Highlighting Our System of Care at Town Hall Meetings

Since late June, we’ve been doing Town Hall meetings. These meetings are an attempt, as I mentioned in this blog a few weeks ago, to narrow the gap between what the frontline staff knows and what the front office knows. The meetings are meant to be two-way communications, a sharing up and down of information.

As part of my presentation, I discuss that we have built a community-based system of care that the patient experiences as a system. It is not perfect, but we should be proud of what we have accomplished. A core building block of our system is the patient-centered medical home. The medical home delivers advanced primary care. Advanced primary care is different than typical primary care. In both models, there are excellent physicians and advanced practitioners and other office staff who care about you and work hard. But advanced primary care is designed to be accountable with you for your health. In advanced primary care, the team, led by a physician, commits to overseeing your health over time. It’s not about a visit, it’s about a relationship. The team includes a nurse care manager, who helps the team stay focused and manage those with chronic disease. The team reaches out to patients to make sure they have a plan and are following the plan. The team connects the patient to specialists when needed. In advanced primary care, there are extended hours of operation, disease-state registries, and many processes designed to check back with the patient (like a phone call after every visit to an emergency room or after an inpatient hospital stay). In advanced primary care, there are also addiction specialists, master’s-prepared behavioralists, and psychiatrists as part of the team. None of this is available in typical primary care. Once again, the physicians and the rest of the office staff in typical primary care are wonderful and work hard, but they don’t have the resources and they are not designed to operate like advanced primary care. In typical primary care, you are more likely to be on your own if you are sick and the office can’t accommodate you. This is when you are left with the choice of going to an Emergency Department for a non-emergency or to an urgent care center, where people will not know you and you will not know them and it is unlikely that they will have your medical record. In advanced primary care, there is a commitment to see you when you are sick. We should all be very proud of advanced primary care!

The State of Maryland is embarking on a new plan to help more primary care physicians get closer to advanced primary care. The program, called the Maryland Primary Care Program https://health.maryland.gov/mdpcp/Pages/home.aspx, will allow primary care practices to enroll and get help from care managers and others, to do what we have been doing in our system. The support for physicians who don’t have the resources to do it themselves will come from new entities called Care Transformation Organizations (CTO). GBMC, through our Greater Baltimore Health Alliance, is applying to become a CTO. Stay tuned!

Congratulations to our Diabetes and Nutrition Center!
Hats off to our Geckle Diabetes & Nutrition Center for being recognized by the American Diabetes Association (ADA) for meeting the national standards for diabetes self-management education. This program has been in existence for over 25 years and has provided patients with education about the disease and how to properly manage symptoms to improve their physical and emotional health.

The ADA Recognition is a four-year certificate awarded to programs that offer high-quality diabetes education services. All approved diabetes education programs cover information relating to the disease, including: nutritional management, physical activity, medication management, and the monitoring, preventing, detecting, and treating acute and chronic complications.

According to the ADA, patient self-care is an essential component of diabetes treatment. Through the support of the healthcare team and increased knowledge and awareness of diabetes, the patient can assume a major part of the responsibility for his or her diabetes management. Unnecessary hospital admissions and some of the acute and chronic complications of diabetes may be prevented through self-management education.

The Geckle Diabetes Self-Management Education Program is available for anyone with diabetes who wants to learn how to manage their new diabetes diagnosis or better manage their current diabetes status.

Congratulations again for this achievement!