More than two dozen University of Florida clinics across Jacksonville are using data tracking and education to remind patients to stay on top of their health and give them the tools to do so.
The clinics are the first academic centers in Florida to earn the Patient-Centered Medical Home certification from the National Committee for Quality Assurance.
The medical philosophy emphasizes data analysis to see if patients with chronic diseases such as diabetes and high blood pressure are keeping their health in check.
A key to the practice is electronically staying on top of patients’ medications and ancillary appointments – especially eye and foot appointments for people with diabetes – so the time with their physician every three months isn’t spent on housekeeping items.
Elements of this philosophy have always been part of the practice of Kenyatta Y. Lee, M.D., associate professor of community health and family medicine at the University of Florida College of Medicine-Jacksonville.
The UF clinics received the Patient-Centered Medical Home designation this summer and are the only system in Northeast Florida to receive it. But Lee has been regarded as a national expert for years, speaking across the country about tracking patients and giving the primary care the same collaborative effort seen typically for specialized diseases such as cancer.
“It’s a constant reminder saying, ‘Hey, take care of your health,'” said Nipa Shah, M.D., chair of the department of community health and family medicine.
Take a listen inside the lobby as patients sign in one Tuesday morning at the University of Florida Soutel Family Practice and Pediatric Center in Northwest Jacksonville, where Lee is assistant medical director, and the “home” piece becomes clear.
“Good morning, Mr. Thomas.”
“Nice to see you, Mr. Williams.”
Staffers know the patients by name. And, just as important, the back office staff knows the patients by their numbers.
If patients are due for a mammogram or a colonoscopy, they get a letter. If their blood work comes back abnormal, they get a letter. If they haven’t refilled their medications, they get a letter or a phone call.
“How many times do you get a card from Jiffy Lube saying you need an oil change, you need to get this belt replaced, or this fluid changed?” Lee asked. “Do you ever get one from your doctor?”
Lee and his staff preach “self-management” of chronic diseases: giving patients the information and the tools to stay on top of their own health.
One wheel-chair bound patient comes in with his blood pressure and heart rate readings on a typewritten page for Lee, whose staff scans it into the computer so it can be referred to a week, a month or a year from now if needed.
Lee walks in to see an 85-year-old patient who has 11 bottles of vitamins and medication lined up on a desk.
She’s a healthy 85, still mows her own grass and trims her own hedges. And, as Lee shows when he scrolls through her extensive electronic file, she stays on top of her health.
She sees him every three months and stops by the Disparity Center next door at least once between visits to have her blood pressure and heart rate checked.
“These are all opportunities for us to see if something is wrong,” Lee said. “Access is everything.”
To Lee, access includes education – even if it’s less than voluntary.
All patients with diabetes must attend a class, where they are provided with facts about the disease, tips to keep track of their own vital signs and pointers on eating right and staying fit. Of the 24,000 patients in the UF clinic system, about 2,300 have diabetes.
Eating right can be the toughest sell, especially when instructor Lashonda Thomas is asking people to change habits five or six decades in the making.
Thomas had just finished a gentle lecture to one patient on her daily routine of eating an oversized portion of grits for breakfast, with Thomas explaining she would be exceeding the daily carbohydrate limit by 9 a.m.
Thomas went through the portion method, showing half of the plate should be a vegetable, with the other quarters split between a lean meat and a starch.
“What about rice and gravy?” the patient asks.
Thomas shakes her head again.
“I’ve got to get Uncle Ben out of your house,” she said. “See, Uncle Ben is cheating on you with your blood sugar.”
And if she’s hasn’t given Uncle Ben the boot, chances are her numbers will show it and get her flagged in the database.
The clinic recently received a $65,000 grant from the American Association of Diabetes Educators to track how to integrate self-education into diabetes treatment. What the clinic will do actually costs closer to $300,000 or $400,000, but the work will help with monitoring – another piece the clinic is constantly trying to improve, Lee said.
The system tracks 50 different data points including weight, blood pressure, cholesterol and A1C – a test that tracks average blood sugar levels over the past two to three months. When results aren’t within recommended guidelines, they show up red in the Excel spreadsheet displayed on the television monitor at the front of the room. When they’re not close to the target range, they show up in purple.
Lee meets every morning with staffers monitoring the grant so he can get updates and track the progress.
The goal is to get the patients to get the symptoms of their chronic disease under control and show improvement when they are weighed and tested.
Medications are monitored, and that’s where Brendia Thomas, Pharm.D., a clinical pharmacist with Shands Jacksonville, comes in. She meets with patients to go over medications and treatments, making sure everyone is on the same page.
Thomas may get to spend a little more time with the patient, who might tell her something they forgot to mention to the physician. Thomas jots it in her notes, which goes in the electronic file.
There’s a desktop computer in every exam room, and it’s the first thing Lee checks when he walks in to see a patient.
Most of the routine work has been done and he can concentrate on the individual patient.
He sees about 20 to 25 patients a day as he bounds back and forth between the clinic and the adjacent Disparity Center.
But far more get some sort of look on a typical day. Office staff is checking data reports designed to flag patients who will soon get one of those letters or phone calls.
“It’s a team,” Lee said. “Everyone has their job and we let them do their job. We couldn’t do this any other way.”