Lone Tree Primary Care wins PCMH ‘Practice of the Year’ award

Emphasis on chronic conditions, follow-up, patient’s role in care
Jan. 20, 2016

The team at UCHealth’s Lone Tree Primary Care knew that years of hard work to turn their family- and internal-medicine practice into a patient-centered medical home (PCMH) was paying off for patients. But validation from one’s peers is always nice, too.

Lone Tree Primary Care (formerly University Family Medicine–Park Meadows) got exactly that last month, when the Colorado Academy of Family Physicians (CAFP) awarded the clinic with its Patient-Centered Medical Home Practice of the Year award.

“I am just so honored that we got this because it helps to show – especially the staff, they’ve worked so hard, and it was not easy – that it’s made a difference,” said Debra Bislip, MD, the clinic’s medical director.

From left, Debra Bislip, Sarah Karp and David Linger of UCHealth’s Lone Tree Primary Care.

The PCMH concept stresses continuity in patient care with special emphasis on those with chronic conditions. It has been a major focus of UCHealth’s primary care practices for years. The AF Williams Family Medicine Clinic was the first to land National Committee for Quality Assurance (NCQA) Level 3 certification for PCMH in 2011; University of Colorado Hospital’s other seven primary care practices have all followed suit, with Lone Tree earning its PCMH wings in 2013.

What’s more, by the end of 2017, all of UCHealth’s primary care practices aim to join UCH’s as NCQA-certified patient-centered medical homes, says Travis Sherman, UCHealth’s senior director of population health.

Write it up

NCQA Level 3 certification isn’t an end in itself, but rather another step in a process of continuously refining the PCMH practice model. That model involves making many changes in how primary care practices approach the work of caring for patients – or perhaps better, the work surrounding the work of caring for patients. As Anita Wolfe, NP, a nurse practitioner in Lone Tree put it, before PCMH, “I wasn’t doing anything different – I just wasn’t documenting it.”

Susan Karp, RN, the clinic’s charge nurse, agreed, saying the practice did a “great job” treating patients before PCMH. The difference, she says, is that “now we’ve got the numbers telling us exactly what we’re doing.”

The success of PCMH hinges on documentation, but it’s not paperwork for paperwork’s sake. Monitoring details of patient status in the UCHealth Epic electronic health record and tracking pools of patients with chronic conditions using patient registries – population management – lets Lone Tree amplify the voices of patients in their own care and ensure that they stay connected with the clinic and on top of their health.

A different path

Lone Tree was neither UCHealth’s first PCMH practice, nor the first to win the CAFP’s PCMH Practice of the Year award. AF Williams earned the honor in 2014 and UCHealth’s Boulder and Westminster were similarly cited last year in a joint award. These awards, says Robin Pettigrew, UCHealth’s director of operations for Ambulatory Services, “are an acknowledgement of the team’s hard work and commitment to making a difference for our patients, not to mention the transformation that is occurring in all of our primary care practices.


“It’s about changing how we provide care as a team, rather than as one individual, and keeping the patient at the center of the transformation work that’s going on,” Pettigrew added. The medical home model has fostered a culture of ongoing process improvement in our practices and has paved the way for this success.”

Yet while the Lone Tree team benefited from the examples of AF Williams and others – as well as from consultations with UCHealth PCMH coach Angel Perez – the practice had to find its own way to PCMH, Bislip says.  For one thing, AF Williams is a much larger practice, and includes medical residents and diverse onsite resources in areas such as behavioral health, social work and case management.

“So it was difficult to say we’re cloning whatever happened at AF Williams because we really didn’t,” Bislip said. “We really couldn’t, because we’re different.”

Staffing was the big challenge, Bislip says. Producing more thorough patient records takes more time to collect information from them and to update their status during and after visits. Creating and updating patient registries also meant additional work for a lean team of 11 providers and nine support staff.

Lone Tree’s big-picture approach will ring familiar to those familiar with PCMH. They’ve created and maintain patient registries for those with diabetes, high blood pressure, and depression, enabling close tracking for follow-up appointments and medication management.  The same tracking happens with complex patients with other combinations of conditions that put them at risk of sudden decline.

Patient role

The clinic reels these chronic and complex patients into their own care through worksheets that describe patients’ goals and why they are important, their confidence that they can attain them, their progress toward meeting them, and the barriers they perceive to doing so. Providers and patients then talk through the worksheets during routine appointments. Medical assistants and physicians/nurse practitioners “huddle” regarding each appointment, talking through the patient’s specifics and establishing what tests should happen before the provider knocks on the exam room door.

With time, Lone Tree Primary Care has also applied its patient-tracking skills to making sure patients are up-to-date on their mammograms, tobacco screenings and certain vaccinations. They’re also tracking those taking narcotic medications to handle chronic pain in a similar fashion. They’re planning on adding asthma patients to a new registry, too.

It is working, the numbers show. From October 2014 to October 2015, the clinic’s pneumococcal vaccination rate rose from 63 to 76 percent and the breast cancer screening rate rose from 52 percent to 80 percent. Ninety-nine percent of patients diagnosed with depression did the long-form PHQ9 screen, up from 91 percent the year before, and tobacco screening was at 100 percent.

Not easy

The clinic’s lean staffing has meant more work for everyone to make all this happen. Front desk staff not only greet patients, but also maintain registries and reach out to patients by phone (chronic and complex patients get calls for appointments every three months or six months, depending on the case). Medical assistants do deep dives into the records of incoming patients to prepare for huddles and to handle up-front clinic-room tasks such as urinalysis or HbA1c blood-sugar testing. For doctors and nurse practitioners, the approach has meant more time on non-diagnostic tasks, such as going over medications or talking patients through their health goals. Physician appointments relating to chronic or complex conditions are booked at twice the typical 20 minutes, though they’re dialing that back to 30 minutes, Karp says.

Just because something’s straightforward doesn’t mean it’s easy to manage, either. PCMH practices strive to have patients always see the same provider; the clinic manages this about 70 percent of the time, says David Linger, manager of clinic operations for Lone Tree Primary Care. That number understates the reality, too. One morning in early January, for example, a patient on the diabetes registry came to the clinic with a sinus infection. Wolfe saw him for the urgent need, but told him he’d need to come back to meet with Doris Sturtevant, MD, MPH, his primary care physician, to discuss his diabetes.

“Because you do get better care when you see the same provider,” Wolfe said.

Creative additions

Lone Tree Primary Care also leverages UCHealth’s scope to help patients boost their involvement in their health. One example is remote pharmacy consultations with Joseph Vande Griend, PharmD, who helps patients better understand their mix of medications and the importance of each. Another is once-a-week office hours with a diabetes educator from CU’s Department of Endocrinology, Metabolism & Diabetes, for both one-on-one and group visits regarding nutrition and other diabetes topics. The clinic has also partnered with the Consortium of Older Adult Wellness (COAW) on a six-week workshop to help patients manage their own health.

While the team isn’t resting on its PCMH Practice of the Year laurels, it’s nice to have been endowed with them.

“We’re really excited that we won the award, because we feel like the outside recognition is going to push everyone to continue to work really hard – because it is hard work,” Karp said.

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.