Strategy: Each Morning the Cherry Health Westside practice starts their day with a team huddle. Per Nancy Pagan, Westside site manager, “I see the staff hurrying to make huddle daily because of the value it provides to the team and the patients.” Staff attends to coordinate care and share knowledge to ensure the best patient care, satisfaction and outcomes. The huddle consists of the Primary Care physician, Dr. Perez, the RN Care Managers, Colleen McGuire and Lexie Bryce, as well as the Medical Assistant working with the physician that day, primarily the lead MA, Gabriella Medina. The huddle also includes a Community Health Worker, Maria Sanchez, as well as Joanne Rapp, the Front Desk Supervisor. During this time Dr. Perez and the team using the day before appointment chart prep, review gaps in care that will need to be addressed with the patient during their visit. This chart prep covers eleven steps the MA does the day before the appointment to ensure care needs are being met.
During the patient visit, the team utilizes workflows specific to their chronic condition, (hypertension and diabetes)with swim lanes. Each lane is designated by provider, MA, CHW/CM and their responsibility with the patient. The workflow also identifies referrals needed either internally, i.e. diabetic educator or externally to community resources. Most recently a new addition to the team was made by way of Community Health Worker. The CHW has a deep understanding of the community and its available resources. Being a part of the community the CHW has the ability to visit patients in their homes, help them access needed community resources and help support their self-management. The practice has been advertising this new team member by way of a community health worker flyer.
Dr. Perez has seen the success of team-based care in the practice. Dr. Perez states that he did not learn about team-based care during his residency, he learned it here in the practice. He went on to say, “Without the care team approach, we would not be achieving our outcomes. We learn together and build trust in team and with the patients. We work on closing gaps in care. Our results show A1C now in control, decreased use of the ED, increased physician visits for chronic condition control, and increased time with the physician. The Care Manager has helped by having patient call her when they feel sick or about issues, and to understand how to manage medication. Now they bring meds to appointment, organize their medical information, and have their advance directive documents completed.”
For more information regarding the content in this article please contact Lexi Bryce @ AlexandriaBryce@cherryhealth.com