Innovative work puts clinic in the spotlight

Exciting things are happening at Family Practice of Holyoke, and the clinic was recently in the spotlight for its innovative work in annual wellness visits, chronic care management, remote patient monitoring and more.

Family Practice earned Caravan Health Region 4 accountable care organization recognition after exceeding goals last year for annual wellness visits and chronic care management program participants.

The free annual wellness visits are preventative care measures and are tracked through the Centers for Medicare & Medicaid Services. Clinic Manager Jayden Miracle said the clinic actually receives shared savings back for the hard work they put into it.

To be a part of the clinic's CCM program, patients must be on Medicare and have at least two chronic conditions (i.e. hypertension, diabetes, etc.). Miracle said that already in 2021 the clinic is just four patients shy of meeting their goal of having 100 people enrolled in the program.

CCM patients are in regular contact with a nurse to monitor their chronic conditions.

A new remote patient monitoring program at Family Practice is being used in conjunction with the CCM program, and it was recently highlighted at the Colorado Rural Health Center annual forum.

Miracle said that Family Practice is the only rural health clinic in the state to be doing remote patient monitoring. "We're setting a standard," she said. "It's innovative work," and more and more organizations are wanting to put Holyoke in the spotlight.

Thanks to an Office of eHealth and Innovation Grant from the Colorado Department of Public Health and Environment, Family Practice was able to get equipment for up to 50 CCM patients.

A biometrics performance monitor, Bluetooth scale and electronic blood pressure cuff can be leased to patients so they can monitor their health from home and have data on hand for their virtual telehealth checkpoints with population health nurse Tamara Laws and local providers.

The grant also provided funds for tablets and internet hotspots for patients who don't have smartphones.

The remote patient monitoring program was rolled out in February, and as of last week, 14 patients were enrolled with more expected to jump on board in the near future.

Miracle said the program has already led to great outcomes. The checkpoints have alerted patients to go to the clinic to get critical care before the situation got worse.

She gave credit to the clinic staff for their hard work on these programs, and she said they wouldn't be successful without the patients being willing to trial the programs alongside the staff.

The clinic is also excited to be offering a new diabetes clinic, facilitated by Laws. Knowing that early detection and treatment can reduce health complications, the program can assist patients with regular checkpoints, medication management, questions and other care needs such as foot and eye exams.

Additionally, the clinic began offering mental/behavioral health services in March. A Colorado Health Foundation grant helped provide a secure room and technology for telehealth appointments with a licensed counselor.

For more information on any of these programs, call Family Practice of Holyoke at 970-854-2500 or stop by 1001 E. Johnson St.