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Pioneering Approaches to Patient Care

Intensive outpatient clinicThe Medical Group partners to provide care in ways patients are coming to expect. These partnerships come under the banner of innovation—but it isn’t innovation for innovation’s sake. Like true entrepreneurs, these teams are finding solutions to the problems that providers and patients face.

The Intensive Outpatient Clinic (IOC), now in its third year, is deepening its relationship with patients by partnering with an at-home nursing service. The IOC serves a vulnerable, high-risk patient population that requires numerous interventions. When those interventions aren’t timely addressed, they can often escalate to a more expensive trip to the emergency room a setback for the patient. Partnering with the nursing service means patients can be cared for quicker, when and where it is best. 

Founded in early 2017 by Peter Weir, executive medical director for population health, the clinic has a patient-centered, population-based attitude toward health.

“Our patients have multiple complex needs, and therefore, they need more time with their clinicians,” said Craig Holbrook, the clinic’s administrative manager. “A lot of times I meet the patients first, and find that they are kind of skeptical. However, as their treatment progresses, the patients understand we are here to help them.”

For example, one of the clinic’s patients, who had been in inpatient treatment for three months, was suicidal and had no housing when he showed up at the IOC. Providers not only worked with him clinically, but helped him find housing. “Today, he has a girlfriend, his ED visits are down, and his perspective on life has changed,” said Ryan Morley, population health director.

BreAnna Holdaway, a nurse practitioner who works at the IOC, said, “We are unique because we are set up to intensely work with patients. We reach out to a patient population that has difficulty accessing care for various reasons, and try to accommodate them. We have the ability to do that here in ways that other clinics do not.”

The Community Physician Group is pioneering an approach to team-based care that is organized around a structure called a Patient-Centered Medical Home (PCMH). A PCMH is a team-based health care delivery model that emphasizes access and continuity, care coordination, collaboration, and patient involvement in improving and maintaining patient health. CPG has led the process for 13 primary care clinics to receive formal recognition by the National Committee for Quality Assurance.  

Julie Day, quality improvement and population health medical director, Annie Mervis, director, and Emily Carlson, team lead, have partnered with clinicians, nursing, and clinic managers to share analytical support and follow progress on key quality metrics. They envision their work in terms of what it can do for our patients and health care transformation more generally. “The economic health of the country depends on it,” Day said, “and the health of the patient is infinitely better when managed in this patient-centered way.”