Meeting Patients Where They Are
TCPi Exemplar Practice: Primary Health Care, Des Moines, IA
Primary Health Care (PHC), a federally-qualified health center (FQHC) based in Des Moines, IA with additional locations in Ames and Marshalltown, participates in IHC’s Transforming Clinical Practice Initiative (TCPI) program. With 3 dental clinics, 7 medical clinics, 4 satellite clinics, and mobile clinics, PHC is paving the path for improving the patient care experience. As a partner of IHC, PHC is implementing patient-centered programs and systems that are changing care delivery as we know it today.
With support from our TCPI program, PHC operates a mobile health unit that provides care in remote service areas. They have also built a homeless outreach program that helps individuals facing housing difficulties with connecting to community resources and services to obtain stable housing. Looking beyond the four walls of their clinic, PHC has formed a partnership with the Des Moines Public School district and United Way of Central Iowa to establish a primary care and dental clinic located inside the Des Moines Public School district Central Campus. This provides students access to primary care and dentistry in a familiar location.
Patient outreach is more than a task – it’s a way of doing business for PHC. PHC developed their RN Patient Navigation System to increase the percentage of patients receiving colorectal cancer screening. A nurse care manager follows up with patients after testing is performed. Recognizing there might be other barriers to receiving care, PHC offers alternatives to traditional colorectal cancer screening tests for those unable to travel as well as outreach to non-English speaking patients. The results from their efforts have been significant – meeting patients where they are while raising the standard of care.
Engaging Patients as Partners in Care
TCPi Exemplar Practice: Orange City Medical Clinic, Orange City, IA
Orange City Medical Clinic, a rural health clinic (RHC) in Northwest Iowa, is improving patient outcomes through active patient engagement. As a partner in IHC’s Transforming Clinical Practice Initiative (TCPi) program, Orange Medical Center is increasing patient safety efforts by establishing an anticoagulation clinic to reduce the percentage of patients on Warfarin who are at risk of having an adverse drug interaction. Clinical pharmacists at the anticoagulation clinic actively involve patients in their care through face-to-face interactions and patient surveys, focusing on the patient’s medications and lifestyle and correlate how these factors may affect health results. Though physicians and nurses often do not have this capability, the pharmacists’ patient engagement strategies are improving patient outcomes. Through our partnership on this program, over 90% of patients on Warfarin are now enrolled in the anticoagulation clinic – all to improve the health of Iowans by engaging partners in care.
Improving Patient Safety and Satisfaction by Investing in Patients
HIIN Exemplar Hospital: CHI Health Missouri Valley, Missouri Valley, IA
Meaningful Person and Family Engagement (PFE) is critical for determining what matters most in managing a person’s health and achieving sustainable improvement in healthcare quality and safety. CHI Health Missouri Valley is a critical access hospital (CAH) in Southwest Iowa that serves mostly rural patients and participates in IHC’s Hospital Improvement and Innovation Network (HIIN) program. The hospital has 25 Acute Inpatient Beds, a level 4 trauma emergency department, and provides various outpatient care, transition care, and skilled nursing care services.
CHI Health Missouri Valley is committed to patient satisfaction and safety. Monthly quality reports are watched closely, and immediate changes are made when patient safety and satisfaction issues arise. Their steadfast commitment to patients led to the development of a full-fledged person and family advisory council known as a PFAC. CHI Health Missouri Valley identified community members to actively assist with advancing patient safety and quality by serving on the PFAC. The PFAC ensures the patient voice is heard and is incorporated into the daily operations of the hospital.
CHI Health Missouri Valley’s PFAC has grown to include seven representatives with a mix of clinical and nonclinical backgrounds. The representatives consider themselves as proud ambassadors of the hospital and secret shoppers in the communities. Missouri Valley considers the representatives as the hospital’s “eyes and ears” that “will give important feedback about what they heard about the hospital.” That’s what investing in patients as partners looks like and IHC is proud to partner with CHI Health Missouri Valley.
Coordinating Care Across the Community
SIM Exemplar Community: Linn County Public Health, Linn County, IA
Linn County Public Health is collaborating with 20 area agencies to enhance communication among independent health and social service organizations – all with the goal of better care and better outcomes. As a partner of IHC through the State Innovation Model (SIM), Linn County Public Health is redefining what care coordination means in healthcare.
The collaboration, known as My Care Community, is a nationally recognized model that encourages providers to coordinate services to improve the health and well-being of patients participating in the program. Through this collaboration, providers make seamless referrals to outside organizations and, as a result, better anticipate future needs of patients and improve the quality of life for families. The collaboration reduces paperwork for patients, back-and-forth calls, and repeated appointments that normally accompany a complex referral process. Patients stay connected to services and programs that address a range of needs for the entire family, from medical treatment and mental health counseling to homelessness prevention and more.
My Care Community partners have collected and aggregated almost 13,000 social needs assessment surveys – connecting care beyond the four walls of a clinic. This program is changing healthcare as we know it today and the nation is noticing. Linn County Public Health was honored at the 2018 annual conference of the National Association of County and City Health Officials (NACCHO) with the “Local Health Department of the Year Award – Medium Category.” The award recognizes and honors the outstanding accomplishments of local health departments for their innovation, creativity and impact on their community. The award specifically recognized the State Innovation Model (SIM) community care coordination (C3) project work.
The collaboration is self-funded by the participating organizations and continues to expand. A complete list of members and additional information can be found at mycarelinnco.org. My Care Community is open to all local patients with no prerequisites or eligibility requirements for using the service.