Staying alive: A survival story from the primary care frontline
By Gregory Reicks, DO, a Family Medicine Physician at Foresight Family Physicians in Grand Junction, Colorado
About 10 years ago, my small Colorado clinic started changing systems in order to provide better care to our patients with diabetes. Fast-forwarding to today, we’re a Level 3 certified patient-centered medical home that’s embraced team care. I’m often asked why—and how—we worked so hard for so long on improvement. My response now is very different than what I might’ve said a decade ago.
In the early 90s, we needed to report to a payer on diabetes care, and were hand-entering data into spreadsheets. To streamline this process, we transitioned to a population-based approach implementing the Chronic Care Model (CCM) developed by Dr. Ed Wagner. We thought we were doing a really good job of managing our diabetes patients, but through our new focus on data, we soon realized we had significant gaps in care. This awareness led to one improvement effort after another. Here is the story of our journey and some of the lessons we’ve learned along the way.
We focused on data
Getting to know our data is the foundation of all the work we’ve done. While we were implementing the CCM, physicians in our community decided to share our spreadsheet data with one another. We compared A1C levels, foot exams, eye exams. Our goal was not to be punitive, but to bring together providers who appeared through the data to be doing well with those who appeared through the data to not be doing as well. We shared information about what learnings there were in terms of diabetes management: collecting data, follow up, and closing care gaps. When we came into some unexpected funding with our health plan partner, Rocky Mountain Health Plans, we decided to invest in a project that we hoped could improve the health and potentially reduce the costs of care in our community. We developed the health information exchange in Mesa County, Quality Health Network.
We leveraged practice coach support
The Rocky Mountain incentive dollars didn’t just fund our health exchange, they also allowed us to utilize practice coaches. Bringing in outside coaches has been an important part of transformation. These first coaches looked at the data with us and worked with us to discover where we could improve. In 2009, we got involved in the CMMI Beacon Communities Program, where we once again connected with practice facilitators. They taught us how to create structured data fields in the EMR we had so that we could track data points, run reports, and act on the data. When we brought in the EMR, the vendor training emphasized documenting office visits, not using the registry functionality. Practice coaches were invaluable in supporting us in more robust use of the technology we already had in place.
We embraced team care
Based on what we learned with Beacon, in 2011 we developed and met the standards for PCMH Level 3 certification. Right about then, the Comprehensive Primary Care Initiative (CPCI) came along. The biggest limiting factor that kept us from expanding the CCM was the need for more money. Does this sound familiar? We couldn’t generate more fee-for-service revenue to support extra infrastructure so CPCI seemed like a good fit. We applied and were accepted, and with those resources we brought in more staff to really start trying to provide better care and better outcomes, particularly for our medically complex high-risk patients. These are always challenging to a primary care practice.
Here’s how our practice looks: we currently have four providers doing direct patient care and billing for their service (two physicians, a PA, and an NP). We have two care coordinators: a PA and an RN, with each supporting a physician. We have an integrated behavioral health specialist who works with everyone in the clinic full-time, and we just hired another half-time integrated behavioral health specialist. Beyond that, everyone else is billing administrative, front office, and a staff member dedicated to registry support. My favorite part of seeing patients now is having a team around me to help me do my job, which is a lot different than it used to be. It’s taken me several years to get there but I understand now the importance of team care, the importance of letting go of things that I thought only I could handle
We built a practice resume
When our practice providers saw what was coming with delivery system changes and payment reforms, we knew we’d be challenged just to stay alive as a small, independent primary care practice. If we didn’t change and innovate, we sensed we might not survive the new payment models. It’s also always been important to us to be recognized as one of the best primary care practices in our community. Like almost everyone, we’ve always wanted our patients to get excellent care. But there’s more to it: we wanted our reputation to be one that would cause patients to choose us. All of the improvement efforts we engaged in helped us build our ‘practice resume’ just as payers started to narrow networks and pick providers based on quality. Being recognized as at the top in our market means that payers choose to have us in their network.
We sought opportunity at all levels
We’ve aggressively sought opportunities at local, regional, and national levels to help us wrap our arms around practice data, and each initiative we’ve been part of has built on the next. Being in the loop with the Centers for Medicare and Medicaid Services (CMS) and specialty societies such as the American Academy of Family Physicians (AAFP) via listservs and newsletters keeps us informed about upcoming initiatives. Likewise, being part of larger groups that share information and being connected with other entities at a statewide level assists us in scanning the environment. As part of our quality improvement process, we bring opportunities to team meetings for discussion. For independent primary care providers, we know there can be a sense of overwhelm at the practice level. It’s tempting to delete messages, but there are opportunities right now for primary care, so we make time to read email.
We committed from the heart
I hear this often: “Greg, I’m already working on meaningful use, I’m doing all of these other activities, I just don’t have time to do anything else and continue to run my practice.” I understand completely. There’s an aspect to continuous improvement that requires a leap of faith. As a data guy, even to my own ears that concept is tough. But here’s the paradox: the additional time requirements placed on providers (via meetings, process maps, building in evidence-based guidelines) establish systems that will make your job easier. The extra work isn’t designed to be a burden. We kept going, and the extra push supported our vision of getting better at what means the most to us.
The market is changing. Primary care providers are not being viewed as all the same, as they’ve been in the past. Payers recognize that, employers recognize that, patients recognize that. All of these initiatives we’ve engaged in have helped build our reputation as a premier primary care practice—and that’s the business case. As long as we continue to be paid predominately fee-for-service and the panel size is important, there’s a business case for improvement.
We started the practice transformation journey in order to survive, but it’s brought us so much more than that. We’ve added 2,000 patients to our panel since January 2013. We remain independent. Our team works well together, and we like our work. We’re still doing the kind of work we’ve always wanted to according to our own vision.
Dr. Reicks is board certified by the American Academy of Family Practice, and his special interests include treatment of chronic musculoskeletal conditions and using health information technology to improve the quality and efficiency of health care delivery. Dr. Reicks is on active staff at the both Community Hospital and St. Mary’s Hospital. In addition, he serves as the Chief Medical Officer of the Mesa County Physicians IPA as well as President of the Quality Health Network, the Western Colorado regional health information exchange.