19 May 2016 All for one: Freeman Family Medicine adopts team approach to care

by Sonja J. Keith
Mike Kemp photos

Freeman Family Medicine is working to improve the healthcare experience for its patients with a “comprehensive care approach” that has garnered the clinic national recognition.

The National Committee for Quality Assurance (NCQA) recently announced that Freeman Family Medicine received NCQA Patient-Centered Medical Home (PCMH) Level 3 Recognition “for using evidence-based, patient-centered processes that focus on highly coordinated care and long‐term, participative relationships.”

The NCQA Patient-Centered Medical Home is a model of primary care that combines quality care, teamwork and information technology to improve care, improve patient experience and reduce costs. Research shows that medical homes can lead to improved quality of care, lower costs, and improved patient and provider reported experiences of care.

The clinic participated in two pilot studies that helped make the transition: the Comprehensive Primary Care Initiative headed by Medicare, with Blue Cross and Qual Choice as participants, and a PCMH study by Nexus Clinical Solutions, a division of Blue Cross. 

The comprehensive care approach reflects the change in the medical community from fee for service to quality of care, according to clinic administrator and PCMH coordinator Freda Freeman. “The insurance companies are moving toward this. The patient is more involved in their care, thus promoting better outcomes.”

Dr. William Freeman describes the team approach as “great” but admits there is a lot of effort involved. “That’s why you don’t find it everywhere. It’s a lot of work, but it’s worth it for the patient,” he said, adding that the clinic was already doing many of the tasks associated with improved patient experience and outcomes, but it wasn’t documented in a format for easy review. “It transforms your practice. It helps us to be more proactive in our care.”

The staff at the clinic was very flexible with workflow changes that had to occur to accomplish this goal. In addition, two new positions were created. Kayla Smith became the care coordinator, responsible for making appointments, sending required documentation and tracking referrals to specialists. She also ensures consult notes are received in a timely manner, following the appointment, so specialist recommendations can be reviewed and implemented.

Melissa Tyler, a registered nurse, is the clinic’s care manager. Her responsibilities focus on high-risk patients with medication review, education on disease processes and implementation of community resources.

“Our goal is to help those who have more complex medical conditions receive the care they deserve, but may find difficult to manage all on their own,” she said.

“Home” refers to the team-based, quality of care guided, comprehensive approach to health care, with the Freeman clinic serving as the central location for all of its patients’ health-related needs. The goals of this approach are better access to health care, increased patient satisfaction, improved health and reduced overall healthcare costs. The new approach risk stratifies patients according to their conditions to ensure those with the highest need are receiving the services they require to maintain the highest quality of life possible. Educational materials are also distributed on different disease processes in an effort to help the patient become an informed team member who can partner with their provider and make educated decisions about their health and the available treatment options.

As an example, Tyler cited her work with patients with diabetes. Typically, a patient who had been diagnosed with diabetes would see their provider every three months for a visit. At that time, needed adjustments in their medications would be made. When the patient returned for their scheduled follow up (three months later), the hope is that the medication change would have worked. If not, then more medication changes would be required and the patient would again follow up in three months. At this rate, there is increased risk for patients with uncontrolled blood sugars to deteriorate between visits and potentially require hospitalization. In their new approach to healthcare, diabetic patients who have high blood sugar readings receive a weekly call and subsequent needed medication changes in an attempt to get the patient regulated between visits and reduce the potential for deterioration and hospitalization. At this time, the care manager is also able to provide patients with education, assess barriers to care and incorporate needed community resources.

Tyler also contacts those who are discharged from the hospital to ensure they receive their medications, are functioning well at home and are scheduled for any recommended follow-up appointments. Without monitoring this transition, the patient’s condition could worsen and require re-admittance to the hospital.

Other features implemented at Freeman Family Medicine include:

Nurse Call Line – A nurse or physician with access to the electronic medical record answer calls after hours to address questions or concerns. “We want our patients to be able to contact someone who knows them during those times of uncertainty when the clinic is not open,” said Tyler.

Patient Portal – Individuals have access to their latest lab work and test results with a secure log-in and password. “The Patient Portal also allows individuals to email their physician with questions and concerns and request appointments,” Tyler said.

Care Plans – The nurse practitioners, Amy Burton and Michelle Churchill, develop individualized care plans for patients with chronic disease processes to help them manage their conditions and achieve their goals. The plans help patients understand where they are, where they need to be and how to get there. “With the patient and their provider working together as a team, healthcare outcomes can be improved,” Tyler said.

Patient and Family Advisory Council – The clinic values patients’ opinions and has developed a council composed of current patients who meet quarterly to provide feedback and offer suggestions. Several suggestions have already been implemented and the clinic has received positive feedback from the implemented changes.  

The clinic also periodically surveys its patients to identify any areas of improvement. “This is a result of our effort to improve our clinic and get valuable feedback in regard to the care received,” said Freda Freeman.

Achieving the highest level of recognition from NCQA would have never been possible without the tireless effort of Whitney Guy from Blue Cross in the Nexus study, Freda Freeman said. “She worked closely with our clinic on a weekly basis to ensure the NCQA standards and guidelines were met.”

According to Tyler, the “Home” method of delivering healthcare has already demonstrated improved outcomes. “This is the future of medicine,” she said.

For more information, please call 501.327.0110 or visit freemanfamilymedicine.com.