The Georgia Health Policy Center recently spoke to Kecia Fulcher, CEO, and Beth Rodriguez, RN, COO, Outreach grant director, at Pennyroyal Healthcare Services (doing business locally as Community Medical Clinic) about how they are growing participation in chronic disease management and prevention programs.
To date, what has been the biggest accomplishment or win in your program?
Beth: Looking at our last PIMS report, what I am most proud of is the fact that we have increased our patient population who has received direct care services by more than a thousand from year to year for this first two years. We saw 1,465 more patients than we did the year before, and that’s all helped through this Federal Office of Rural Health Policy grant. Additionally, we have been able to teach 225 people with counseling activities and we actually increased our goal.
Kecia: One of our strongest accomplishments was the tobacco cessation. In the years before the pandemic, we had 40 people that had quit smoking and that was the most in Christian County. It was due to our collaborative efforts of the Kentucky Cancer Program and the local health department, as well as referrals to the Kentucky Quitline. Those numbers took a hit during the pandemic, because there was not as much participation on Zoom. But, I am thrilled that it is up and running again and that we are seeing the benefits of those people coming in and quitting smoking because it not only decreases the risk of cardiovascular problems but also cancer.
What is a tip or early learning that you would share with an organization launching a similar outreach program?
Kecia: I think one thing is choosing partners in your community that you are already working with and are familiar with. We had strong connections with the community partners, and I think that helped us to get off to a good start. We have been pulling our resources together because the goals that we have for this program and that they have for their program are very similar goals. So, it is working together and not being competitive. Especially in rural areas where we have limited resources, it is good to be able to share and I think we benefited from that.
Beth: Your original plan is what you hope to do or want to do, but as you learn things or when you learn that something does not work, then don’t be afraid to plan, do, study, act and make a change. In our original plan, we were going to purchase equipment ourselves to do remote patient monitoring that way, but we just did not have the manpower. Then, there was a problem with the company that we were going to use. So that did not work out. So, now, we use a vendor, and they contact the patients on our behalf after our patients with chronic conditions have been referred. The health coaches from the vendor tells us if there is a problem or if we need to get a patient in to be seen or if we should have them come see me for a one-on-one in-person training and education.
How do you see participation in the Federal Office of Rural Health Policy’s Rural Health Care Services Outreach Program impacting your broader health improvement efforts?
Beth: I feel like the Rural Health Outreach Program has impacted the broader health improvement goals because it helped create that foundation for us to figure out how we can be sustainable once the grant fundings are gone. Without that, we would not have been able to figure out how to start the remote patient monitoring. I am seeing 170 patients one-on-one and it is going to create impact for the individuals and our community, so it is a win-win.
Kecia: We have been able to see more patients in the way that our remote patient monitoring program has been implemented. When we have a patient that has an issue that needs to be addressed immediately, like having repeated high blood pressure readings, they get in touch with Beth, and they send that information and Beth will either get them in immediately for a nurse’s visit with her or with one of the providers. There is a real benefit to having real-time data is that you can address it before a health condition gets out of hand.
What will your organization be doing more of or differently to emerge stronger from the pandemic?
Kecia: One, I will never be that short of personal protective equipment ever again. Second, we are more resilient than we realized. We were already using telehealth before the pandemic, and we still are using telehealth. Probably 10% or less of our patient appointments are telehealth, but there are occasions when that is very beneficial, particularly in a rural environment. The third thing that we did was when we came back after shutting down briefly, was we worked in shifts to reduce exposure and we had teams that worked together. One team was working in the clinic taking care of urgent care needs, but there was also a group that was working from home. Even on days where there’s inclement weather or sometimes staff feels bad or may be contagious but not necessarily can’t work, so it is very rare now that we are completely closed on a day unexpectedly; for example, during severe storms because we can use telehealth to still see people.