In January 2017, St. Peter’s joined a five-year pilot program to improve its primary care services. The new patient-centered, team-based model is known as Comprehensive Primary Care Plus (CPC+). St. Peter’s is one of more than 2,900 primary care practices nationwide participating in the pilot model of CPC+, which was created and funded by the Center for Medicare and Medicaid Services (CMS).

St. Peter’s primary care physician Andrew Gilbert, M.D. explained that with this model the patient’s health care support system expands into a multidisciplinary team of clinical experts from nurses and doctors to care managers, mental health specialists and pharmacists.

Physician-led team-based care engages a greater number of staff in patient care and creates a culture where the patient is owned by the whole team, not just the physician. As a result, all members feel engaged, begin working to the fullest capacity of their licensure and understand that they play a key role in caring for the patient. Instead of the primary care physician trying to do everything in a 15-minute appointment, there is now a whole team of health care providers who are responsible for the patient’s care – from nurses and doctors to care managers, mental health specialists and pharmacists. The team works together to anticipate the patient’s needs, communicate their findings with each other and make sure no aspect of the patient’s health slips through the cracks.

“People are starting to realize that we need to beef up primary care,” said Gilbert. “Primary care is the central hub of all health care. When we invest in preventative primary care, the cost of health care nationwide will go down.”

From the patient’s perspective, it’s a one-stop shopping experience. In a single doctor’s visit, a patient could receive treatment from his or her primary care doctor, have a preventative screening with a nurse and a medical assistant, and visit with a mental health specialist. With this approach, the amount of care is more but the cost is actually less.

“It’s all about access,” said Amy Emmert, the director of clinic quality and population health for St. Peter’s Medical Group. “It’s about getting the patient the care they need when they need it. All providers are accessible for a ‘warm handoff’ if the patient needs anything. Everyone is able to put their arms around the patient and make sure they’re cared for in a very holistic approach.”

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The model appears to be working. “When I was diagnosed with diabetes, I was in denial about it and never took care of it,” said St. Peter’s patient, Bill Dunmire. “Dr. Gilbert and everybody in his office stressed to me the importance of managing my diabetes. The team approach between everyone in the office made it a lot easier for me to understand what I needed to do. Jess, Dr Gilbert’s pharmacist, calls me once every 10 days or so to see how I'm doing or if I have any questions. It makes me feel like I'm more than just a number. It shows they really do care.”

St. Peter’s adoption of this new model of care was driven by its physicians from the beginning—not just to keep pace with trends in health care but to best address the needs of the Helena community.

“It was us taking a hard look at the level of care we provide and how we can take that level from good to great,” said Gilbert.

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