The Pediatric Place: Creating a centralized hub to facilitate information exchange

Gathering at the start of their workday are, from left, Dr. Nichole Ellis, Jenny Spahr, pediatric nurse practitioner; Cindy Norton, practice manager; Kathy Petersen, family nurse practitioner, and Katie Allwardt, care manager.

This is the first article in a series highlighting some top performers in the Patient-Centered Medical Home Designation Program.

When The Pediatric Place of Hillsdale built a new facility two-and-a-half years ago, they added an island at the center of the exam rooms that the staff calls the “central brain.”

This feature facilitates real-time collaboration and enables the health care team to get a handle on what’s going on with a variety of patients. For example, when the team noticed that many of their patients had the flu recently, they were able to notify the school district promptly.

Pediatric Place, a designated Patient-Centered Medical Home, joined the Collaborative Care Designation Program last year. A nurse from the practice was trained to become the care manager, a position that plays a central role in the collaborative care model.

“As part of our efforts to develop strong relationships with the patients, we thought it was important to have a community and staff member already known by the patients to serve as the care manager,” said practice owner Nichole Ellis, D.O., a medical director with Integrated Health Partners. “Since our nurse began handling care management duties, we’ve seen a significant improvement in patients we’re treating for anxiety and depression.”

To receive CoCM designation, a primary care practice must already have PCMH designation and meet Collaborative Care-specific capabilities. The Pediatric Place has been a PCMH provider for the past 10 years.

Dr. Ellis believes the program has helped improve the value of health care the practice delivers. “The PCMH interpretive guidelines provide a great outline for how to deliver high-quality care, and hold us accountable to ensure we have standardized, documented processes. I really appreciate the way the PCMH program is set up because it allowed us to slowly add more capabilities as we grew, allowing us to see the positive impact this additional support creates for patients.”

Following are a few of the processes that she believes have had the most positive effect on the practice overall:

• Follow-up after specialist referrals — The staff makes monthly calls to families when a child has been referred to a specialist to ensure that they’ve made an appointment and that it was scheduled in an appropriate time frame.
• Lab and test tracking — The staff calls families to make sure routine lab testing and other tests were done.
• Follow-up after emergency department visits — The staff follows up with families when their child has been to the emergency department to schedule a follow-up appointment.
• Patient education — The staff educates parents about when they might want to make an after-hours call to the provider, helping to avoid unnecessary emergency department visits. Much of the focus is on letting new moms know what type of symptoms warrant an after-hours call.

Cindy Norton, the office manager, has been employed at the practice for nearly 30 years and has served as the office manager for five years. She’s worked closely with the practice’s physician organization, IHP, to implement data registries and other tools to help identify patients who need follow up, and then contacts them to close any gaps in care.

“Consistency and persistence are key to making sure patients get the care they need,” Norton said. “We work hard to ensure that none of our patients fall through the cracks.”

If you’d like to learn more about becoming a PCMH-designated practice, talk with your physician organization or send an email to valuepartnerships@bcbsm.com.