Back in 2006, when Robert Smith, M.D., founded Finger Lakes Family Care in Canandaigua, N.Y., he couldn't have known that the quality improvement work he undertook early on as a solo physician would put his practice ahead of the proverbial pack more than a dozen years later.
FP Robert Smith, M.D., shows patient Bodo Seuthe his chest X-ray during an office visit. "I make it a habit to show my patients their imaging as well as graphs and trends of their test results so they can better visualize what is going on with their health. They truly appreciate this," Smith tells AAFP News.
Smith also didn't anticipate that after a decade in private practice, he would sell his practice to the local hospital in 2016.
Today, Finger Lakes Family Care is one of 10 family medicine practices managed by Thompson Health System -- a subsidiary of the larger University of Rochester Medical System.
"It doesn't change how we do quality improvement; I just don't manage the business side of the practice anymore, and that is wonderful," Smith said in an interview with AAFP News.
"Quality improvement benefits all of us (clinic and patients) because it allows for tighter control of chronic diseases, and patients get better and more efficient care. It makes us accountable," he added. "And patients appreciate that that we are always striving to take better care of them."
- Finger Lakes Family Care in Canandaigua, N.Y., has the whole care team and even clerical staff members on board with its quality improvement efforts.
- The practice began learning about population management more than a decade ago through its participation in a medical home initiative.
- The practice, now hospital-owned and part of an accountable care organization, is able to compare its quality data with other family medicine practices in the system.
Accordingly, patient surveys about the clinic routinely reflect a high level of satisfaction.
The practice also fares well when it comes to comparing quality data with the other family medicine clinics managed by Thompson Health.
"The staff is accustomed to tracking patient outcomes and running lists," said Smith. "It's just part of what we do. Even the clerical staff takes pride in seeing those hemoglobin A1c numbers decrease for our patients with diabetes."
Circling back to the early days of his solo practice, Smith noted that in 2008 he participated in the Rochester Medical Home Initiative(www.pcpcc.org) -- a three year project that helped his practice attain a Level 3 patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance.(www.ncqa.org)
Back in those days the payment piece was fairly straightforward.
"We received extra payments per month for people with certain chronic diagnoses, and that was a way to pay us a little extra for the chronic care, population management, medical home type stuff we were doing," said Smith.
That initial PCMH project ended after three years and was followed by a second, smaller initiative that served as the predecessor to a Rochester-based accountable care organization (ACO) called Accountable Health Partners(ahpnetwork.com) that oversees quality metrics across the board for all participants.
"We're still seeing extra payments and bonuses for quality measures associated with the ACO," said Smith.
Training the Team
When Smith first pulled his practice into the PCMH world back in 2008, there was some serious training-up for his staff and care team.
"Initially through the Rochester Medical Home Initiative, we had people from the project coming in and we did lunch meetings a couple of times a month explaining what population medicine was all about," said Smith.
Team members spent time looking at the lists and quality measures and figuring out how to do things on a smaller scale to manage populations and improve the quality of care.
Diabetes was one of the first chronic diseases the team tackled.
"How do you get your diabetics better controlled? Well, it's getting them in more frequently, it's changing medications more frequently, it's educating them about diet and exercise.
"It's also about looking at barriers and sometimes getting social workers and dieticians on board," said Smith
And there are some situations that call for advocating for patients by convincing their insurance companies to approve the right medications, he added.
"Everybody has a different barrier," said Smith, and that has not changed through the years.
The practice team has grown through the years to include two family medicine nurse practitioners, one registered nurse, two licensed practical nurses and three clerical staff members.
Smith sees 25-plus patients a day and said the practice is profitable month after month. "And we're still able to maintain our own culture," he noted.
The practice still embodies the cradle-to-grave care that is the foundation of family medicine.
"'Newborns to 90-year-olds,' is what I tell people," said Smith.
Quality improvement efforts have grown with the practice, as well.
"The major benefit of the EHR (electronic health record) these days is that we can run reports on anything. So on a monthly basis we can run our own reports, but we're also getting quality metrics from the hospital's practice management team," said Smith.
"So we know which of our diabetic patients are out of control; we know who's lacking on pneumonia vaccines.
"And then we have a clerical staff member who runs lists all the time and just calls people and says, 'Hey, we've noticed that you need a mammogram. Can we get that scheduled for you?'"
Or if a patient on blood pressure medication hasn't been seen in more than 12 months, the same staff person will proactively call to schedule an appointment and get that patient in.
"I don't have to tell staff members to run lists and get our numbers up or get visits in because they like to see our patients getting healthier. We just take pride in what we do," said Smith.
And since the practice doesn't have a specific care manager, everyone in in the office takes a role in care management, population management and quality improvement, and "contributes to all the measures we're monitoring," said Smith.
"We do that every time we pick up a chart," he added.
For instance, said Smith, "If a child comes in for an ear infection, I make sure the immunizations are up to date. And when adults over the age of 50 come in with a sinus infection, I make sure their colonoscopies are current."
Just Being There
An important component of the quality care puzzle is just being there for patients.
"One of the things we do best is ease of access," said Smith. "Wait times are very minimal and we get patients in for same-day service by opening up spots for urgent care early in morning and setting aside some same-day appointments every day," he added.
"We'll double book that 3-year-old with the ear infection at 4:30 if we have to because that's a quick visit, it keeps parents happy and it's an easy treatment for the child," said Smith.
The clinic's wide scope of care includes joint injections, skin surgeries for dermatologic issues, spirometry and electrocardiograms.
"We try to do as much as we can here without sending patients to urgent care, ERs or other specialists, where patients have to wait longer and risk being overtreated," said Smith. "We run the office efficiently."
As for payment, Smith noted that he's on an incentive plan, so he appreciates staying busy and building better metrics -- the end result of which is a larger share of the ACO's profits.
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