Coordinating Quality Care

When I began my service at WellSpace Health in the clinical quality department, I was
given the freedom to choose a project that would positively impact the organization's ability to
complete preventive screenings and chronic condition management, thus improving gap-in- care
closure rates. With another team member, we developed a three-pronged approach: to identify
gaps in care; to determine action needed to close gaps; and to implement interventions to ensure
gap closure. We observed that providers struggled to address patients’ preventive care needs in
addition to acute medical issues given strict time constraints. To assist with this, we developed an
automated chart tool that summarizes gaps and identifies actions for each missing care need. The
tool presents the information in a manageable way that saves time for providers while ensuring
that all health maintenance checklist items are addressed. Our program has expanded from a pilot
of four care teams to 36 across ten health centers in six months, impacting thousands of patients.
This experience helped me realize my passion for public health work and has demonstrated to
me that it is possible to provide high-quality comprehensive care even in resource-limited
settings.

While half of my service has been dedicated to working on this project, the other half of
service is dedicated to performing in-person support to FQHC care teams. In this role, I schedule
follow-up appointments for patients who have clinical quality care gaps, educate patients on
preventative screenings, connect patients with specialty services like behavioral health, and help
patients navigate the healthcare system. Despite barriers to care, I help integrate clinical quality,
primary care, and other services into a more accessible package for patients. I have seen how
overwhelming and frustrating health care can seem to patients with limited medical literacy. I
have also learned that making a patient feel heard is an important tool in building trust.

Within our patient population, there are many reasons a patient might be distrustful of
their care team, such as a language barrier, a negative experience with a past doctor, or a
stigmatized condition. It is my job to identify and address such issues so that they are not barriers
to adherence with preventive care recommendations. For example, one woman didn’t want a pap
smear because she had been scheduled with a male doctor. I wrote a note in her chart to only
schedule with female Women’s Health providers and got her an appointment where she felt
comfortable. In another instance, an underweight patient was skeptical of our tobacco cessation
program but agreed to a consultation after we discussed it could help her regain her appetite.
Another patient didn't want an invasive colon cancer screening despite family history of the
condition. We settled on a take-home kit with instructions printed out in his native Russian, an
option he didn’t know he had. With these patients and others, I have learned how to employ
empathetic listening to tailor my approach to each individual’s needs and challenges, which are
diverse and often unseen. I also strive to move past the label of "difficult patient" and reframe the
designation as someone who simply needs more help with a barrier they have not yet overcome.