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Utah Healthcare Institute – St. Mark’s Family Medicine

Getting Patients’ Perspective is an Eye-Opener

The Institute of Medicine’s special Committee on Identifying Priority Areas for Quality Improvement (2003) found that “…improvements in care coordination could result in significant benefits across the continuum of care across the life span,” and subsequently recommended national focus on this “cross-cutting” topic. Staff from the Utah Healthcare Institute—St. Mark’s Family Medicine, under Dr. John Berneike’s leadership, are piloting a newly developed Beacon Diabetes Self-Management (DSM) Care Coordination Program.

Elisa Scheringer, RN, and Medical Assistants Heather and Kelly, received training to increase their understanding in a variety of topics, such as Motivational Interviewing, the Stages of Change Theory, and Health Literacy to provide comprehensive assistance for 15 patients with diabetes, identified as high risk for significant medical problems. This team is eagerly implementing the program in a pilot study for their clinic. They are using their electronic health record (EHR), developing a Care Coordination template, and monitoring patients’ diabetes indicators closely.

The team recently shared feedback about the program, which has shown improvement in patients’ A1C’s, which is exciting, but have also noticed other changes in how they view patient care. “Getting patients’ perspectives has been a huge eye opener,” Heather stated, with Kelly adding, “It has helped us understand their needs and problems on their level, rather than us telling them what we think they need.” One of the most useful components, Kelly noted, is considering patients as going through the Stages of Change, “We identify which stage they’re in, and then design our care plan according to this—meet them where they’re at.” Motivational Interviewing, the team shared, is helping them consider care as disease management versus care according to “the provider perspective.”

Elisa and Dr. Berneike determined the positive effects the program has had on the staff as well, “It has engaged our team much more, and gives us ownership of our patient care,” both Elisa and Dr. Berneike noted, “It is also increasing Heather and Kelly’s job satisfaction, and making them feel important to our clinic.” The team is stimulated by the opportunity to bounce ideas off each other, “We really feel we are making a change in patients’ lives now, it is much more than just taking a blood pressure. It is truly supporting and empowering patients, making joint goals, and being a link between patients and their providers.”

Key to their success is having “the time to succeed,” Heather stated, noting that they are given time to care coordinate their patients. Kelly believes patients are improving their outcomes due to the extra attention they receive, “Patients seem surprised that we are really trying to work with them as individuals to find out how we can help them improve their self-care.”

It is obvious that this highly motivated team is “sold” on care coordination, “This is the kind of thing that is very appropriate to the way we practice medicine,” Dr. Berneike noted. “We go into medicine because we want to make a difference in patients’ lives. This program helps us to truly engage our patients—this should be the norm in Primary Care, and hopefully will be as we continue to transform health care.”