Chronic Disease Management

It is easy for patients to become overwhelmed with management of chronic conditions. The other day I saw a middle aged woman in follow-up. She had initially presented for an acute respiratory illness. She was overweight and blood pressure was elevated. She mentioned that she would like to lose weight, quit smoking, eat better, and become more active. We discovered with routine labs that she was also diabetic! We treated for acute illness and began to help her with lifestyle changes. I quickly referred to to our Patient Educator for free help with tobacco cessation, weight loss, diabetic education and overall wellness. The patient educator helped her to quit smoking via the "Quit Now" program. They met weekly for education and support. She was able to begin losing weight, getting her sugar under control, and begin an exercise program. During follow-up her blood pressure was controlled, her sugar was controlled on diet alone, and she continued to be a non-smoker! "I could not have done it alone!" She told me.

"one-stop-shop"

One of the most rewarding things about practicing at my community health center is the ability to offer comprehensive primary medical and dental care as well as behavioral health services. Last week I saw a young man who had not received medical care for some time due to lack of health insurance. When he learned of our services he scheduled an appointment in hopes of getting a "check-up" and medication refilled. He shared with me that he had recently witnessed the suicide of a family member and was experiencing severe distress related to this trauma. We talked for a while and he was thrilled to hear that we had a psychologist in the center that could help him process what he had endured. He also mentioned that he had some dental issues and needed some work done that he had neglected due to finances. We were able to provide him with a check-up and medication refill, as well as lab work and appointments to return for counseling with the psychologist and dental work with the dentist! Everything we provided was discounted on a sliding scale to a rate that was affordable for him!

Welcome to Dr. David Neff

Welcome to our newest Ambassador - Dr. David Neff, Site Manager and Family Practitioner at Hopewell Prince George (HPG) Community Health Center, a site of Central Virginia Health Services

Somehow it is totally appropriate that Dr. Neff began as a Site Director in Hopewell at Thanksgiving time in 2004 – because he feels he has much to be thankful for. And talking with his co-workers, they feel very much the same way.

Initially Dr. Neff was not planning on being a physician but instead, with his love of science, he went to pharmacy school and practiced two years as a pharmacist. During this time, Dr. Neff made an important discovery – working as a pharmacist at a big retail store did NOT provide the one to one personal interactions that he thrived on. Dr. Neff had been involved in the Co-Step Program Commissioned Officer Student Training and his supervisor went to the National Health Service Corps to recruit Dr. Neff as a way to enter Medical School at Virginia Commonwealth University.

Immediately after medical school, Dr. Neff worked at another Virginia Community Health Center, but moved to be closer to his home and family. Originally from California, Dr. Neff now calls Virginia home for his wife and five children – three foster and two adopted children. Being closer to home means Dr. Neff can participate more actively in his children’s activities and yet pursue the profession he clearly loves. The choice of working in a Community Health Center for Dr. Neff means no rounds and other erosions to his family life.

Dr. Neff describes his interest in public health and his enjoyment in dealing with people as having a ministry aspect – and not just treating illness. He sees his current role as a merger of medicine, social work and mission. His practice of medicine goes beyond the script to include consideration of housing, social and outside medical resources.

The Hopewell-Prince George area is a community of both agricultural and industrial business with most patients native to the area. Dr. Neff’s patient group currently has a high level of unemployment and disabilities are frequently on fixed incomes and often have diabetes, high blood pressure and heart conditions. On a typical day (excluding earthquakes, hurricanes, and power outages) Dr. Neff begins at 9 AM, and with a break for lunch, concludes his day between 4-5 PM.  As a testament to his incredible efficiency and skill, Dr. Neff usually has an initial schedule of 24 patients per day, which with no-shows and work-in translates to about 20 actual patients per day.

In addition to excellent support staff, Dr. Neff also has third year medical students from Virginia Commonwealth University who may assist with patients. Under Dr. Neff’s direction, HPG is a wellness center that provides comprehensive care with dental services, behavioral health services and has a Medical Assistance Program (MAP).  His greatest challenges are patients with significant lack of resources and lack of transportation.  Dr. Neff describes Community Health Centers as a way to have a well balanced life style of family and profession, and “a very rewarding place you can practice medicine the way you were trained without having to run a business.”

Community Health Center Model

I am frequently asked how I ended up practicing for so many years in a community health center. The answer is simple...It "fits" me well. I was first introduced to the Community Health Center (CHC) model by my mentor when I was a pharmacy student because of my interest in working with underserved populations. That introduction led to a scholarship from the National Health Service Corps (NHSC) which offers scholarships and loan repayment for health care workers in underserved areas (nhsc.bhpr.hrsa.gov). After residency, I fulfilled my scholarship obligations in a rural CHC. I loved working in a setting where I could practice medicine and help patients without regard to finances. I loved that the administration took care of all billing and collections and could offer a sliding scale for our services. I loved providing care for folks that could not otherwise afford health care. I loved the comprehensive and holistic nature of our practice. My current practice offers medical care, dental care, behavioral care (psychologist), and a patient educator/nutritionist. My office has a "wellness center" multi-purpose room where we have exercise classes, Yoga, Tai Chi, fitness/wellness groups, diabetic and chronic disease classes. I love that I can refer patients just down the hall for all of these services at little or no cost to them!

PCMH Story Time!

What does the Patient Centered Medical Home feel like for the patient?  The story I'm about to tell you is based on my actual experience with obtaining health care for my daughter when she was a baby. 

My daughter was 5 months old when she got her first ear infection, which was accompanied by flu-like symptoms, high fever, lots of snot, vomiting and pain.  Thus began a cycle that would last until she was almost 2 years old.  We would adhere religiously to our antibiotic regiment and ibuprofen/ acetaminophen routine, and after several weeks of smooth sailing it would start all over again.  Eventually she was diagnosed with childhood asthma and chronic otitis media and she was on a regiment of inhalers, nebulizer treatments, and several allergy medications.  The poor child could practically operate the nebulizer before she could walk.

Little did we know, our pediatric practice had many elements of the Patient Centered Medical Home.  We loved it.  Here is what it felt like to us.

Friends of ours recommended the doctor, who I'll call Dr. V.  The practice was set up so each patient selected their personal doctor.  Whenever we called to make an appointment, they addressed us by name and told us when Dr. V's next appointment was.  It was always the same day (except well-child visits which we scheduled well in advance).  We saw her every time with very few exceptions.  When I would call with the occasional question, I would leave a message with Dr. V's nurse (who also knew us by name) and she would return my call within 2 hours.  After hours, they had an agreement with the closest hospital to answer urgent calls.

For questions about a problem we thought our daughter was having, they encouraged us to first look on their website which had a list of common illnesses, symptoms, and their recommended course of action depending on the severity.  I feel like I looked at their website at least once every few weeks!  It really helped us decide what to do.  I could also email them if I wanted to, but I never needed to use this function because they were so responsive to phone calls.

At the end of every visit (of which there were a lot!), Dr. V would give me a printed summary of what happened during the visit, my child's diagnosis, and our agreed-upon course of action, along with frequency of her medications and what to do in case of a bad reaction.  She would make sure she answered all our questions.

Eventually, we decided to get ear tubes for our daughter.  It was a godsend and changed our worlds.  When the decision was made, Dr. V arranged the appointment with the specialist to have the procedure done, and followed up with us afterwards to see how it went.  Another time, our daughter had a febrile seizure and went to the emergency room in an ambulance (that's another story!).  The next day, Dr. V called us wanting us to come in and see if everything was alright.  I was so impressed that she knew we had been to the ER!  Another time, we called the after-hours line and again, Dr. V followed up with us the next day to see if everything was alright.  What I then thought was just great customer service, I now realize as also great medicine.

During all of this, my husband I both worked full-time.  I exhausted my leave going to all these appointments (and was exhausted in general!).  But the clinic had Saturday hours which was soooo helpful to us on several occasions. 

I really could tell that she cared about my child and our entire family.  She will never know how grateful I am for the breastfeeding encouragement she gave me.  Dr. V was so excited when we appeared for an appointment and told her we were expecting another baby!  And she was so sad when we told her we were moving to another state.  I miss her and that practice; they were kind of like an extension of our family.  And our home. 

Knowing what I know now about Patient Centered Medical Home, they hit many of the high notes.  They would probably easily qualify for Level 2 or 3 NCQA PCMH status.  It is sad that I felt lucky in our practice, compared to stories I heard from friends and others.  I wish everybody were so lucky... and that "lucky" becomes commonplace as this becomes everybody's experience.

Think about your practice.  What would your patients' experience stories sound like?

Patient Centered Medical Home's #1 Fan!

I have a secret to share with you.  When I was hired, I had a tiny fraction of a clue as to what I was supposed to be doing in this job.  I avoid saying “no clue” because I had my job description in hand!  What did "Patient Centered Medical Home" mean and what would my role be in operationalizing it for our member Community Health Centers?

I am a researcher at heart.  During my first months as the new Healthcare Transformation Specialist, I read everything, watched countless Webinars and attended every training I could.  There is a lot of information out there!  In this process I quickly became a huge fan Patient Centered Medical Home - and not just because it's part of my job!
 
In its simplest terms, becoming a PCMH – or “PCMH transformation” - means that a primary care practice aligns itself to reflect seven basic principles which you can learn about here.  National accrediting bodies such as the National Committee for Quality Assurance (NCQA) and the Joint Commission are offering formal recognition programs.  Our organization, the Virginia Community Healthcare Association, has implemented the Home Improvement Project as a coordinated approach to helping 100% of Virginia's CHCs achieve PCMH transformation and formal recognition.
 
Whether its within my job or describing what I do to a friend, when I start talking about Patient Centered Medical Home I start channeling my inner Oprah and start overusing words like "excited," "love," "dream," "journey," "eager" and "great."  I can't control it.  Here let me show you by outlining the three major reasons I am excited about PCMH:

A) As a patient and mother/daughter/wife/sister of current and future patients I would love for the PCMH to be my, their and all patients' experience with the health care system every time;

B)  I am eager to work with practices to help implement this model because once they adopt and begin implementing their PCMH journey (which will not be easy, admittedly) there is evidence that providers will be more satisfied because this is how they dreamt of practicing medicine in the first place and

C) Based on data that demonstrate significant cost savings and increased quality in practices that implement the PCMH model, I believe it will be a great part of the solution to all of the ills (pun intended) in our country’s health care system today.
  
I’m happy to report that I now have a pretty good grasp of my job (at least a whole clue or more!) and we are getting down to the business of helping our CHCs through the Home Improvement Project. My hope and vision is that the primary care community, through channeling its inner Oprah and embracing the PCMH movement, will live its best life now and in turn help patients do the same.

Mary Beth Cox & the Patient Center Medical Home

Mary Beth Cox is on a mission to improve and transform the way that Virginia’s Community Health Centers provide healthcare!  She is the Healthcare Transformation Specialist with the Virginia Community Healthcare Association.  Mary Beth’s primary role is to help all of Virginia’s Community Health Centers (28 organizations with 115 sites) achieve Patient Centered Medical Home (PCMH) transformation and recognition.

The Patient Centered Medical Home – or “PCMH” – is a model of providing primary care that is both old-fashioned and revolutionary.  It is old-fashioned in the sense that the concept of patient-centeredness is fundamental to all medical care; without patients there would be no need for care!  In addition, the medical home term has been used for decades by organizations such as the American Academy of Pediatrics.  It is revolutionary in the sense that the healthcare system has strayed far away from this fundamental principle and it will take some major reconstruction to get it back on track.  Coupled with integration of modern technology and ramping up to serve an expanded population of insured patients by 2014, PCMH is a big job!

Mary Beth has been with the Association since February 2011 and is both excited about PCMH and up to the task!  She is especially passionate about working with Virginia’s Community Health Centers to ensure access to quality, affordable healthcare for all.  Mary Beth holds master’s degrees in Public Health and Social Work from the University of North Carolina at Chapel Hill, and a Bachelor’s degree from the College of William and Mary.  In addition, she brings over ten years’ highly relevant experience coordinating, evaluating and leading community-based health initiatives.  Mary Beth’s keen interest in PCMC dovetails nicely with her interest in maternal and child health issues and systems-level initiatives that can do the most good for the most people.  When she’s not working, Mary Beth also enjoys being involved in the community and keeping joyfully busy with her husband, two young children (ages 3 and 17 months) and three dogs! 

To further explain how Virginia’s Community Healthcare Association is helping all Community Health Centers (CHC’s) in Virginia achieve Patient Center Medical Home (PCMH) transformation and recognition, Mary Beth will be blogging and answering your questions. So please welcome Mary Beth to our Ambassador’s Blog!