Care Coordinator Update

Debi Jefferson, Care Coordinator

My quality goal is to establish a more proactive and sustainable process by building process, measuring outcomes, and learning as we proceed to address each practice’s unique level of transition to Population Health.

The words “partnering” and “team effort” describe what I have witnessed over the past 10 months. This collaborative effort has helped us achieve the success we are seeing in closing gaps and improving cost savings in our first contract year with First Choice and as of June 30^th, our Cigna contract. Less than one year into the process, we have adjusted each quarter to learn how to meet the goals of our payer contracts.

I want to give a big “Thank You” to EvergreenHealth Primary Care (EHPC) practices; Eastside Family Medicine, Lakeshore Clinic, Totem Lake Family Medicine and Woodinville Pediatrics, who have spent the last 45 days creating rapid response processes to fill the priority gaps identified in Sara’s article, including adolescent well care, breast cancer screening, cervical cancer screening, and chlamydia screening.  

Each practice has taken on a process that aids them in a uniquely effectively way to close gaps. Reaching the goal has been in fact, a process, not perfection. However, with every step of the process progressing, we become closer to the goal. 

“We give good care when we see the patient. The biggest gap is just getting patients in that we haven’t seen” said Dr. Paul Buehrens, Lakeshore Clinic and EHP Medical Director, which is why these goals are in place.  

Now that we are in the third quarter of my role, we have collectively learned several ways to condense and refine the process to reduce manual time.  Sara and I continue to share these revelations at our quarterly visits to your practice, monthly practice manager’s meetings, and individually. We support the good care EHP providers are already providing and over time, we see we can make your work easier as well as support increased, high-quality patient contact. 

We also help to reduce some of the work your staff is doing for patients who need coordination. Over the next ten months as we launch Wellcentive in each of your practices, the improved connectivity will help save even more time in determining right patient, right care, and right time factors and influences. 

Measuring our success is the most important part of our Care Coordination work. Monitoring differentiated outcomes, accelerating the feedback loop to improve the pace of learning, and taking immediate steps to improve are standard day-to-day support services Sara and I provide you in our joint effort to engage unseen patients.

“Let’s engage our missing patients to give them better care” said Karole Sherlock, Director of Operations, EHPC. 

In the next newsletter, I will detail my role in connecting the dots for your patients from emergency room and hospitalizations, to transitional care or back to their primary care provider.