Interview with Dr. Grace Nweke, Sunrise Health Care PC

Since 2012, HealthTeamWorks has supported Sunrise Health Care PC, a small independent practice in Colorado Springs, with practice transformation in several initiatives. We interviewed Dr. Grace Nweke about their practice transformation journey and the experience working with practice facilitators.


Tell me a little bit about your practice transformation experience and partnership with HealthTeamWorks.

Our practice transformation journey with HealthTeamWorks started in 2012. At that time, we were “green” in practice transformation. Being a small practice with staff limitations while starting to take a deeper look into comprehensive primary care, it was difficult to identify what needed to be changed and how to implement the changes. Being in partnership with HealthTeamWorks made it easy for us. Practice facilitators came into the practice and helped us navigate through the transformation. They also helped to identify areas to improve, set and achieve goals.

I remember when we started to use the Electronic Medical Record (EMR) software in the early stage of the practice transformation. The software was new and difficult for us. The support of the practice facilitator was crucial in learning to read and analyze the numbers and measures.

It has been very valuable to have this external support to help us connect with the regional resources, analyze data and implement quality improvement processes.

As you reflect on your practice transformation history and your relationship with HealthTeamWorks, what do you think were/are your biggest accomplishments in your practice transformation journey?

During our first practice transformation program we started engaging more with patients and their families and developed our Patient and Family Advisory Council (PFAC). We were able to start risk stratification, analyze utilization data and identify the problems in our emergency department utilization and hospital inpatient utilization. We had struggled with electronic clinical quality measures (eCQM) and started to develop workflows to improve the measures.

Participation in the State Innovation Model (SIM) initiative helped us to improve behavioral health integration. Previously we had only a collaborative care agreement with a mental health organization in the area. Now we have behavioral health services on site. We had access to practice facilitators and a clinical health information technology (HIT) advisor, which allowed us to drill down more into EMR data. We were able to customize data reports and create valuable connections with community resources that benefit our patients.

With the current practice transformation program, we are better positioned for advanced payment models. We continue improving all the work we started a few years ago. We have reduced the emergency department and inpatient hospital utilization and are now able to measure and improve our patient experience and improve the electronic clinical quality measures (eCQMs).


What role did your practice facilitator play in achieving these accomplishments?

Practice facilitators have been crucial to us in our practice transformation journey. They have helped us to create workflows, set realistic goals and action plans, and look more intentionally at the data. They have brought valuable knowledge from other practices and initiatives. Our current practice facilitator made us aware of a grant offered through a local hospital, that allowed us to obtain our current Telehealth software. That was a tremendous help for us.

I see our practice facilitator being part of our practice. This quote from one of my Medical Assistants sums it up:

“Our practice facilitator believes in us. She knows we can do this practice transformation work and at the same time she is there when we need help”.

It is great to have someone who is very knowledgeable, reachable and knows your practice very well.  We truly cherish our quality improvement meetings with our practice facilitator.

As you reflect on this practice transformation journey, how did coaching support adapt to meet your changing needs?

Coaching support throughout the years has adapted very well to our needs. As a small practice we don’t have all the resources the larger systems have, as we go through different practice transformation programs. Having a practice facilitator is an advantage for us. They help us with researching and connecting to valuable resources in the community. Throughout the years, in our participation in different practice transformation programs, I have requested to have HealthTeamWorks as my practice transformation coaching support. They know us and are very in tune with our practice and can help us to align our quality efforts for all these different programs. Having the same coaching support throughout different programs makes it easier to adapt to the rapid changing needs.

Speaking of rapid changes in healthcare, how has the practice transformation work helped you to strategically respond to those rapidly changing demands in our current healthcare environment?

I have definitely seen benefits of our practice transformation work. It has helped us to shift how we deliver care during the COVID-19 pandemic. Practice transformation support really puts us ahead of the curve, as we already have developed processes on alternative care, care coordination, and care management to name a few. Due to the knowledge gained through our participation in different practice transformation programs, we were able to implement Telehealth to better serve our patients during the pandemic. It has been very helpful to have risk stratification processes in place, and more efficient outreach to patients.

We were also able to add a Clinical Pharmacist to our practice. Our Clinical Pharmacist has supported practitioners in reaching out to patients, making recommendations to us and helping with transition of care. The concept of team-based care approach and having all these resources available in our practice are very valuable to patients and to our practice.

Overall, being part of practice transformation has been a great experience for us. Especially having the strong relationship with our practice facilitator. She knows us and makes recommendations that benefit our practice. We listen to her, because we know she has been working with us for a while, and that is a relationship I do appreciate.

Interviewed by Israel Ortiz, Program Manager, HealthTeamWorks