Ideas that Work – Chronic Care Management

Ideas that Work – Chronic Care Management


hi my name is Cindy Warriner and I’m here
from hqi health quality innovators we’re here today at Chickahominy Family
Practice with Dr. Anup Gokli primary care physician and Dr. Michelle
Thomas pharmacist who works within the practice today we would like to share
how Dr. Gokli and Michelle worked together in a family care practice
setting and how utilizing a pharmacist to assist the physician with chronic
care management and other activities within the practice how that is helped
patients and how that is assisted to practice so dr. Gokli could you share
sure thanks I’m a board certified family physician in Virginia for about 30 years
or practices rural practice between Richmond and Williamsburg and after
first few years of practice we hired of our first nurse practitioner and then
our physician assistant and since then we have the manage our practice as a
team approach to patient care and we grew very fast and about six years ago
we outgrew the location we were in so we moved into a new location and around
that time Michele approached us and told us what a PharmD can do for the practice
and for the patient care and we were not aware of what fun we can do so at that
point we worked with her to set up our diabetic education programs and patient
care for diabetes management and she started working with us for two times a
week but she got busy right away and after what a year or so she has been
working full-time with us and at this point she has improved the patient care
for the practice diabetes management care has improved and few years later
Medicare came along with some new programs and your wellness with a
chronic care management and Michelle took a lead into developing those
programs for our practice and we brainstormed and formalized all those
programs and that has had the practice and reputation care tremendously and in
fact what outcomes have improved to the point where we had a huge bonus of a
commercial in from last year and we hope to get more bonuses from different
insurances and all that so we shall has been very instrumental in improving the
practice and the patient care for practice so thank solution so for me
working with Chickahominy Family Practice has been a great
opportunity because I think as a pharmacist coming in I add a new element
a new perspective on things and I’m able to help with developing the newer
programs and helping with monitoring patients medications making sure they’re
taking what they should be taking how they should be taking in we have a
collaborative practice agreement and I’m able to help in particular patients with
diabetes to make sure they’re on the appropriate medications and the purposes
chronic care management program has been particularly helpful with that because
in between patient visits I can help to assure that patients aren’t just all the
medications when they come to see us but in between visits they’re handling
things appropriately they’re checking their blood sugar everything’s running
it should and it’s not we make sure that they’re back in or we make the changes
that are needed so doesn’t wait well in fact patient’s love the call and the
care so much they did music every month Michelle or one of our associates called
the patients and when they come and see me a victory for
once you always appreciate the calls you make and your people make and how the
advaithic and care of patients have truly appreciate in there I think that
patients like in and also Rumble it seem to be a little bit of the savings of
time to the addition because make sure that if you need refills we take care of
that they don’t have to have that phone call if they have self care to type
questions we can answer them without having to go back and pull the position
in every time and also I think that we make sure patients get vacuum for their
follow-up appointments that they might have otherwise pushed off model but
there’s a specialist as well because bottoms will refer them but they don’t
actually follow through on that and let’s really push them to make sure that
happens on the other end making sure the information comes back to the physicians
to let them know what happens with the specialist and our program has grown so
much chronic care management part of it that we had to temporarily have shut it
down and rolling the patient into the program because we cannot manage we have
to hire more people to manage the program and patients there is so many
locations are asking for it I just want to add one more thing that financially
VR of private practice we are not associated with in hospitals or anything
so finances are addicting how can we are for someone like Michelle and Mass
practitioners but financially it has been also good practice initial joining
us and I’m sure she has paid for so multiple times over but it has been a
good patient care and it has WT right well I think that’s great well this is
wonderful news and I think it’s a wonderful opportunity and I can’t thank
enough both of you for taking the time today to share how you have both
provided better care for your patients and also
our pharmacists can help support primary care practice and the outcomes that they
are hoping to receive with their patients using climate share manager

Leave a Reply

Your email address will not be published. Required fields are marked *