Published July 2023
Providers from Saratoga Hospital and Open Door Family Medical Center shared challenges in closing gaps in care in the pandemic/post-pandemic world and some creative strategies to help overcome them.
What have you learned over the last year that might be helpful to your colleagues when dealing with closing gaps in care for their patients?
At Open Door, our clinicians stress preventive care at every visit, regardless of the visit reason, to take advantage of each opportunity to discuss immunizations, required screenings, or other services that the patient may need. There is also an organizational expectation that preventive care is discussed during a visit, and this is evaluated during the clinician peer review process. Each of our sites conducts quarterly staff meetings which include a review of quality measures and scores so there is heightened clinician awareness on the importance of gap closure. Open Door has expanded the role of team-based care compared to last year due to the Dramatic Performance Improvement project with Coleman Associates, which promotes a team approach to caring for patients.
Saratoga Hospital has expanded the dietitian's role to provide Annual Wellness Visits, Intensive Behavior Therapy for weight loss, diabetic retinopathy screening, as well as other screening appointments and functions. Our registered dietitian is a valued part of the team and is collaborative, pitching in to help wherever needed. This approach helps to support the practice's model of preventive care. It is equally important that the care team has routine case conference meetings to discuss complex cases, barriers to care, and quality metrics. This supports closing gaps in care in a timely manner and reinforces with all staff the need to address the barriers to care that our patients may experience. These creative solutions have served as the "launching pad" for program development supporting our patients' disease management goals.
Since many people have recently delayed preventive care, how have you overcome the obstacles and stay connected with your patients?
Open Door used CareMessage, a text messaging platform, to contact patients that had gaps in care. For example, during the summer of 2022, Open Door texted adolescents that had not had a well visit in the calendar year. We asked them to schedule an appointment prior to the upcoming school year and offered backpack incentives to get them in.
We also utilize “Patient Visit Planning Reports” to address care gaps for patients that come into the health center for an appointment. Over the past year, we have prioritized the need for morning huddles between the clinicians and their support staff to review gaps in care and plans for addressing them at the time of the patient visit.
One of the strategies we had at Saratoga Hospital was to convert our Nutritional Services to telehealth, which kept our visit volumes about the same as before the pandemic. Registered Dieticians (RD) conducted telephonic outreach to make sure patients had what they needed; food, medications, etc. This began our virtual Nutrition Prescription Program where patients can learn the curriculum via telehealth. “Preventive health” as it relates to the most common chronic disease conditions was the overarching learning component throughout our 12-week course. This patient-focused approach to disease management supports continuing self-care and adoption of new methods for living healthy lives.
Saratoga Hospital is performing very well in closing cancer screening measures such as cervical, breast and colorectal. Can you share your approach?
Addressing food security during the pandemic helped us to build trust with our patients. These connections through telehealth counseling allowed regular contact with them and presented opportunities to discuss other health screenings. We kept visits in person when appropriate (for cervical cancer screening), but we also utilized screening strategies that did not require an in-office procedure such as Stool DNA testing. This screening follows U.S. Preventive Services Task Force(USPSTF) guidelines and can be collected at home. Many eligible patients elected to take advantage of these screenings.
Open Door has had success engaging populations that may have challenges receiving childhood immunizations. What strategies did you implement to be so successful?
We have a workflow in place where a nurse checks the New York State Immunization Information System (NYSIIS) vaccination registry for children who come in for a visit for any reason, not just a physical examination. If the child needs vaccination(s), the clinician discusses it with the parent or guardian, and the immunizations are given during the visit. We also use vaccine templates to assist in documentation. There is now reimbursement for vaccine counseling which pays for the work and time clinicians dedicate to discussing vaccines with patients, parents, or guardians.
Our nurses also use the Relevant database to periodically outreach patients, both adults and children, who are missing vaccines per the Advisory Committee on Immunization Practices (ACIP)vaccine guidelines. We receive all ACIP recommended vaccines from Vaccine for Children (VFC) and Vaccine for Adults (VFA) which enables Open Door to offer free vaccines to our uninsured patients. We always have ample stock of vaccines on hand to close gaps in care.
For school-aged children, Open Door has eight School-Based Health Centers (SBHC) which provide preventive primary care as well as acute care. The SBHC clinicians use the Relevant reporting system at Open Door to identify and close gaps in care, including immunizations.
Saratoga Hospital is particularly good at getting patients with Diabetes to engage in condition management (eye exams and HbA1c testing). What do you attribute to your success?
Providing Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT) services by an RD on-site, embedded into the practice makes a significant impact on patient engagement and clinical outcomes. The registered dietitian at the Community Health Center, Stephanie Samascott, completes warm hand offs from the primary care provider (PCP). This immediate connection to a new member on the patient's care team is instrumental in strengthening the patient's investment in their health. Injection education and diabetes technology training with patients coupled with chronic disease management classes and the Nutrition Rx program has been the magic formula to meet the needs of our patients with diabetes. Our registered dietician also works to improve the practice's quality measures by monitoring patient's lab results and notifying the providers when patients are due for updated labs.
Open Door has performed well in prenatal/post-partum measures. What are the key drivers in this success?
We have a Midwifery program with six midwives who provide prenatal and post-partum care. There is no access issue for these services. The midwives collaborate closely with each other to provide team-based care. There are dedicated prenatal and women's health nurses who track and reschedule appointment cancellations and no-show visits to ensure continuity of care for our patients.
We thank the contributors of this discussion for bringing ideas, creativity, and patient-centered solutions for the continued health of their patients:
- Dr. Renee Rodriguez-Goodemote, MD, FAAAP
- Dr. Karin Borrelli, MD
- Stephanie Samascott, MS, RD, CDN - Registered Dietitian
- Lisa Hodgson, RD, CDN, CDCES - Clinical Nutrition Manager
Open Door Family Medical Center
- Dr. Daren Wu, Chief Medical Officer
As a Federally Qualified Health Center, Open Door provides top-notch health care to those who are hardest to reach, regardless of their ability to pay. Often, Open Door serves patients who may not otherwise have access to care – including low-income families and individuals without insurance.
Saratoga Hospital is the Saratoga region's leading health care provider and the only acute-care facility in Saratoga County. The hospital’s multispecialty practice, Saratoga Hospital Medical Group, provides care at over 20 locations, delivering the programs and services that can have the greatest impact on individual and community health.