Baylor Family Medicine at Legacy
Family Medical Center at Terrell
Baylor Occupational and Family Health Center at TI
City Square
City Square- Pediatrics
Since 1997, our Community Health Services department has partnered with the Baylor Health Care System and Health Texas Provider Network to bring extremely high quality medical services to inner city Dallas. The following letter tells the wonderful story:
Congratulations!
We have not only completed the application process for NCQA Patient Centered Medical Home recognition for all of our adult, geriatric, residency and pediatric practices, but have now received the results. All practices received the highest possible level of recognition. Level 3 is the highest level for Electronic Health Record (EHR) practices and the highest for paper practices is Level 2. Out of a possible 100 points, our EHR clinics scored in the mid-90s on average. This means that we now have 60 practices, 271 physicians, and 59 non-physician providers (APRNs and PAs) in recognized medical homes. This is the second highest total of any system in the nation.
During this implementation and application process we have seen engagement in new discussions around topics like pre-visit planning, ambulatory care coordination, patient/family activation and patient access. More practices have extended hours than ever before. Heart failure readmissions have dropped significantly. Diabetes scores have improved. Guidelines have been standardized across our practices including many specialty practices. Insurers are coming to us asking for PCMH contracts that allow for new funded resources and opportunities for shared savings.
The journey started many years ago with the Quality committee's work on quality standards and measurement of preventive services and diabetes metrics. It continued with the work of the Service Excellence committee, the Ambulatory EHR committee, Patient Safety committee, Disease Management and EHR Content Committee, and then the PCMH Task Force. The medical home applications included work from all of these committees.
Join me in thanking the chairwomen/chairmen and members of these committees for their hard work as well Sarah Gahm and David Winter for their leadership. Of course we should especially thank Pat Link, the PCMH Director, and her team of consultants, writers and contributors: Endia Kendrick, Michell Martin, Niki Shah, Patrice McConnell, Ashley Wood, Vivian Plumlee, Joe Brumbelow, Nancy Trinh, Kelly Risinger, Beulah Casey, Cynthia Granade and Tim Houtchens. We also need to thank our physician auditor team who gave personal time to audit over 2,300 patient records, Drs. Hickl, Astbury, Aponte, Molen, Massey, Stroud, Thompson, Bassel, Berry, Caudill, Garcia, De Leon, Holbrook, McMillin and Sharp.
The journey of course never ends. We are already implementing the new PCMH criteria into our practices. Many of these are meaningful use criteria. We are also preparing to apply for NCQA recognition for our new practices under these new guidelines as well as preparing to support BQA non-HTPN practices.
We are blessed to have a group of physicians, nurse practitioners, physician assistants, administrators and staff who strive to provide safe, effective, efficient, equitable, timely and patient centered care. It makes our work more enjoyable and meaningful.
Thank You All,
Cliff Fullerton, M.D., M.Sc.
VP Chronic Disease Baylor Health Care System
Chief Quality Officer HTPN
What a privilege to be working in tandem with our partners at Baylor and Health Texas! CitySquare continues to help provide the highest quality care possible to low income neighbors in the inner city of East and South Dallas.
Way to go, CitySquare team!
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