Transformation is happening at St. Luke’s and among members of our network, perhaps in places it might not be expected.
Primary care practices in rural communities we serve, including Baker City, McCall and Shoshone, are significantly advanced in their transformation to the primary care medical home model, necessity being the mother of invention in some instances.
The case of a single physician in an entire county of Idaho is an instructive example. Here to tell you about his clinic’s transformation is St. Luke’s Content and Communications Coordinator Randall Post.
- David C. Pate, M.D., J.D.
Changing health care is difficult enough for a health system in a large city, but how do you drive transformation in a rural town with only one physician?
For St. Luke’s and the residents of southwestern Idaho, that’s where St. Luke’s Health Partners (SLHP) comes in.
St. Luke’s Health Partners is the financially and clinically integrated network that brings together St. Luke’s and independent providers and facilities in the journey from the traditional fee-for-service approach to value.
The collaborative effort with Dr. Keith Davis and the Shoshone Family Medical Center in Shoshone shows just how effective such partnerships can be, whether they involve part of a large system, a regional provider group or a small rural clinic.
Led by Dr. Davis, the clinic serves a county the size of Rhode Island from a cramped building that is more than a hundred years old. An early adopter of team-based care and clinical transformation, the Shoshone clinic has used a patient-centered medical home framework for several years, even with limited resources and under challenging circumstances.
Shoshone and the surrounding area were without a pharmacy for about a decade until the recent arrival of telepharmacy services. The owner, Jason Reading, expressed interest in an innovative pharmacy integration model with Dr. Davis.
A community health grant from the PacificSource Foundation provided much-needed funding to allow the clinic and pharmacy to pilot the program. A staff pharmacist would float in the clinic a half-day per week, allowing clinical staff to see an additional patient, increasing access and enhancing the level of patient-centered, team-based care. The pharmacist is now in the clinic one full day per week and expanding services as needed, assisting with transitional care and Medicare wellness visits.
Over the past decade, Shoshone also has successfully incorporated nurse care managers, integrated behavioral health services and most recently, integrated pharmacy services.
In 2016, Dr. Davis and his team met with St. Luke’s Health Partners team members to discuss clinical practices and assess opportunities. That meeting was followed by a collaborative learning session with representatives from St. Luke’s McCall, another innovator in team-based care services within the network, to discuss lessons learned and to share best practices.
Over the next two years, members of the SLHP team worked with the Shoshone group to redesign workflows, improve documentation, enhance communication and identify funding opportunities to help support the expansion of integrated behavioral health services and establish integrated pharmacy services.
The Shoshone group has built registries based on the common electronic health record system to identify high-risk patients with certain chronic diseases and is working with SLHP care management resources to ensure improved transitions of care and decrease readmissions after discharge from St. Luke’s Magic Valley and St. Luke’s Jerome.
And while transformation takes time, the team is seeing evidence of success. Among the achievements: improvements in the quality of life for diabetic patients and others with chronic and complicated health conditions. In a targeted effort to reach a small group of diabetic patients, the team was able to lower A1c levels. Working with patients on stress management and meaningful goals has improved everything from patients’ participation in appointments to treatment compliance, blood sugar levels.
“It has been extremely positive, and my staff and I have consistently benefited from SLHP efforts to help us with the PCMH (patient-centered medical home model of care) including integration of behavioral health and integration of a clinical pharmacist,” Dr. Davis said. “They were instrumental in our efforts to find grant funding to help offset the initial cost of pioneering some of these activities in a rural — even frontier — setting.”
Tyler Hemsley, who served as the SLHP Pharmacy program coordinator throughout the partnership, views the Shoshone Family Medical Center as a great example as care organizations move from traditional fee-for-service activity toward the value-based approach.
“Everyone is struggling to figure this out, whether that’s in McCall, Shoshone or the Cloverdale clinic in Boise,” Hemsley said.
“It’s a little bit different in each place, but we are making it work.”
There’s no question it’s working for Dr. Davis and his patients.
“It is pretty amazing to my staff and I that we have received this great service and support at no cost to us,” he said. “Very rare in the current healthcare landscape!”
Randall Post works in the Communications and Marketing department at St. Luke’s.