Reflections on Success: Health Center Voices

West Virginia

Primary Care Systems, Inc. and Tri-County Health Clinic, Inc.
Clay and Rock Cave

Primary Care Systems, Inc. (PCS), located in Clay, and Tri-County Health Clinic, Inc. (TCHC), in Rock Cave, collaborate to provide care for over 15,000 users in central West Virginia. In 2007, PCS and TCHC implemented a new model of care using a modified version of the care model supported by electronic health records. The new workflow, reassignment of job duties, and reminder tracking-system resulted in more effective preventive care and outreach to center patients whose needs range from routine care to support in managing chronic illness. Imbedded in this new model is an emphasis on self-management.

David was a hypertensive, diabetic, hypercholesterolemic, obese patient who rarely sought preventive services or followed up on chronic illness care. With the implementation of a new workflow and electronic health records, the centers have been able to contact David when he is due for a test or an office visit. David receives education from clinic coordinators and care managers. With these tools, David has made significant lifestyle modifications: losing 85 pounds and stopped needing his diabetic and anti-hypertensive medications. Through the marriage of the new care delivery, collaboration between centers, and the electronic health record these goals have been achieved.