups and group activities, which is helping with depression and isolation. Pictured are members of the “Hope, Health and Healing” committee, from left: (back row) Kim Slaughter, Jessica Dent, Quill Giles and Ruthie Peevey; (second row) Jessica Gillispie, Katye Hale, Jackie Martinez, Cathy Parker, Donna Whitehead and Alison Allsbrook; and (front) Nancy Ridgley and Dr. Victor Bell.


New Horizons Healthcare, in Roanoke, Virginia, set a goal to transform their practice into a Patient-Centered Medical Home (PCMH) and better position themselves for the evolving state of health care, specifically the advancement of value-based care. Read how they worked together to become a high-performing practice, achieve their performance goals and improve patient outcomes. New Horizons Healthcare is being highlighted as an exemplary practice in HQI’s “Spotlight on Excellence” feature for October 2018.

  1. What challenges do you encounter on a day-to-day basis?

The demographics of our patients are diverse. Many who are uninsured or under-insured, as well as our Medicaid and Medicare patients, often have outside factors affecting their efforts to get well or stay healthy. Many lack transportation, have limited finances, or cope with other issues that lead to inconsistent follow-up appointments and compliance with clinical advice. Committing to improving their health is not necessarily a top priority. About 15% of our patients also have a language barrier.

  1. What goals did you want to accomplish as part of the Transforming Clinical Practice Initiative (TCPI)?

First and foremost, we wanted to achieve PCMH certification, which we ended up doing with a Level 3 recognition and a top-level score of 100%.

We also wanted to take our care coordination to the next level by improving chronic disease management, decreasing emergency department visits and preventing unnecessary hospitalizations.

  1. How did you reach those goals?

Our staff already work well together but we wanted to increase the level of teamwork even further. And we did. We created daily huddles, monthly care coordination meetings, and quarterly all-department meetings where we focused on quality care and discussed how to achieve our goals.

On the process side, we bumped up our use of EHR-messenger campaigns, created registries, closely watched our quality reports, and boosted patient engagement by sharing more information with patients, not just clinicians. Our care coordination team used our EHR system to boost care planning by connecting patients and their families with external resources. This included increased engagement with community health workers and other partners. They helped us offer health education to our patients and other members of the community.

  1. How did your improvement efforts positively affect your patients?

We refined our processes to help patients better manage their chronic diseases. As a result, our data showed that when we better coordinate care, our patients adopt healthier lifestyles and we reduce health care costs. Here are some of our specific results:

  • Improved A1c results for 96 patients with an out-of-control HA1C (>9)
  • Improved control (<140/90) for 369 patients with hypertension
  • Improved screening and cessation counseling for tobacco use for 2,221 patients
  • Improved screening rates for colorectal cancer by 61.1% with 839 patients screened.
  • 3,384 more patients were seen for their annual wellness visit
  1. What was the bottom line for achieving success in TCPI and what would you recommend to others looking to improve their practice?

We used resources provided by HQI’s Practice Transformation Network and PCMH to build our care coordination efforts with a focus on integrated team-based, patient-centered care.

HQI offered guidance with using huddle sheets, chronic care guidelines, quality goal setting resources, and offered individual support. We also worked with our EHR vendor to find the best way to capture our data and communicate with our patients using messenger outreach, patient portals and Healthcare Effectiveness Data and Information Set (HEDIS) dashboards.

Getting our clinicians and other staff to buy into taking part in TCPI was a challenge because we were already involved in other initiatives, so we tried to get everyone on board early. We used friendly competition as an incentive and offered small rewards. Now, seeing patients improving their health and being removed from chronic care lists is what drives our staff.

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