Dr. Delmont Improves Care Coordination and Health Care Quality
Dr. Jacqueline Delmont is a practicing internist and founder of a three-site primary care practice with locations in Queens, New York and on Long Island, New York. The practice, which is a Level 3 National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH), primarily serves low-income and underserved patients. Dr. Delmont and her practice are using their electronic health record (EHR) system to improve care coordination and help their patients navigate the health care system.f
A Challenging Patient Population
Dr. Delmont faces the challenge of coordinating care for underinsured, low-income patients with many health care needs. Her practice also faces cultural barriers, such as serving many patients whose first language is not English. “We are operating in a difficult terrain with patients who need a significant amount of support,” she said. “We have to do more with less to help our patients navigate the health care system.” To best serve her patients, Dr. Delmont had to find unique ways to provide high-quality, coordinated health care. She knew Health IT could help.
Improving Care Coordination
Dr. Delmont’s practice is using Health IT to help patients navigate the health care system. For one key health care quality improvement effort, the practice is using patient lists and disease registries to identify those patients who need preventive health care. For example, the practice regularly generates lists of patients who have not been seen for physicals in the past year or who have elevated hemoglobin A1c levels.
With patient data in hand, a care management team composed of nurses, medical assistants (MAs), and receptionists is able to improve care coordination for these patients. The team starts out by contacting the patients to schedule preventive check-ups. Next, the team ensures patients have everything they need, whether it be transportation to their appointment, educational materials, or glucometers. “With our EHR system, we can concentrate our limited care management resources on our high-risk patients,” said Dr. Delmont.
Improved Preventive Care
After implementing an EHR system and improving care coordination for their patients, Dr. Delmont and her colleagues saw substantial improvements in health care quality.
- Annual wellness screening visits increased by 50%.
- The practice’s breast cancer screening rate increased from approximately 80% to over 90%.
- The practice’s colon cancer screening rate increased by 25%.
With Health IT, Dr. Delmont and her colleagues are improving health care quality for their high-risk, underserved patient population.
Continuing to Spread Health IT
A true Health IT champion, Dr. Delmont is continuing to spread Health IT in her community as Chief Medical Officer at Beacon Health Partners (BHP), an accountable care organization (ACO) headquartered in Westbury, New York. Dr. Delmont is applying her practice’s lessons learned to help the ACO’s providers improve care coordination and health care quality as the leader of BHP’s population health management efforts. Using Health IT, Dr. Delmont and her team generate provider-by-provider reports to help BHP’s members understand gaps in care and implement processes to effectively engage patients and address their health care needs.
Furthermore, Dr. Delmont and her colleagues at BHP recently began an initiative to facilitate Level 3 NCQA PCMH transformation for 60 of the ACO’s physician practices. “Our team is helping the providers assess and improve their workflows, train MAs and front office staff, and target many of the same issues we resolved at my practice,” said Dr. Delmont. “We are hopeful this work will translate into achieving the triple aim for our patients – better health, better care, and lower costs.”