Safety Net Medical Home Initiative – UPMC Matilda Theiss Health Center

Eletta Cameron took a road trip in search of a patient who had not been seen in a month at UPMC Matilda Theiss Health Center. Then a social worker and patient integration specialist at the center, Cameron knew the woman needed her diabetes medication. Cameron left messages for the patient and cold-called family members, but no one could track her down.

“So I knocked on her door, meds in hand,” Cameron says. “I discovered that her husband had died two months prior. She was being evicted, and she was smoking furiously. I’m thinking, ‘no wonder she hasn’t made an appointment.’ We delivered her medication, started to address her smoking issues, and connected her with housing services. That visit allowed us to re-engage with her and resume her weekly appointments with our care team.”

This level of outreach would not have occurred before UPMC Matilda Theiss partnered with the Pittsburgh Regional Health Initiative (PRHI) in PRHI’s Safety Net Medical Home Initiative (SNMHI). SNMHI was a four-year program to transform primary care safety net practices into patient-centered medical homes (PCMH), with the goal of improving patient outcomes, quality of care delivery, and patient and staff net medical home

The PCMH model prioritizes a systematic approach to providing coordinated care to patients. The National Committee for Quality Assurance (NCQA) provides PCMH recognition to those organizations that meet a set of rigorous standards for PCMH, including how effectively the organization uses health information technology, establishes channels to coordinate care, designs office practices and work flows, and provides patient-centered preventive services and clinical care.

PRHI provided training and on-site coaching to ten local community-based health centers to streamline care, improve communication, and mine data for quality improvement efforts. Cameron and colleagues at UPMC Matilda Theiss focused on reducing “no-show” rates for appointments, which had reached 32 percent prior to SNMHI. To reduce no-shows, the center worked with PRHI on empanelment – the process of aligning patients and care team workers through patient outreach and data analysis.

The center surveyed patients to learn about their care preferences, finding that many wanted to schedule appointments closer than one month prior to their next visit. Patients also preferred to see their assigned physician, but rarely did so if they missed a scheduled appointment or required an acute care appointment. By analyzing patient data, UPMC Matilda Theiss discovered that many patients missing appointments were elderly and suffered from multiple, chronic diseases. In addition, although many of these patients lived close to the center, they had limited access to transportation and limited mobility.

Based on patient feedback, UPMC Matilda Theiss developed a modified open access scheduling system that provides more flexibility. Patients can now schedule appointments within two weeks of their next visit. The center also synched physicians’ schedules with those visits to improve continuity of care, and devoted additional time to visit pre-planning and staff huddles among providers, nurses, pharmacists, and social workers. For patients experiencing transportation issues, UPMC Matilda Theiss linked them to services to ensure they could consistently reach the Center.

“The processes put in place while becoming a PCMH allowed us to engage patients and also understand the strengths of each care team member,” says Cameron. “We began to see how it all connects.”

By putting patients first, UPMC Matilda Theiss reduced its no-show rate to eight percent and achieved the highest level of PCMH recognition from the NCQA.

“Participating in SNMHI reinforced the idea that care doesn’t just happen within four walls of a health center – it happens in between those visits,” Cameron says. “When you consider the greater context of a person’s life, you hear what the barriers are to their overall wellness – whether that’s physical or mental – and you work together to overcome them.”