We all want quality health care, and we all kind of know it when we experience it, but it can be useful to sort out the various pieces that make quality primary healthcare possible. Certainly it is required to have dedicated and talented healthcare professionals but there is more.
The other pieces of the quality puzzle can be grouped under three major topics or quality domains. It is these three areas where continuous effort is needed to provide excellent primary healthcare, and it is where the staff of the Cabin Creek Health Centers put much of their effort.
Access and Location: Access is better if the services are not too far away from you, if the hours when the health center is open are at times that are convenient and if the cost to you is reasonable. CCHS has health centers that serve five different communities around Kanawha County. The centers are open every weekday and offer extended hours some days during the week.
Access and the Cost of Care: Patients are provided services without regard for the ability to pay. CCHS offers steep discounts for medical care, dental care and for prescription medications for patients without health insurance and patients covered by Medicare and other insurance who have difficulty paying the deductibles and co-payments. The amount of the discount depends on the patient’s household income.
A PEIA Access Program: CCHS participates in a partnership t with PEIA that gives PEIA members the option to join the Comprehensive Care Program (CCP). CCP members agree to receive their primary health care from CCHS and have NO CO-PAYMENTS for medical visits at CCHS facilities and discounted co-payments for prescription medicines dispensed by CCHS pharmacies. CCHS takes additional responsibility for reporting on the quality of care for the CCP members.
Access to Your Medical Information (the Patient Portal): At CCHS patients have quick internet access to their medical record through a Patient Portal to their electronic medical record. If you have access to the internet you have access to your important health information including your list of medical problems and medications, immunizations and lab test results. Patients are provided their username and password at registration. The Portal includes email communication with your health center.
24-Hour Access: CCHS offers patients 24-hour telephone contact with CCHS medical providers. If you have an urgent problem or an urgent medical question after hours, patients are encouraged to call the after- hours call service. The operator will take your name contact information and the medical provider on call will call you back shortly. If you are unsure about whether you need to go to an emergency room, call our medical provider on call.
Access and the Range of Services: All of the CCHS health centers offer adult and child medical care, and behavioral health counseling and laboratory. Prescription medicines, including discounted medicines for people without adequate health coverage are available at all sites either from the on-site pharmacy or by a mail-out service. If you need to specialist care or special diagnostic procedures such as x-rays not done by CCHS, you will be referred. Note that CAMC has an agreement with CCHS to provide free hospital services for uninsured patients with lower income – this is the Community Access Program or CAP. Once the patient agrees to a referral to a specialist or other service, CCHS will monitor that service to make sure that the service did happen and that the records from the service are returned to your medical provider so she/he can discuss the results with you.
If you need to be hospitalized, your hospital physician care will be managed by your specialist or by the hospitalist physicians at the hospital of your choice. If you use one of the CAMC hospitals and you inform them that you are a patient of one of the Cabin Creek health centers your medical provider will be notified of your admission and we will contact you to plan your follow-up care after you are discharged.
In addition, the application of evidence-based medical findings may be relatively simple or quite complex. An example of when applying the medical evidence is relatively simple is deciding to advise all pregnant patients not to smoke. There are multiple reliable studies that make clear that cigarette smoking (and also passive exposure to cigarette smoke) increases the risks of premature birth, low birth-weight, miscarriage and other problems for the baby. And there is no risk in applying this advice to all pregnant women regardless of their other health conditions and the recommendation has little cost.
In other situations, when the treatment has risks and high costs associated with it, the evidence or science may be just one consideration in making a treatment decision. Deciding on whether, for example, to have surgery to correct low-back pain involves considering what the research shows about the surgery’s risks and benefits, understanding the patient’s very particular medical condition and the patient’s attitudes toward the surgery which may be influenced by many factors including cost, especially if the patient is uninsured.
Bringing Science into Practice: Given that the body of medical scientific study is constantly growing and changing it is important for health service organizations to make it possible for their medical professionals to stay abreast of new science and plan how to bring the best care into actual practice.
In addition, to hiring qualified and credentialed medical staff members with appropriate education and experience, here is what we are doing at CCHS to promote the practice of medicine based on science and medical evidence.
The medical staff has access to internet resources for researching evidence-based care guidelines and studies including Up-To-Date, Essential Evidence Plus and The Physician’s Letter.
We hold monthly Not-So-Grand Rounds (smaller versions of the grand rounds at major hospitals) at which there is a presentation and discussion of important clinical skills or diagnostic and treatment recommendations.
The clinical teams hold weekly Team Huddles to discuss questions regarding care decisions that members of the team choose to raise and to discuss any adverse events. The Huddles include physicians, nurse practitioners and physician assistants, medical assistants, pharmacists, psychologists or social workers and administrators.
Following the lead of major academic medical centers, representatives of drug and medical equipment companies are not permitted to meet medical providers at the health centers or leave samples or pay providers.
Clinicians organize workgroups routinely to research and develop clinical guidelines or systems of care to address such issues as improving PAP smear adherence; caring for ADHD; appropriate care for chronic pain and anxiety; and diabetes care; self-care for obese patients.
CCHS is a member of the Quality Commons, an AHRQ Action Research Network, of large medical centers and selected healthcare practices from around the country. CCHS was one of two QC practices to participate in a research project to study the impact on workflow and staff attitudes of the conversion to a new electronic health record.
Strong relationships with patients allow clinicians to deal directly with health risks and problematic health behaviors and allow patients to feel comfortable discussing difficult symptoms or conditions. In addition to providing the necessary foundation for patients to become engaged in their own care, perhaps more important, the relationship itself can be healing or therapeutic for both the patient and the clinician. “The relationship is the care,” according to Dr. Donald Berwick, former President of the Institute for Healthcare Improvement (IHI).
Trusting and respectful relationships are also important among the clinical team members. Relationships among team members are strengthened when the members of team share a common goals, when they have opportunities to share information about work , when tasks are well defined and when group learning is fostered. When these things are happening the work is better coordinated, there are fewer errors and there is more satisfaction with the work.
While much of medical care is delivered one patient at a time and certainly examining in some detail what happened to an individual patient can be a useful way to determine whether quality was provided.
Over the past ten years healthcare research and policy makers have identified and promoted a wide number of indicators of quality healthcare. Quality indicators usually fall into two categories:
1.) whether the patients have received services that research shows are associated with better outcomes for the particular health problem; or
2.) whether the actual clinical outcome has improved for the patients with a specific medical problem.
For example for patients who have been determined to have high blood pressure an indicator of quality is whether an accurate blood pressure has been taken in the past three months and the measure of quality could be what percent of a clinical team’s patients with high blood pressure (HPB) have had their blood pressure measured in the past six months. This is sometimes called a process measure because we are measuring a clinical process or whether a service or action was carried out. The practice or an outside agency may also set a goal for this measure such as 90% of all patients with HBP should have their blood pressure taken within the past six months.
An example of an outcome measure for patients with HPB would be the percent of adult patients whose blood pressure was below 140/90. The blood pressure value that is set as the measure has been determined by research that has established that maintaining a blood pressure at this level significantly reduces the risks of serious health problems such as heart attack and strokes. The goal for this measure might be 80% of all patients with HBP would have a blood pressure under 140/90.
The big idea behind setting indicators, measures and goals is that they are useful tools for determining if a health center is producing the results that are wanted. The indictors provide a way for the staff and to see the results of care for all patients and to plan and take action if the results are below expectations. The quality indicators provide a window into the practice of medicine. Certainly it is not the only window but indicators are becoming more and more important especially so with the federal government and private insurers now factoring the indicators into how hospitals and health centers will be paid.
CCHS regularly examines its practices using multiple quality indicators, some of which are required by participation in special health programs such as the Federal Community Health Center program and Blue Cross’s Quality Blue program.