Success Stories

Mobile Integrated Health Care working to reduce ER visits and hospital stays, while keeping patients healthier and safer in their own homes

Cheyenne County Clinic - St. Francis, KS

“People don’t realize how important it is to know your patient, to see them in the home and to learn what the barriers are,” said Tammy Church, RN. “One encounter can’t tell you the whole story.”

Through a grant awarded to the Cheyenne County Clinic in St. Francis, Kansas, Church and the EMS director Reid Raile began the mobile integrated health care service, working with high risk patients (patients at risk for complication or admission) in 2016. Church had two goals - to help patients stay safely in their homes and to reduce the number of avoidable emergency room and hospital visits.

“There are so many barriers to care that you can identify if you visit a patient’s home. But first,” Church said, “you’ve got to earn their trust. I’m not going into their homes to take over their life. I just go in with the education. We come up with a care plan and set up a routine. I find frequently that people don’t take their medication as prescribed.”

Church has worked with about 40 patients. Typically they start out with frequent home visits and then transition to semi-monthly or monthly home visits. Eventually they may only require a follow-up phone call to ensure that their care plan is being followed.

Practice works to reduce labor intensive claims-based reporting

PTN group Pictured: Comprehensive Adult Medicine, Wichita
Top to bottom: Carlene Klassen, MD; Amy Blincoe, MA, Glenda Murray, OM; Didi Henriques, RN (Not pictured, Kim Jones, MA)

Using data to improve care plays an essential role in delivering quality healthcare for patients, and succeeding in the Merit-Based Incentive Payment System (MIPS).
Barriers such as cost, limited staff, and convenience often restrict access to the tools necessary to track and send quality data to CMS. As a result, submitting quality data to MIPS through the CMS web interface, or a third-party data-submission service such as an EHR (Electronic Health Record) registry, or a qualified clinical data registry is not always an option for smaller practices. For those practices that fit this scenario, claims-based reporting is usually the only option. With claims-based reporting, clinicians must use codes specified by CMS that indicate a particular quality measure was performed with a patient. For healthcare professionals, the claims-based method can be difficult to track and labor intensive.

Throughout 2016, Dr. Carlene Klassen and her staff at Comprehensive Adult Medicine, Wichita, worked with the Kansas Practice Transformation Network (PTN) to develop a plan that addressed how to succeed in MIPS via claims-based reporting.

Lead Nurse Didi Henriques and Office Manager Glenda Murray worked with their PTN Quality Improvement Advisor, to develop an efficient and effective way to track clinical quality measures and report the measures via claims. Henriques modified the EHR health maintenance section to include alerts that appear both when specific quality measures apply to patients and if that measure has been completed. Murray, who reviews the claims for the practice, utilizes the modified health maintenance section to verify completion of quality measures, allowing addition of appropriate codes.

The Wichita practice sees more than 800 patients a year; these coding changes have resulted in considerable time savings for the practice and also provides a streamlined tracking methodology for patient compliance.

- written by Janie Rutherford
(posted 7-10-17)

Satanta District Hospital testimonial

“My personal experience with KHC has been instrumental in changing the way we do things here. Through the camaraderie and sharing of ideas and information for making changes we have achieved a team that is always ready to rise to any challenge that is put before us.

Because we are a very small CAH, we need help with designing programs that impact patient care, family involvement and nurse and physician participation, we have found a wonderful resource in KHC. I have called or sent emails whenever we have something that we want to work on.

Ransom Memorial Hospital - Falls Improvement Project

Click here to view Ransom Memorial Hospital storyboard video that highlights a Falls improvement project at their facility in Ottawa, Kansas.
Click here to read more. (PDF)

Coffeyville Regional Medical Center - Culture of Safety

Coffeyville Regional Medical Center - Culture of Safety
Click here to view the 2017 AHA Rural Conference Coffeyville Regional Medical Center’s storyboard video that highlights a Culture of Safety improvement project at their facility in Coffeyville, Kansas.
Click here to read more. (PDF)

Wesley Medical Center - Sepsis Case Study

Wesley Medical Center
HEN 2.0 Sepsis Case Study
Click here to view the video

Labette clinic is seeing a valuable exchange of information through PFAC

The feedback goes both ways between the Patient and Family Advisory Committee (PFAC) and the Labette Health Physicians Group, according to Missy Beasley. Recently she was invited to present at the PFAC meetings at Labette Health in Parsons, Kansas.

Beasley is the clinic manager of the 25 physician and NPP multi-specialty clinics located in Parsons, St. Paul, Erie, Altamont, Cherryvale and Independence. Her clinic is a member of the Kansas Healthcare Collaborative Practice Transformation Network (PTN). It was one of the first to join, in October 2015. Beasley works with Josh Mosier, PTN Quality Improvement Advisor. Through their work on the PTN improvement measures, particularly patient involvement, Beasley said a PFAC committee was something the hospital-owned clinic had been wanting to set up. She was glad to join the hospital’s group which comprises 11 community patient and family advisors, one Board of Trustee liaison, and five or six hospital employees.

Finding a simple tool that results in many positive changes

Sumner County Family Care Center clinic partners
From Left: Lacie Gregory MD, Stephen Hawks DO, Joel Weigand MD, Steven Scheufler MD, Shana Jarmer MD, (not pictured Larry Anderson MD)

Finding a simple tool that results in many positive changes

Amber Dawson hadn’t been at her new job as Administrator of Sumner County Care Center more than a few days when she ran across an email from Practice Transformation Network advisor Jill Daughhetee.

The Sumner County Care Center in Wellington has 11 providers and 30 employees and is celebrating 40 years of service this year. However, a recent string of turnovers in the administrator position had left the lines of communication down and employee morale down, too. Amber wanted to change that and Jill’s email offered some tools.

Together we're better

Frequently unintentional silos keep team members and co-workers from collaborative work. It happens in many organizations, including health care. People on different teams, who don’t see one another often or at all, may miss what ought to be obvious chances to work collaboratively.

With a new take on an old adage, making sure the right hand knows what the left hand is doing can make a big difference in providing better patient outcomes, more efficiency and cost savings.

Clinic finances move back into the black thanks to PTN participation

“It was incredible,” said Mary Barrett, office manager of her husband’s family practice in Neodesha, Kansas. After less than three months of work with the Kansas Practice Transition Network (PTN), she has made adjustments that “have been a game changer” in Dr. Bradley Barrett’s clinic.

Kansas PTN Quality Improvement Advisor Jill Daughhetee first met Mary in January and together they performed a Baseline Practice Assessment. “Jill analyzed our strengths and weakness,” Mary said, and candidly added, “we have some weaknesses.” With this list, they got started.

Preventive care getting a boost at the Eureka Clinic

Focus on the whole patient means special attention to preventive care.

This single practitioner clinic serves all of Greenwood County Kansas and beyond. Jennifer Larsen is the physician’s assistant. “We’ve tried to focus on whole patient care, especially preventive care,” she said.

Family Health Care Clinic in Lindsborg

Family Health Care Clinic in Lindsborg, Kansas became part of the Compass Practice Transformation Network last year. 

 After completing the Practice Assessment Tool, FHCC found that they weren’t capturing structured data consistently to document the quality care that they were providing as a practice.   

“Secret Patients” provide feedback

Ottawa Family Physicians in Ottawa, Kansas have found an effective tool to get patient feedback. “It’s just very simple,” said Betty Franklin, administrative assistant.

Franklin explained that two or three weeks ahead of time, they look through the patient schedule and randomly pick three or four patients. A staff member calls them and asks if they would be willing to be a “secret patient.” If they agree, a Patient Satisfaction Survey is mailed to them, along with a self-addressed, stamped envelope.

Labette Health - Adverse Drug Events Case Study

Labette Health
HEN 2.0 Case Study: Adverse Drug Events
Click here to view the video

Success Stories

Mobile Integrated Health Care working to reduce ER visits and hospital stays, while keeping patients healthier and safer in their own homes

Practice works to reduce labor intensive claims-based reporting

Satanta District Hospital testimonial

Ransom Memorial Hospital - Falls Improvement Project

Coffeyville Regional Medical Center - Culture of Safety

Wesley Medical Center - Sepsis Case Study

Labette clinic is seeing a valuable exchange of information through PFAC

Finding a simple tool that results in many positive changes

Finding a simple tool that results in many positive changes

Together we're better

Clinic finances move back into the black thanks to PTN participation

Preventive care getting a boost at the Eureka Clinic

Family Health Care Clinic in Lindsborg

“Secret Patients” provide feedback

Labette Health - Adverse Drug Events Case Study

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