Mark Dangl, 59, has spent a lot of time in emergency rooms.
“I’m diabetic,” he said while sitting in the waiting room at Silver City Health Center, a Kansas City safety-net clinic for the uninsured and underinsured.
“I’m on insulin, but for a long time I couldn’t get it,” said Dangl, who is uninsured. “I’d go to places, they’d tell me who to call, and I’d call but I couldn’t get through, or they’d say they’d shipped it and I never got it. I used to go months at a time without my meds.
“I’d end up passing out or being dizzy or incoherent, and I’d have to go to the emergency room,” he said. “Being dizzy may not sound like much, but you get to a point where, really, there isn’t anything else you can do. You’re so sick you have to go to the hospital.”
That doesn’t happen now. Not since Dangl found Silver City Health Center.
“This is a place that spends time with you,” he said. “It’s like you’re part of something here. It’s like you belong. The care is exceptional. I wouldn’t be alive if it wasn’t for them.”
Silver City Health Center, a project of the University of Kansas schools of nursing and allied health, is a leader in national and state campaigns aimed at promoting patient-centered care — the notion that patients fare better when they have wellness partnerships with their primary care physicians rather than when they visit doctors only when ill.
“We believe very strongly that Silver City Health Center is a place where patient care is No. 1,” said Mary Virden, the clinic’s administrator. “We do everything we can to view things from the patient’s perspective.”<a name="continued"></a>
In April, the clinic was the first in Kansas — public or private, nonprofit or for-profit — to earn Patient-Centered Medical Home recognition from the National Committee for Quality Assurance.
Increasingly, patient-centered care is viewed as a way to lower health care costs and improve outcomes.
“The patient-centered medical-home model focuses on taking care of the whole person rather than just dealing with the illness at hand,” said Chris English, chief quality officer at the Kansas Association for the Medically Underserved.
“It means if someone isn’t coming in for their appointments, you find out why and you help them take on a more active role in managing their health,” English said. “You’re proactive.”
Silver City Health Center, for example, keeps close tabs on its diabetic patients, using a computer spreadsheet.
When someone misses an appointment, they are called. If there’s a problem, it’s resolved. If a patient’s telephone has been disconnected, someone goes looking for the patient.
The center also makes sure that its diabetic patients are aware of their blood sugar levels.
“It’s evidence-based practice,” Virden said. “We know that if your hemoglobin A1c level is at 7 percent or less, we’re not as likely to see the nasty sequelae that comes with being over 7 percent — things like kidney disease, blindness, or the lower-extremity blood flow problems that lead to amputations.”
Virden noted that three years ago, about 28 percent of the clinic’s diabetic patients were below the 7 percent level. But after the clinic expanded its patient-centered care initiative, the number of patients with A1c levels below 7 percent reached 47 percent by the close of 2010.
“Now, keep in mind that three years ago, our diabetic population was 155 patients,” Virden said. “By the end of 2010, it was 215. So not only is this an improved outcome, it’s an improved outcome for more patients.”
Making health a priority
Most of the clinic’s diabetic patients, she said, are “euphemistically speaking ... train wrecks” when they show up at Silver City Health Center.
“By the time they get here, they are chronically ill. Their cases are complex,” Virden said. “Half of our patients are uninsured, and three-fourths of them (uninsured patients) are living below the federal poverty level, which means they’ve had to set priorities. Those priorities tend to be rent and food.
“Health care isn’t a priority because they know they can’t afford it,” she said. “They wait until it gets so bad they have to seek help.”
When pressed, Virden said, diabetic patients often admit to going a year without insulin.
JoAnn Peterson, a nurse practitioner, shared that when she started at the clinic four and a half years ago, it wasn’t unusual to have three or four diabetic patients in a year undergo “lower extremity amputations.”
But with patient-centered care, the clinic didn’t record a single amputation in 2008, 2009, or 2010.
“We just had our first one in a long time,” Peterson said, referring to a patient who’s expected to have a toe amputated. “So, looking back, I’m sure we’ve prevented quite a few.”
The clinic takes a similar approach in caring for its patients with high blood pressure.
Silver City Health Clinic, located in Kansas City’s Argentine district, is named for the silver smelter that employed hundreds of workers in the mid- to late 1800s.
Much of the Argentine district is Hispanic, and Virden said about 60 percent of the clinic's patients are Hispanic.
The clinic had 1,217 patients last year, logging 5,120 patient visits. Much of the clinic’s caseload in comprised of children, young mothers, and pregnant women.
The safety-net clinic in Salina — Salina Family Health Care — is expected to apply for family-centered care recognition this fall.
Two more Kansas clinics earned National Committee for Quality Assurance recognition for their patient-centered care policies last month:
• KU MedWest Family Practice, Shawnee.
• Kansas City Internal Medicine-Menora, Overland Park.
Eight physician-run clinics are expected to apply for national recognition within 24 months. Eleven more have started to work patient-centered care practices into their daily operations.
“It’s a very difficult process,” said Lisa Roberts, a coordinator with Kansas Patient Centered Medical Home Initiative, a three-year, foundation-funded project coordinated by the Kansas Academy of Family Physicians.
“I tell people it’s like trying to build a plane while you’re flying in it,” she said. “I mean, you’ve got all these patients coming in, you’ve got all these policies and procedures in place, and then, while you’re in midair, you’re changing the way you do things.”
Initially, the project is focused on eight clinics:
• American Medical Practice of Winfield and Augusta;
• Cheyenne County Clinic and Cheyenne County Hospital, St. Francis;
• Ellsworth County Medical Center and Rural Health Clinic, Ellsworth;
• Dr. Mindi S. Garner, Pittsburg;
• Sabetha Family Practice, Sabetha;
• Internal Medicine Group, Lawrence;
• KU Wichita Adult Medicine, Wichita; and
• Plainville Medical Clinic, Plainville.
Blue Cross Blue Shield of Kansas and Blue Cross Blue Shield of Kansas City last month agreed to offset some of the costs tied to the clinics’ move toward patient-centered care.
“Essentially, these eight clinics will be able to bill some services they may not be providing now – things like electronic prescriptions, quality reports, or taking time to encourage patients to take part in our care management programs for chronic illnesses like diabetes, heart disease, or asthma,” said Mary Beth Chambers, a spokeswoman for Blue Cross Blue Shield of Kansas.
The company’s overture is limited to the eight clinics and, as yet, does not include the state’s safety-net clinics.
Reinventing Medicaid: State Innovations
Promoting the program
Last month, an article in Health Affairs journal profiled efforts by Medicaid programs in 17 states to promote patient-centered care, using a variety of financial incentives.
Kansas wasn’t mentioned.
“That’s because there aren’t any (financial incentives for Medicaid providers),” said KAMU’s English. “There are in other states, but there aren’t in Kansas.”
In recent years, officials at the Kansas Health Policy Authority – now the Division of Health Care Finance within the Kansas Department of Health and Environment – have discussed adding patient-centered care incentives to the state’s Medicaid budget. The incentives, however, have not been funded.
That’s not necessarily been a hindrance, Roberts said.
“It’s made us pioneers,” she said. “I’m convinced that the systems that we’re putting in place in Kansas are more efficient and are going to be more sustainable than those that are depending on financial incentives.”
English agreed, noting that the safety-net clinics’ support of patient-centered care is long-standing and has not been incentive-driven.
“Patient-centered care is the direction of the future. It's what works; it’s where we’re all headed,” he said. “But I say that tongue-in-cheek because, really, it’s what most safety-net clinics do already. Now, it’s just a matter of getting recognized for it.”