CHRISTUS Santa Rosa Health System’s efforts to implement changes in the way healthcare is delivered began shortly after the passage of the Affordable Care Act. Nearly four years ago, the Health System created a network of patient-centered medical homes focused on improving the care of patients. That network has now evolved into the CHRISTUS Connected Care Network. “How patients receive health care is changing,” says James Martin, M.D., chief medical officer at CHRISTUS Santa Rosa Health System. “Patients are responsible for a much higher percentage of the cost of healthcare services. Employer health insurance plans are shifting greater cost to employees, and employers are narrowing networks of providers to better manage their health care costs. Responding to this shift, the CHRISTUS Connected Care Network began with a strong group of primary care providers.”
A Plan Into Action
The CHRISTUS Connected Care Network’s initial launch made the program available to CHRISTUS Santa Rosa Health System Associates by offering access to a group of participating primary care physician practices committed to operating as patient-centered medical homes, which are accredited by the National Committee for Quality Assurance. The concept of the patient-centered medical home focuses on family medicine, internal medicine and pediatric primary care physicians — all dedicated to arranging and providing for your family’s primary care needs through disease prevention, wellness, education and support.
Janie Velasquez, a member of our patient registration team and breast cancer survivor, was among those Associates who saw the immediate value in the CHRISTUS Connected Care Network. Through the program, Janie’s primary care physician, Dorothy Overman, M.D., of Hill Country Medical Associates, coordinates follow-up care with her cancer specialists.
“Dr. Overman knows everything about my health, and that makes me feel more comfortable,” Janie says. “She is always there to make recommendations about preventive care, and our strong doctor patient relationship is what I value most about this program.” Dr. Overman recognizes the importance of an integrated care system, especially for patients with more serious diagnoses or chronic conditions.
“Patients should have a primary care physician who knows them personally and leads their medical care team,” Dr. Overman says. “Patients then have someone to call for acute care who can also provide their annual exams and preventive care. Coordinating specialty care is vital to keeping duplication of tests and exams to a minimum.”
Greater efficiencies reduce costs and improve care for patients and the healthcare system while fostering a deeper bond between patients and their primary care doctors, which is part of the vision of the CHRISTUS Connected Care Network organization and its participating physician practices. The CHRISTUS Connected Care Network is a physician-led organization dedicated to improving patient care, with the result being better outcomes and lower costs for the patient.
“From a primary care perspective, having all of your patient’s information is crucial,” says Warren Albrecht, M.D., chair of the Regional Board of the CHRISTUS Connected Care Network – San Antonio/ New Braunfels. “Primary care physicians need the most recent records and test results to formulate a treatment plan and to communicate with specialists more effectively.”
As part of the improved communication process, the CHRISTUS Connected Care Network is implementing a sophisticated information system called Wellcentive to allow physicians and care coordinators to formulate a treatment plan and to have the latest information available about patients. Care coordinators provide additional support to patient-centered medical homes by keeping track of a patient’s preventive health needs, helping to schedule appointments and serving as a point of contact for patients.
“Care coordinators, combined with more complete medical information, help us better manage our patients,” Dr. Albrecht says. “For example, we can help ensure patients with diabetes are returning for follow-ups and maintaining their health goals. Making patient care a team effort is an added benefit for providers as well as patients.”
A Bright Future
Janie is one of many patients realizing the benefits of integrated care as the CHRISTUS Connected Care Network becomes available at convenient locations in Bexar, Comal, Kendall and Medina counties. “The care coordinators call me personally,” Janie adds. “They keep me informed about my lab results and any changes, and they are constantly updating my health records. I love the program, and their conscientiousness is a great benefit.”
Even with a team approach to health care, preventive care on the part of the patient is a vital component of the CHRISTUS Connected Care Network approach. “Janie recognized she needed to be diligent about taking care of herself because she has a family history of cancer,” Dr. Overman says. “By doing the necessary risk assessments and follow-ups, Janie’s breast cancer was found early and treated, and she is in complete remission. Any time a patient goes through a diagnosis like cancer, it brings physicians and their patients closer. Now, we celebrate each year without cancer.”