Safety Net Support for High-Value Care
Leslie Dunlap, a nationally-certified physician assistant at the University of New Mexico (UNM) Hospital, came across the Choosing Wisely campaign by chance several years ago while doing research for her master’s degree coursework and it was like an epiphany. She found resources to use with patients in her primary care clinic work and in teaching other students about appropriate care.
Today, Dunlap focuses on promoting and supporting limb salvage for diabetic, neuropathic and vascular compromised patients whom she treats through UNM’s Center for Healing in the Lower Extremity (CHILE) program, which won her selection earlier this year as an inaugural Safety Net Value Champion Fellow with the MacColl Center for Health Care Innovation. But the lessons of Choosing Wisely have stayed with her.
Through CHILE, she is helping clinicians and patients better understand the nature of wounds and wound healing for those with diabetes, nerve dysfunction and vascular disease, and thereby decreasing major limb amputations for those with foot wounds. Dunlap said that the CHILE program is helping to decrease emergency department visits, hospitalizations and overuse of IV antibiotics where oral medication would suffice.
“Overuse is not on everybody’s radar,” said Dunlap, who views the nine-month fellowship as a validation of her efforts at UNM to make others mindful of ordering tests, treatments and procedures in their daily clinical practice. The CHILE program has had strong results under Dr. Eric Lew, decreasing below-knee amputations by half and admission time for CHILE patients by two days, she said.
The CHILE program is creating diagnostic and treatment guidelines for providers not familiar with diabetic foot wounds, such as recognizing when a wound is infected, or advising patients to stay off of their feet or wear protective shoes to promote wound healing. “We have instituted a comprehensive team to manage diabetes, wounds and foot issues,” said Dunlap, noting success with limb preservation efforts despite social and economic challenges within their community.
The fellowship program provides training and mentorship to clinicians who are working to reduce medical overuse by bringing organizational, cultural or behavioral change to the home institutions, all safety-net settings that serve sizable medically vulnerable populations.
Dunlap said the support that the fellowship provides – bimonthly webinars, ongoing coaching and frequent check-ins with mentors, networking – would enable her to have an even greater impact in shaping how UNM providers care for populations with limited resources. She hopes the CHILE program will spur other high-value initiatives and increase general knowledge about medical overuse.
Dr. Roberto Diaz Del Carpio, a primary care physician specializing in internal and preventive medicine who is another 2019 Safety Net Value Champion Fellow, said the number-one benefit for his work would be meeting and collaborating with other clinicians who are passionate for high-value care. Six clinicians were selected.
“Sometimes you can feel like you’re the only one pushing value,” said Diaz Del Carpio, who has led the transformation of primary care practices into patient-centered medical homes at the Hertel-Elmwood Internal Medicine Center as a member of the UBMD Internal Medicine team in Buffalo, NY. “It is so energizing to find people who are doing similar work and are passionate about it.”
He said he had already gained insight from the faculty mentors, some of whom have great expertise in data collection in clinical settings and how best to use for quality improvement. He said he had already learned an important distinction between big data and little data, such as one-on-one chart reviews. Both types of information can provide valuable insight, but for different purposes, he said.
In promoting high-value care at UBMD, Diaz Del Carpio said one of his first steps was to introduce the language of quality improvement, as developed by the Institute for Healthcare Improvement, to all clinicians and health care workers – identifying clear aims and a measurement plan, and then beginning to test small changes to gauge success.
“When we find something is not working, we are able to articulate the problem, determine the goal and say these are the measures that will indicate improvement,” he said, adding that the fellowship would help him bring even more tools to his work in transforming clinical practice.
One concrete step under his leadership has been to change the way they handle scheduling of follow-up appointments. They have a semi-open schedule, which has eliminated long waits for office visits, and staff now call patients at least a month in advance to set up a timely appointment.
Patient care is handled by a team of clinicians, including nurses, an on-site nutritionist, and behavioral specialists, who can provide more continuous support than the physician alone. The percentage of patients they are treating for uncontrolled diabetes, prevalent among the UBMD population, has declined significantly over the last three years, Diaz Del Carpio said.
“For some patients, we are in constant contact to adjust insulin levels,” he said, “and some patients are telling us they finally understand what a card is. We are definitely changing the way we practice.”
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