Measuring the Quality of Healthcare, One Less Sick Patient at a Time

Early in the service year, my fellow corps members and I watched a TED Talk by Rebecca Onie; titled “What If Our Healthcare System Kept US Healthy?” Onie concludes her imperative talk by stating: “I believe that we all have a vision for healthcare in this country. I believe that at the end of the day when we measure our healthcare, it will not be by the diseases cured, but by the diseases prevented. It will not be by the excellence of our technologies or the sophistication of our specialists, but by how rarely we needed them. And most of all, I believe that when we measure healthcare, it will be, not by what the system was, but by what we chose it to be.” When I listen to this quote, I think of the work that my host site does to create better primary healthcare for its patients. Delaware Valley Community Health (DVCH) provides high quality community based, primary medical, dental and behavioral health services to patients served. The organization strives to improve their patients’ healthcare by adopting the patient-centered medical home model approach. This model is comprised of comprehensive and accessible care for a patient, all in one location; a one-stop shop for mental and medical wellness for patients and communities served.

Population Health Management serves as part of DVCH’s initiative to become a more patient-centered medical home. Annually the organization identifies populations of patients, in its centers and reminds them of needed care based on patient information, clinical data, health assessments and evidence-based guidelines. As the Care Navigator at Maria de los Santos (MdlS) Health Center, one of DVCH’s five sites, my duties largely consists of contacting patients who are due for care and coordinating a plan for the patient to receive services.I am impacting the health of patients through outreach and education for preventive care. MdlS has set parameters to contact patients who need preventive care, immunizations, and specific medications, chronic care services or who have not been seen recently.

At my host site, I often talk to patients about the importance of preventive care and encourage patients to complete screenings for the big three: cervical, breast and colon cancers. Similar to what NHC Philly member Josh Finkel explained in his blog, I stress how it’s necessary to complete the screenings as soon as possible because early detection and treatment is crucial for cancer diagnoses. I make calls attempting to get patients who are 50 years or older to complete a pap exam, mammogram, and undergo a colonoscopy. I try to expedite the process of completing the cancer screenings, jokingly telling patients, “I will do all of the hard work, so all you have to do is show up for the appointment!” I normally schedule the appointments, create the referrals if necessary, and even take the time to prepare a fact sheet about the screening process for the patient’s knowledge. I also use the calls to educate patients about another project I work on, DVCH’s patient portal service. The Patient Portal online service allows patients to access their primary healthcare at their convenience, via their smart phone, tablet or laptop with Internet connection. Due to MdlS’ large volume of patients, this service has been exceptionally helpful to patients who don't have the time to wait on the hold waiting to schedule an appointment. The portal offer many services including the ability to schedule appointments, access medical records, request refills, and even send a message to a medical provider.

There are days when I make calls and speak with patients who no longer have insurance and cannot afford the cost of an expensive colonoscopy procedure. I try to work with the patients, getting them to complete the less invasive and expensive alternative, an InSure FIT test. For uninsured women, Maria de los Santos has a partnership with Temple Fox Chase who stations their Mobile Screening Unit van outside of the center to provide free mammogram screenings each month. They utilize all the community resources, support and funding they can in order to get people the care they need. We work collectively to make a better primary healthcare home, one less sick patient at a time.
 

This blog post was written by NHC Philadelphia member Jazzmin Boyd.
Jazzmin serves as a Care Navigator at Delaware Valley Community Health: Maria de Los Santos.