Spotlight on Excellence

Spotlight on Excellence – Rio Family Medicine Reduces Hospital Readmissions and High-risk Medication Use While Keeping Preventive Screenings Near 100 Percent

February 6, 2019

Rio Family Medicine staff include, from left, Yafel Valera, Dr Ernest Pugh, Mercedes Herring, Shelley Walker, Cynthia Lewis, Dr. John Carpenter, Debbie Bammann and Sarah Moore.

Rio Family Medicine is Health Quality Innovators’ exemplary practice in February’s “Spotlight on Excellence” feature. We are recognizing this high-performing practice for reducing unnecessary hospital readmissions and emergency room visits, maintaining a high-rate of preventive screenings, and decreasing the use of high-risk medication use among their patients.

Rio Family Medicine, an independent practice in Charlottesville, Virginia, is part of a clinically integrated network (CIN) managed by a local health care system. Rio participates in two Alternative Payment Models (APM): Medicare’s MIPS (Merit-based Incentive Payment System) and a shared-savings program with a commercial payer.

  1. What makes your practice efficient?

We implemented several best practices, including huddles, which allow our team to conduct pre-visit planning for patients. We review charts of patients coming in for appointments to make sure their vaccinations and preventive tests are up to date. If a patient was seen by another health care provider, we make it a priority to get that record, which helps us close the gap on referrals. For example, of 415 patients seen by specialists in the first quarter of 2018, reports were provided to us 85% of the time.

  1. How has pre-visit planning affected your preventive screening rates?

Our patient preventive screening rates were high in 2018. Breast cancer screenings were 98 percent and colorectal cancer screenings were 97 percent. Immunization rates were also high; 98 percent of eligible patients received the influenza vaccine while 98 percent of adults 65 or older received vaccinations for pneumonia.

  1. What has been your operational approach to reducing readmissions in the community?

More than 20 percent of our patient population are Medicare beneficiaries. We saw over 600 patients with Medicare in 2018 and 76 percent of these patients had Annual Wellness Visits with one of our physicians. We offered advance care planning during some of these visits, which helped patients plan for their future health and saved them money. When offered during an annual wellness visit, there is no cost to beneficiaries for advance care planning. Last year, we also saw 54 patients within two weeks of being discharged from a hospital as part of our Transition Care Management service. This helped patients recover and helped them avoid a hospital readmission.

  1. How did your staff meet the challenge of reducing patient use of high-risk medications?

First, we used PDSA (Plan, Do, Study, Act) cycles and our EHR system to identify over 120 MMEs (morphine milligram equivalents). Our doctors and patients developed a plan to eliminate at least one high-risk medication, and we reduced these rates from 6.7 percent to 5.1 percent in one year. We also reduced the rate of patients on two or more high-risk medications from 7.3 percent to 5.9 percent.

  1. What is at the core of Rio Family Medicine’s success?

Overall, our caring attitude is what sets us apart. For members of the care team, showing up every day isn’t just showing up for work but fulfilling a commitment to their patients. Both of our providers earned their education locally at the University of Virginia. The physicians and the rest of our staff are dedicated to this community.

  1. What would you recommend to other facilities striving to become a high-performing practice?

Get everyone on board. The whole team must show a positive attitude, believe in the improvement process and have the mindset that we are going to be the best.

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