Bronson Internal Medicine: Embracing team-based care to support patients

Dr. Andrew Chen stands with medical assistants Sara Harmen, left, and Kristin Goff.

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

In addressing the needs of a wide variety of patients, Bronson Internal Medicine in Kalamazoo places a high value on the team-based approach — an integral part of the Patient-Centered Medical Home program.

A PCMH practice since 2016, Bronson has nine primary care providers and one nurse practitioner, supported by a social worker, nurse care manager and pharmacist. Having an extended care team is especially helpful when treating patients with chronic conditions or social factors that affect their health.

More recently, the practice also joined the Collaborative Care Designation Program, which builds on the PCMH foundation. The program uses the services of a behavioral health care manager and consulting psychiatrist in addition to a primary care provider, to help ensure that behavioral health needs are met.

“Patients are more complex today, with more challenging needs, and they’re living longer,” said Dr. Andrew Chen, who joined the practice in 2021 after completing his residency. “Team-based care will be a necessity moving forward.” 

PCMH successes

Dr. Chen pointed to the following processes as being the most instrumental in the practice’s success:

• Using a team-based care model
• Following evidence-based medicine
• Trusting the team to support patients in managing chronic conditions and behavioral health needs
• Providing same-day access to patients to avoid unnecessary emergency department and urgent care visits

Also, the practice uses the Epic medical records system, which provides real-time reminders of gaps in care and the services patients need. The system also provides the MyChart portal, allowing patients direct communication access to their health care providers.

Telemedicine is another factor that’s been crucial to the success of the practice, particularly during the COVID-19 pandemic. It’s allowed providers to meet with patients virtually for various medical needs, counseling related to medications, lab results and mental health needs, as well as for COVID-19 follow-up.

Bronson Internal Medicine is also part of the Provider-Delivered Care Management program in which care management is delivered in the physician’s office, provided by trained care team members who work in conjunction with the physician. “This has allowed providers to have access to quick communications about the patient’s plan of care and how care management could support them,” Dr. Chen said.
 
Advice for other practices

Asked if he had any advice for practices working to implement PCMH capabilities, Dr. Chen replied: “It’s important for providers to trust and utilize the ancillary staff such as social workers, complex care managers for chronic conditions, behavioral health care managers for mental health issues and pharmacy staff for medication issues. It’s also important to delegate follow-up when appropriate and refer patients with complex conditions who need support to care management.”

Other articles in the series

Check out the following two articles, which appeared in the April and May issues of The Record.

• “The Pediatric Place: Creating a centralized hub to facilitate information exchange”
• “MyMichigan Family Practice Center: Building a high-functioning team”

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.