Although the goal is for every diabetes patient to have controlled blood glucose levels, Conifer has more than met this population health quality improvement goal.
Conifer participates in the Comprehensive Primary Care Plus initiative and among the Colorado State Innovation Model (SIM) practices working to integrate behavioral and physical health while gaining capabilities to succeed with alternative payment models.
HealthTeamWorks has supported Conifer with primary care practice transformation services as part of the SIM effort since 2017. That support includes practice facilitation to develop a culture of teamwork and improving processes and workflows for front-desk personnel, in concert with care management, to better assess and meet whole-patient needs. HealthTeamWorks supported the practice to structure its quality improvement efforts and learn how to leverage its electronic medical record system to pull data for effective clinical measurement, reporting and health improvement efforts.
Chronic condition management is now more structured and patient-centered. A Plan/Do/Study/Act quality improvement effort focusing on hypertension has improved accuracy of blood pressure readings while empowering patients with logs, monitoring and self-management tools.
In the past year, Conifer has successfully integrated screening for social determinants of health into its workflow. HealthTeamWorks and Conifer staff met with Cynthia Farrar, the regional health connector for Jefferson County, to help the practice identify community resources so that, when a social health need was identified, Conifer can refer the patient effectively. To meet its behavioral health integration goals, depression screenings are now a part of annual patient preventive care visits at Conifer. For those with a previous positive screening result, the practice re-screens on a quarterly basis or when the patient visits the practice for care.
HealthTeamWorks credits a positive team culture and willingness to make room for quality improvement activities as a big part of Conifer’s success.
“Admittedly, our early response to participating in Colorado’s SIM, in conjunction with CPC+, was a bit of reluctance, as we felt we already had integrated behavioral health with our physical health services,” says Conifer’s Rob Sarche, MD. “With the encouragement, tools and leadership provided by SIM personnel, we have been able to do more. Primarily we have benefitted from increased teamwork and communication, resulting in better and more consistent behavioral health services. Our patients are better served by the way in which our practice has integrated longitudinal care management with our behavioral health services. We are grateful that CPC+ and SIM have helped us realize the truth in the old adage that, ‘even good can get better.’”
[Pictured in the photo above: Members of the Conifer Medical Center team include (left to right) Sheena Tambulin, Robert Sarche, Julia Hankins and Denise Stuart.]