Due to limited access to primary care, many patients do not get the care that they need, allowing disease to worsen to the point that care is given in settings such as the emergency room or in the hospital. In 2015, Coastal Family Medicine began a four-phase project to help its most vulnerable patients receive quality primary care. The team expected to decrease preventable admissions to the hospital by ensuring patients receive the care they need before their conditions worsen to the point of hospitalization.
Coastal Family Medicine serves about 4,000 patients. 56% of our patients have primary Medicaid coverage with an additional 13% having secondary Medicaid coverage. In a 2015 survey of 110 Coastal Family Medicine patients, they identified the following barriers to their own care: distance to the clinic (47%), clinic availability (36%), difficulty being able to make it to different clinic sites (23%), and hours of operation (30%).
Coastal Family Medicine held a two-day Lean session to align our strategic priorities with New Hanover Regional Medical Center and improve clinic flow for our patients. In the session, we reviewed the overall patient experience to see what could be improved.
The project aims to deliver high-value, person-centered care to improve the health of the high-risk Medicaid population by focusing on the removing barriers that limit access and quality of care.
In 2015, Coastal Family Medicine established a home visit program to bring care to our sickest patients who had limited mobility and were home bound, eliminating the barrier of distance to the clinic. These patients had the highest Emergency Department (ED) visits and admissions. In 2016, a walk-in clinic at Coastal Family Medicine was created to address our patients’ need for acute or same day care. In early 2018 Coastal Family Medicine created a no-show letter and call service to assess for patient barriers to care and help eliminate those barriers. In April of 2018 Coastal Family Medicine clinic went into its fourth phase; which brought lab testing from an offsite facility to inside the clinic. This removed the barriers patients had with multiple clinic sites. The project has been a multi-year evolution and a systematic breakdown of barriers. Results have shown a decrease in admission rate, ED utilization, and lower cost than expected for our clinic’s Medicaid patients as well as other improvements in patient quality of care.
The goal of the interventions at Coastal Family Medicine was eliminating barriers to care. By eliminating these barriers, CFM hoped to achieve a 5% decrease in Medicaid admissions. Quality of care improvements would be tracked using this data as well.
Coastal Family Medicine monitored the inpatient admissions and Emergency room use of our 18 home visit patients. These 18 patients had a combined 61 emergency room visits in the 12 months before home visits. In the 12 months of 2018 the same 18 patients had only 9 ED visits. A similar trend was seen for inpatient admissions. In the 12 months before home visits the 18 patients had 28 inpatient admissions. In the 12 months of 2018, the same 18 patients had only 4 admissions. This is an 85.2% decrease in ED visits and 80.1% decrease in admissions for this group of patients.
In Phase II, CFM focused on eliminating the access to care barrier for patients. A downtrend in Inpatient admissions for our Medicaid population can be seen around the same time that our walk- in clinic became operational (Figure 7B). Our admission rate prior to this intervention was 14.48 Medicaid patients per month. Following walk-in clinic this number decreased to 10.42 Medicaid admissions per month. This is a 28.0% decrease in Medicaid hospital admissions. Our data also shows a switch in the low acuity diagnoses seen in the ED for pediatric patients. In a three-month period pre-intervention there were 71 pediatric patients seen in the ED for an upper respiratory infection (URI). In the same three months after intervention the following year, there were only 27 ED visits for URI, showing that we were effectively redirecting low acuity patients from the ED to the clinic (Figure 4). This was sustained in 2018. Similar trends were seen with other low acuity diagnoses such as fever and Otitis Media.
The no-show communication phase identified and eliminated barriers, thus helping CFM set 25 new Medicaid rides to the clinic, schedule 5 patients for home visits, and reschedule 120 patients for better fitting appointments.
By bringing a phlebotomist to the CFM clinic during business hours, the lab completion rate has increased to more than 90 percent from a rate of 38-50% before the intervention. A similar jump was seen in diabetic eye exam rates. Prior to having a camera in house, the screening rate was 32.3%. It improved to 66.7% and continues to climb.
Coastal Family Medicine has been able to bring higher quality care to our patients while keeping inpatient admissions, Emergency room use and overall cost down. Much of this success is due to four-phase improvement process focusing on patient identified barriers to care.
- Toren Davis, Medical Director/Faculty Physician
- Sonali Batish, Practice Manager
- Janalynn Beste, Program Director/ Faculty Physician
- Liz Kyle, Pharmacist/ Faculty
- Becky Watford, Clinical Coordinator
- Brianna Hitchner, Chief Resident
- Kevin Briggs, NHRMC Lab Manager
- Carol Irving-Clinton, Lab/Phlebotomy
- Shannon Ferrell, Community Care of the Lower Cape Fear