Location: Kissimmee, FL
Practice Type: Multi-specialty group practice, part of a larger health system (not hospital or health plan-based)
Primary Care Physicians: 4 physicians
Approximate Annual Patient Visits: 18,603 for primary care visits (calculated based on patients per day)
Reimbursement Model: Capitation and fee-for-service
The Kissimmee site is one of 26 Family Physician Group sites in the Orlando area. The site has built a care team to support both the health and social care needs of their largely elderly, low-income patient population. Kissimmee has three registered nurses who work as case managers, a health coach cross-trained as a medical assistant (MA), a psychiatrist and a social worker on-site, joined by several trained MAs who handle referral management.
From hospital visits to at-home care, Family Physicians Group prides itself on being connected to patients 24/7. For patients with certain conditions, they offer in-home monitoring to help support the patient and avoid costly health crises. Clinicians and staff not only evaluate the medical needs of each patient, but consider the patient’s psycho-social needs as well. For example, the practice provides patients with access to a waiting room concierge service meant to address non-medical issues faced outside of the clinic. Spanish-speaking patients may use the service for matters like translating a letter from a health insurance company or finding connections to additional community resources.
In addition, to maintain this holistic approach outside primary care, the practice has identified specialists who meet their high standards for patient care and use these specialists whenever they can, sometimes bringing them on-site. The Kissimmee location was one of the first in the group to provide on-site access to a community psychiatrist, integrating physical and emotional healthcare. They track the quality and affordability of the care provided by specialists and share this information with the specialists. Through this feedback loop, they have been able to help improve the value of the specialists they use.
Patient care at the Kissimmee site is very team-oriented, and case managers function as the leaders of these care teams. They evaluate all new patients and formulate the vast majority of a patient’s care plan, integrating input from the physicians who provide additional clinical support. The case managers also see all patients following a hospitalization or emergency department visit prior to primary care provider evaluation and follow all patients admitted to skilled nursing facilities.
In addition to the case managers, each primary care physician works closely with two MAs. One is dedicated full-time to identifying and addressing gaps in care, quality measures and paperwork for health plans. The second MA prepares the patient for his or her appointment with the provider. This ranges from conducting any necessary blood work prior to the visit to preparing the room and reviewing the patient’s medications on-site, thus allowing the physician to focus more on the patient. Physicians and their MAs work together in an office to encourage constant communication between them. Primary care physicians at Kissimmee say the extra time they have—thanks to this level of support from case managers and MAs—allows them to spend more time focusing on the patient and performing procedures they may not otherwise have time to do.
Dr. Nayana Vyas, MD, Founder and President of Clinical Affairs, answers questions about Kissimmee’s model for providing high-quality care and keeping costs low.
Q: What are some of the unique ways in which you stay deeply connected with your patients?
A: “Surgery preparation, for example, happens in the office, which includes physical examination, blood work, EKGs, PFTs and anything else needed. We also make sure that we have the right indications for surgery with the preferred provider and the right location, weather it is inpatient or outpatient. Our doctors are kept in the loop through regular communication with the hospital case manager and outpatient case manager. They additionally have access to speaking with our hospitalist doctor for updates and care coordination. Our home-grown hospital census tracking system provides updates on new hospital admissions, discharges and care provided at the hospital level. We also prepare patients emotionally and socially for what to expect after surgery and how much time to take off. It’s not just surgery and medicine that get patients well. It’s everything that goes on around the patient to support him or her.”
Q: Are there challenges with providing the type of integrated, holistic care that Kissimmee provides?
A: “Our biggest challenges come from outside of our office walls. Sometimes the ER doesn’t understand patients’ situations completely including their multiple chronic conditions and the full list of medications they take. Additionally, patients may be assigned to the care of providers who are not involved in their medical treatment which could result in duplication of services. Some of our patients are very sick, and some specialists who don’t know them well may not understand their circumstances. You must look at the bigger picture—is it the right time and the right place for a certain procedure? I treat my patients like family. I want the best care for them.”
Q: How does your practice overcome the challenges of providing holistic care to a low-income patient population?
A: “Our multi-disciplinary team approach allows the doctors to focus on patient care while other issues are managed by additional staff members. We have a social worker to help patients with life issues, and case managers who follow the care of each patient outside of our clinic very closely. We have a pharmacist to oversee patients’ medications and call out anything that could cause them harm. Health coaches focus on all chronic disease management. We have a home visit team and integrated behavioral health onsite. I strongly believe if you don’t treat the mind and the body together, you can’t provide the best, individualized care that’s right for each patient.”
Q: What advice do you have for a practice with patient needs similar to those at your site wishing to improve its relationship with its patients?
A: “You must have a team approach, so that the physicians can focus on what they were trained to do—patient care. Having sub-specialists come to the office is a huge help, and the need for specialists who understand and share your vision for patient-centered care is important. Quality healthcare is about looking at the whole patient—medical, social, emotional and financial.”