“Patient-Centered Medical Home”

DAYTON - Most people contact their doctors when they are unwell, but what if it were the other way around? What if your doctor contacted you when she was concerned about your health?

This type of proactive healthcare is the future of medicine, according to Dayton's Columbia Family Clinic Manager Cheryl Skiffington. Now patients and residents in the Columbia County Health System are on the leading edge of this movement thanks to a new program initiated by Skiffington along with the health system's chief operations officer, Shane McGuire, and others with the Dayton and Waitsburg clinics, Dayton General Hospital, and Booker Rest Home.

The program is called "Patient-Centered Medical Home," and the entire staff of the local health district is getting involved. Having full buy-in is not only critical, it is one of the biggest challenges to other health systems trying to introduce the program, said Skiffington, who took her position with the clinic in October 2013.

"Cheryl's team has been great about getting on board quickly and making changes so they can work on these projects to improve quality in general and patient care in particular," said Barbara Obena, a practice coach with the Washington Health Improvement Network who works with Skiffington and other clinic managers around the state trying to incorporate Patient-Centered Medical Home principles into their practices. Obena will work with Skiffington for a year, after which the district hopes to be certified in PCMH.

What is Patient-Centered Medical Home?

The Patient-Centered Medical Home (PCMH) model emphasizes partnerships between patients and health care professionals, Obena said. The goal is to achieve "the triple-aim," which includes improved patient experience, reducing the burden of chronic disease, and reducing health care costs, she said.

Some future financial incentives might be reimbursement advantages or reduced insurance deductibles or copays for patients who use PCMH-certified clinics, Skiffington said.

"Whether or not we get reimbursed for it, there will be a financial benefit," she said. "And we all know it's the right thing to do."

Increasing Local Patient Numbers

The project at Columbia County Health System aims to increase the number of local citizens using the system's services. The district has 5,000 patients of record, Skiffington said, yet many of those are not community members but visitors and passers-by.

A significant problem is what happens to local patients who are referred to Walla Walla or other metropolitan health systems for tertiary care, she said. Tertiary care can be critical for many patients and includes specialty care not offered locally, such as pediatrics, obstetrics, surgery, cardiology, neurology, dermatology, and oncology.

But the Dayton and Waitsburg clinics often lose a patient once he or she has been referred to outside care, Skiffington said. Specialists from Walla Walla or the Tri-Cities are notorious for scheduling follow up visits and referring Columbia County patients to additional health care services in Walla Walla or the Tri-Cities - and these patients may not realize they can get their blood work done or have their physical therapy provided locally, without having to drive all the way to Walla Walla or other places.

A component of Patient-Centered Medical Home includes staffing both the Dayton and Waitsburg clinics with a nurse whose job is to schedule these referrals and then check in with the patient later and encourage them to use local services for routine follow ups, lab work, and other continued needs.

Record Keeping Challenges

Another project, one that Skiffington and others thought would be "low-hanging fruit," was to ensure all patients over 65 received a pneumococcal vaccine to prevent pneumonia. That disease the fifth highest killer of older adults, according to the Centers for Disease Control.

This proved to be a tedious and frustrating task. The nurses assigned to determine which patients should receive the vaccine had to search through not only two separate electronic health records systems (the one the clinics are using now and the one they used previously), but also many very thick paper files on patients and finally online through the state's vaccination database.

"It was very frustrating," Skiffington said. The vaccination information then had to be entered just right into the electronic system so that reports could be generated. And when they finally got that figured out - after four months - the next project, looking at which patients should receive the tetanus/diphtheria/ pertussis (DTap or Tdap) vaccine, placed the nurses back at square one with data retrieval.

"We've had lots of challenges," Skiffington said. "But we've been told that for any organization to go through this, that is one of the big challenges - the technology, because no system is really designed to do this."

Not Just a Project But a Philosophy

For Physician's Assistant Kim Emery, one of the providers at Columbia Family Clinic, the work is worth it. "I don't think of this as a project so much as the way our patients should be taken care of - a philosophy of the delivery of medical care."

Emery worked in the University of Washington Neighborhood Clinics before moving to Dayton and taking up practice with Columbia Family Clinic. This UW clinic participated in the Washington State Collaborative for Patient Centered Medical Home and is certified in PCMH.

"The goal is to keep everyone as healthy as possible rather than only 'fixing what is broken' when we are sick," Emery said. "Prevention of chronic conditions and prevention of progression of chronic conditions are key goals."

Goals and Projects

The health district has been working on Patient-Centered Medical Home measures since the beginning of the year, and they have identified several areas of concentration, including addressing chronic health issues such as improving outcomes of diabetic treatments, hypertension, chronic pain, and asthma.

Selecting diabetes was easy, since the health system already has the Dots for Diabetes awareness program (going on this month). Asthma was added to the list, Skiffington said, because the district has at least 300 asthmatics, and the state already provides an asthma trainer who travels the state working not only with providers but also schools and members of the community.

Other projects considered part of the PCMH method at Columbia County Health Systems include preventative measures such as tobacco cessation, mammography, and immunizations.

"Although there are some associated costs as we need to keep patient directories and registries to have the needed follow up at the appropriate times," Emery said, "the benefit is that we can follow the evidence-based medical guidelines for our patient-specific conditions more appropriately and no one gets 'lost to follow up' or 'slips through the cracks.' Thus we improve the health of our entire community."