Ahead of the Curve on Patient Outreach

Strategic Moves Put Memorial Primary Care in Strong Position for COVID Response

A few years ago, Memorial Primary Care began to change the way it served patients – providing expanded services via telehealth to better serve those in need.

“For example, we knew that due to a lack of access, a large majority of Behavioral Health patients receive their psychotropic medications through their primary care physicians,” said Melida Akiti, Vice President, Ambulatory Care and Community Service. The solution: Instead of patients having to wait for an appointment with a psychiatrist through telehealth, they are connected immediately to a behavioral health team to establish a therapeutic relationship.

“That was our first baby step into telehealth,” Ms. Akiti said.

Memorial then completed an assessment of all the primary care services to determine their telehealth-readiness, which meant continuing to expand the number of providers on the virtual consultation network, and ensuring that everyone had the ability to complete their telehealth consultations through MyChart.

“Everyone needed to be connected – physicians, medical assistants, health coaches, case managers – to support patients and their families,” said Tammy Scott Reese, Director, Care Management and Population Health Management.

Where services needed to be enlarged, Memorial responded, adding pharmacists to the virtual consultation network for visits on medication management, and instructing patients on using their mobile devices to request prescription refills. All this helped ensure that virtual consultations could seamlessly take place when other issues hindered face-to-face doctor-patient visits. By March and April 2020, Memorial Primary Care had conducted 13,000 telehealth encounters.

“We had incorporated telehealth so deeply into our culture that we never stopped providing services when the pandemic began,” Ms. Akiti added.

The expansion into telehealth was not only transformational but anticipated a crucial need.

“Memorial Primary Care’s journey has been ahead of its time. Everything we’ve been working toward came to fruition in the pandemic,” Ms. Akiti said.

DOC Reaches More Patients with Home Visits

The move to telehealth is just one step that Memorial Primary Care has taken to increase its patient outreach. The Diagnostic Outpatient Care, or DOC, program, which sends medical assistants to visit patients in their homes, helps patients who have transportation and other issues that have prevented them from keeping their regular doctor-office appointments.

The DOC teams conduct in-home assessments using equipment that measures conditions and vital signs. This information is uploaded to a provider who completes the visit via telehealth with the patient and the medical assistant. Since the program began in October 2018, DOC team members have made 446 visits to patients’ homes.

“The technology that the DOC teams use is an extension of what telehealth is meant to do, but takes it to the chronic-care level,” Ms. Akiti said. “The provider is able to gather the data and provide clinical assessment of the patient including prescriptions — everything we need to monitor the patient’s health.”

Memorial Primary Care Program Now Provides Legal Aid

A generous grant from the Health Foundation of South Florida established Memorial Primary Care’s new Medical-Legal Aid Partnership in September 2019. The partnership provides direct legal representation for Memorial Primary Care patients who have health-related legal issues – at no cost. Since the partnership’s inception, it has made more than 200 referrals on medical and health-related matters.

“The grant is for three years, but we are looking toward establishing this as a long-term program,” said Melida Akiti, Vice President, Ambulatory Care and Community Service. “It has a demonstrated value in the improvement of population health.”

Life Coach Helps Welcome a New Life

How to shop for groceries, balance a checkbook, do laundry, apply for a job – these are just some of the life skills that Memorial’s Healthy Youth Transitions (HYT) program teaches approximately 175 young people who are aging out of foster care every year. HYT helps them transition to adulthood by teaching them how to live independently and productively.

And in Life Coach Kiensha Sands’s case, it even involved welcoming a new baby into the world.

At around 10 one night, she received a frantic call from her 19-year-old HYT participant. The pregnant teen’s water had broken – what should she do? Instructing the new-mom-to-be to have 911 take her to Memorial Regional Hospital, Kiensha raced there and stayed at the teen’s side until her healthy baby boy was born.

“Personal birthing and labor coach isn’t on the list of what HYT life coaches usually do, but Kiensha was the only responsible adult and positive role model in this young woman’s life,” said Tim Curtin, Executive Director, Community and Youth Services. “Kiensha went more than the extra mile in this case – she went the extra 10 miles.”