Location: Rochester, NY
Practice Type: Ambulatory care site with population management responsibility
Primary Care Physicians: 5 (all certified in both internal medicine and pediatrics)
Approximate Annual Patient Visits: 31,375
Reimbursement Model: Fee-for-service
Ridgewood Med-Peds is an independent, physician-owned primary care clinic that provides care to a relatively healthy population of families. The majority of their patient population is between the ages of 18 and 50. They do not provide any on-site ancillary services, but phlebotomy services are available within the building. Ridgewood’s physicians are supported by four licensed practical nurses (LPNs), one registered nurse (RN), one nurse practitioner (NP) and four telephone schedulers.
Ridgewood’s physicians—all trained in both internal medicine and pediatrics—share a passion for practicing medicine using evidence-based principles. The team stays up-to-date with the latest evidence-based practice guidelines and uses this knowledge to provide their patients with the best care possible. For example, for patients with chronic illnesses, the timing of prescription refills is coordinated to prompt visits back to the clinic at the appropriate intervals.
The team closely manages the referral process by using a small, informal network of trusted specialists to perform procedures or provide complex patient management or consultation. The providers are expected (and given the time) to create a referral note that clearly articulates the expectations and boundaries of the referral as well as the results of the work-up that led to the referral. Specialists who perform testing and/or procedures outside the boundaries of the referral note are contacted directly by the practice to understand their rationale. Specialists who consistently go beyond the boundaries without a good explanation do not receive referrals. In addition, physicians closely manage patients before and after their referrals, set patient expectations and engage their patients in the selection of specialists, which leads to higher patient engagement and satisfaction.
Research suggests that in order to fulfill all of the recommended guidelines for preventive care1 and for the care of chronic disease patients2 in a panel of 2,500 patients, physicians would need to spend 18 hours per day meeting with patients, completing necessary paperwork and providing care. The Ridgewood team responded to this by delegating as many of these tasks as possible to the broader care team. The practice employs LPNs rather than medical assistants (MAs) due to New York state licensing law (for example, MAs cannot administer vaccinations in the state). The LPNs follow protocols to guide them through tasks like the preparation of patient rooms or anticoagulation management. LPNs also ensure that lab work and diagnostic testing is completed in advance of the corresponding patient visit. Meanwhile, the RN can handle procedures, including electrocardiograms, allergy shots, blood draws and diabetes training and education. The team “huddles” frequently to discuss scheduling, labs, consults and quality to plan for the coming week. By sharing the workload, Ridgewood’s physicians have the time and flexibility to maintain their relationships with specialists, stay on top of emerging evidence, come to consensus about how to respond to it, and ensure that their patients get all recommended care.
John Chamberlain, MD, lead physician, answers questions about their model for providing high-quality care and keeping costs low.
Q: Since you don’t have specialists in practice with you, how do you cultivate and maintain these relationships?
A: “Most of the specialists we use we have known for a long time. We may have worked with them at a hospital, trained with them or shared a patient experience together. This is important, because communication about a patient is usually a lot better with specialists we use regularly. In our practice, we don’t hesitate to pick up the phone and call a specialist if we have a question. However, cultivating and keeping strong relationships with specialists can be challenging because there is a different culture in medicine now than there used to be. Things are more compartmentalized, and it’s less likely that you will run into people in the halls. You have to be more proactive. We do the best we can to give the patient the best care possible, especially if we’re sending them somewhere else for that care.”
Q: How does your unique referral management process benefit your patients?
A: “The specialist gets complete information on the patient and knows why they are coming and what our expectations are. Referrals are generated at the time the physician sees the patient, and we attach all the relevant information we think the specialist will need. [The referral note] then goes to a designated staff person that holds it for 72 hours before it is given to the consultant, to ensure there is a detailed note accompanying the referral. It won’t be processed without the note. By the time the referral reaches the specialist, they have all the information they need to accurately treat the patient.”
Q: Why is providing exceptional patient care at a low cost important to you?
A: “It’s important to me because it’s important to our patients. Among the physicians at Ridgewood, providing exceptional care is a basic value we all share. I think that’s why people go into medicine—to do the best they can. Quality is something that is built into one’s genetics that, for some of us, translates to a professional career. Outcomes do matter and make a difference, too. If you do the best you can over a long period and have enough patients who are happy, this reinforces the work involved. At the end of each day, if I can say I did something that mattered for someone who means something to me, it’s tangible, positive reinforcement.
The economical part is straightforward to me. We all live in the real world and know what things cost. We have reluctant patients who worry about what things cost. Our practice is in a middle-class suburb, so our clients have greater resources than those in an impoverished area, but they are not wealthy either. We must be good stewards of their resources, because we are essentially spending the patient’s money. If you don’t spend it wisely they might not get what they want or need, and those conflicts with our primary goal of providing the best care we can. Our ultimate motivator is that it matters to patients if we spend their money so we spend it wisely.”
Q: What do you think makes Ridgewood Med-Peds unique?
A: “The best part of my practice is that I have really good partners who share the same values and who are very bright and capable. I never worry about the care they are providing to their patients or my patients. I know they’re going to do the best job they can—simply put, I trust them. A practice’s culture is important, but I’m also lucky that I have patients I can readily identify with. They are just like me and this creates a real sense of collaboration among us. That makes practicing medicine fun.”