August 20th, 2018

Inside TriValley Primary Care—Lower Salford, family medicine physician Deborah Topakas, DO, uses her intuition and skill to care for patients. She also communicates with an entire team that includes her in-office colleagues, nearby specialists, and local hospital providers.

As a member of the Grand View Healthcare Partnership, LLC (GVHP), Dr. Topakas and her TriValley colleagues can reach out to more than 50 regional doctors who also are GVHP members. Together, they strive to provide patients—especially those with chronic illnesses like congestive heart failure and diabetes—with the right care at the right time, while avoiding unnecessary testing.

And the partnership is already delivering on that promise. In late June, Aetna—which entered into an Accountable Care Organization Agreement with GVHP in fall 2016—announced that the partnership met Aetna’s quality and financial targets during its first year (2017).

Under the Aetna contract, GVHP and its providers are responsible for managing the health care of nearly 9,000 patients who are either covered by Aetna plans or self-insured. To track quality, Aetna records seven wellness screening measures, including colorectal and breast cancer screening, medication monitoring (compliance with lab follow-up), and four diabetes-related measures. By providing highly coordinated care in an integrated delivery network, GVHP successfully increased compliance for all seven measures, scoring 100 out of a possible 100 points.

 

How GVHP Providers Collaborate to Deliver High-Quality Care

GVHP providers achieved these results by using shared data and making tight connections with each other and with patients. For example, they make sure patients leaving Grand View Hospital (or its emergency department) schedule an appointment with a primary care provider within one week of discharge when appropriate. They rely on care managers to make follow-up phone calls, answer questions and help patients with chronic disease care.

They also use electronic medical records and secure, HIPAA-compliant texting to virtually consult as needed.

That all came together one recent Saturday when Dr. Topakas saw a patient who came to TriValley Primary Care with shortness of breath, chest tightness and new leg swelling. She used secure texting to reach Mark Kudes, MD, FACC, with Alderfer & Travis Cardiology in Sellersville, who was that weekend’s on-call cardiologist.

“Dr. Kudes verified that the patient’s EKG was unchanged from prior studies, so it was appropriate to send her to Grand View’s ER for further cardiac and pulmonary evaluation,” Dr. Topakas said. In the ED, the patient was treated for bronchitis. That same week, Dr. Topakas’ office contacted the patient by phone for follow-up, and also asked her to follow up with Dr. Kudes’ office.

This type of collaboration is at the heart of the GVHP partnership. “Delivering higher quality care at a lower cost is everyone’s goal in health care,” said Keith Hammerschmidt, GVHP’s executive director. “I applaud all our providers for making this a reality for the people of our community and achieving these extraordinary results.