Practices in Transformation
Older, smarter, healthierby Lisa S. on Monday, February 06, 2012 4:14:02 PM MST
AgeWell Medical Associates aims to build better seniors
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As the only private primary-care practice in the Colorado Springs area focused on adults age 60 and older, AgeWell Medical Associates will soon move to a spacious 8,000-sq.-ft. facility to accommodate its growing patient population and the many services it needs, such as case management, a memory center and a pharmacy consultant. “We want to be a center of excellence for the older adult,” says Kathy Willemyns, one of AgeWell’s nurse practitioners.
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AgeWell's new facility under construction
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Part of that ambition involves the transformation into a patient-centered medical home (PCMH). AgeWell joined HealthTeamWorks’ PCMH Foundations program in August 2010. “Our founder, Dr. Jeffrey Kulp [a geriatrician], is a visionary,” says Willemyns. “He felt there was a better way to deliver primary care than being a slave to the 15-minute visit. He believes the medical community needs to become more efficient and effective. The PCMH Foundations program gave us the avenue to get there.”
Kulp says,“The PCMH concept equips primary care practices to do their part in achieving the “triple aim” of health care reform – better patient experience, population health and reduced costs.”
Measuring clinical success
With the help of HealthTeamWorks’ Quality Improvement Coach BJ Dempsey, AgeWell has made great strides. “At start of the program, 18 percent of their diabetic patients had hemoglobin A1C* measures of 9 or higher — now it’s less than 8 percent,” Dempsey says. “They used to screen 27 percent of their diabetics for depression; now they screen 99 percent. Before, only 51 percent of their patients achieved the target (geriatric) blood pressure of 140/90 or less, now 75 percent are there.”
Because the elderly often present with a variety of chronic conditions, AgeWell aims to “optimize their health, minimize the number of medications and focus on the entire person — including behavioral health,” Willemyns says. “This means depression, loneliness, substance abuse, isolation. These issues are not unique to older people, but they present confounding challenges.”
The journey to PCMH offered new challenges. “For us to have tried to do this without HealthTeamWorks — I can’t envision it,” says Lori Trivelli, AgeWell’s practice manager. “The coaching has been invaluable. We are so grateful to have that kind of experience in our corner. Dr. Kulp’s leadership and vision, and Kathy’s role as [PCMH] champion helped us work out solutions to the challenges we encountered. PCMH work comes with tremendous culture change, but it’s gratifying to watch the team come together and focus on the complete panel of patients and the practice as a whole.”
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AgeWell Medical Associates staff proudly display their Golden Galaxy Team Award as a PCMH, presented to the most-improved practice at the HealthTeamWorks PCMH Learning Collaborative on Nov. 4, 2011. From left to right, Kathy Willemyns, NP, provider champion; Lori Trivelli, office manager; Jeff Kulp, MD; Nan Galloway, MA; Joyce Reiter, RN; Lisa Foster, NP; and Wendy Miller, reception.
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Adopting a registry, team-based care
The group’s first challenge was adopting a patient registry to track patients and their care, Willemyns says. “We started with heart disease/stroke patients and quickly added diabetes. The registry has been so beneficial, because we can see when patients aren’t reaching target measures and we can do outreach to improve their health.” Before the registry, “We had no way to prove we deliver exceptional care.”
Confident about the benefits of technology, AgeWell is shopping for an electronic health record (EHR) system. In addition, “We made the transformation to team-based care,” Willemyns says. “At first there was some resistance — for example, over ‘ownership’ of a group of patients. But now there’s fluidity. One person can pick up where another left off and in 10 seconds have a complete idea of the problems of the day, without struggling to make patient visits worthwhile. We had a fear that teams would be like islands, but that’s not so.”
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Trivelli and Willemyns recognize that achieving PCMH status is not an endpoint. “We realize the work is never done,” Willemyns says. “We continue to set the bar a little higher and achieve new goals. As we adopt an EHR we will look at new ways to connect with patients.”
*Hemoglobin A1C is a laboratory test that indicates blood sugar control
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