Spotlight on Excellence

Spotlight on Excellence – Chronic Care Needs Among Challenges for Virginia Rural Provider in TCPi

August 14, 2019

Health Quality Innovators’ August “Spotlight on Excellence” features Crewe Medical Center, a four-provider practice specializing in family medicine to over 7,500 patients in Crewe, VA, which is a predominantly rural area. The poverty rate in this area is 28.7%, which is substantially higher than the Virginia average of 11%. The poverty rate, along with the closing of other local health care providers, challenges the practice to meet the needs of an underserved population, many of whom have chronic care and long-term medical needs. With a lack of provider offices in the area, Crewe Medical Center frequently has walk-in patients lined up waiting to see a clinician.

  1. How did you meet the challenge of dealing with an influx of walk-in patients waiting to see a clinician? We had to rethink our workflows and make a push to maximize our efficiency within the practice. We worked with our quality improvement advisor from HQI (Health Quality Innovators) to implement a Patient Visitation Card. Patients receive it at registration, and it asks them to write down their health concerns, follow-up needs and feedback for us. It helps us engage our patients from the get-go and keep our practitioners on track to meet their needs during a visit. Since we started using the card, we have reduced patient visitation time from one hour to 40 minutes, which allows us to see additional people.
  2. How has your practice been successful in helping people manage their chronic conditions? Our patients with diabetes are at a higher risk for heart disease, infections and other health-related complications so chronic care management is a prime area of focus for us. Our clinical staff uses enhanced care plans to establish documentation and direction for our patients with diabetes. We have found that these plans help educate and encourage medication and nutrition compliance. We also have been connecting our patients to community resources such as diabetes education courses, and many of our patients have responded well to this additional support. This has helped us exceed national measure benchmarks for A1C control.
  3. What other changes did you make after joining the Transforming Clinical Practice Initiative (TCPi) to improve care coordination? We implemented transitional care management (TCM) visits in 2018, which allow our staff to better manage patients as they transition out of acute care settings such as an inpatient stay or skilled nursing facility. Our patients and staff have both benefitted from this change. TCM visits provide a foundation for coordinated care after discharge and allow our staff to review testing/treatment results, provide follow-up education and establish necessary additional referrals. This has led to significant costs savings as well. During the second half of 2018, we billed 54 units of TCM, which created an estimated cost savings of $71,095.
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