To help patients, Christiana Care Health System www.christianacare.org located in Delaware is using a new personalized approach to primary care by using a model called “Patient-Anchored Care Teams” (PACT). Each patient is provided a team to provide care that consists of a registered nurse, two or more medical assistants, and usually a nurse practitioner or resident physician.
Christiana Care launched the new model last fall in four primary care practices to include Foulk Road Family Medicine, Lancaster Pike Internal Medicine, Smyrna Family Medicine, and Wilmington Adult Medicine.
A personalized care team very familiar with their patients’ needs provides continuity of care, improved access to their primary physician and other caregivers, and also a range of care settings to include office visits, group medical visits, telephone visits, and patient portal interactions.
Using communication and data technologies, the PACT model is changing patient outcomes. At the Wilmington Adult Medicine site, the PACT team has focused on increasing the percentage of patients who get mammograms. In five months, they have seen that number rise from 55 percent to nearly 68 percent.
Another example of improved care was noted at the Foulk Road Practice where a patient being seen for an unrelated issue, exhibited signs of depression to the medical assistant. Because of the team’s new PACT workflow, the care team was immediately able to get the patient a behavioral health consultation and potentially avert a crisis.
Another program at Christiana geared to Medicare beneficiaries called Care Link, currently serves nearly 75,000 Medicare beneficiaries and health plan members in the greater Delaware region by using a real-time robust information technology enabled network of care coordination support services. This helps the medical staff communicate with each other and provide the correct information at the right time.
Care Link integrates information from regional health information exchanges plus other health information. The information can include admission and emergency department, visit information, physician visits, lab results, radiologic reports, pharmaceutical use, claims data, plus the platform incorporates a prediction analytics engine to help to examine issues before they escalate.