Whole-person health: A SIM blog (2/14/2018)

Projecting a caring culture: Practice transformation through a patient’s eyes

By Heather Grimshaw, SIM communications manager


‘Building capacity’ is a common phrase among practice representatives who participate in the Colorado State Innovation Model (SIM) to assess processes, revise care teams and refine how data is collected, reported and used to enhance patient care and to negotiate value-based contracts. It’s easy to assume that most of this work is invisible to patients yet during a recent SIM podcast one care team learned otherwise from a patient, whose story prompted an emotional response.

“Hearing that has made all of our hard work worth it just in that one story,” said Kris Hubbell, BS, RN, CHC, clinical quality coordinator, Roaring Fork Family Practice in Carbondale.

Practice transformation work
The work that SIM practices do to provide team-based care has a positive effect on all members of the care team.

“It used to be one or two of us as the leader of the practice,” said Gary Knaus, MD, Roaring Fork Family Practice in Carbondale, a SIM cohort-1 practice. “Now everyone is a leader.”

That approach has yielded positive results for SIM practices that report higher morale, lower burnout rates and a positive change in team interactions.

Daily huddles as well as team coaching and staff trainings funded with SIM small grants boosted staff confidence levels and encouraged more vocal participation. “Everybody has the same voice,” Hubbell said.

And they have a full picture of what patients need, which expands access and projects a culture of caring that has been noted by patients.

“I have experienced the follow-up care, the calls, the team approach and I feel very well taken care of and very safe” at this practice, said Mary Catherine Conger, who shared the patient’s perspective during a SIM podcast with the practice care team.

“That’s powerful,” Hubbell noted. “That brings tears to my eyes.”

A unique lens
The work the practice did with SIM funding has alleviated some of the responsibility Knaus shouldered. “It used to be all on me,” he says. “Now with a team that can do some of the mental health things, we have built capacity, systems and a culture” so the responsibility is shared by 39 people, “not just me one-on-one with patients.”

That team focuses on prevention, communication and interventions that consider all aspects of a patient’s life.

“We recognize that you can’t take care of your diabetes if you’re worried about your housing, food or transportation,” Hubbell explained. “We’re here to help [you with] all facets of your care. You can be assured that the practice is looking at you, not just your diagnosis.”

That approach has resonated with Conger. “The systems that you’ve put into place are effective and working,” she told the care team, which talked about the work they’ve done to ensure a patient-centered approach. “For the first time ever, I have been able to relax a little bit and feel like I’m not solely responsible” for my medical records and care.

Conger shares an example of the integrated care she’s received during the podcast. And what might surprise some healthcare professionals is how simple it can be to reach patients and how much those efforts mean to them.

“For me this has been such great care. I want everybody to be able to receive this kind of care,” Conger said. “I’m very grateful that you are doing what you’re doing. As a patient I feel it.”

Listen to the podcast: https://soundcloud.com/user-118904494/roaring-fork-patient