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Primary care practice earns recognition for population health management

The Family Doctors (Shreveport, Louisiana, U.S.A.) uses data from its Allscripts Professional EHR™ suite to help improve care for patients with chronic disease. Blue Cross Blue Shield of Louisiana recognized The Family Doctors and its physicians with 26 awards in 2015 for highest achievement in population health management.

Improving care for a community that struggles with chronic disease

The Family Doctors serves a community facing significant health concerns. The State of Louisiana has some of the highest healthcare costs and lowest quality outcomes in the United States. According to America’s Health Rankings® of the 50 states, Louisiana has not ranked above 47th in more than 20 years. Chronic diseases are especially costly, as Louisiana has one of the highest rates of cardiovascular and diabetes mortality rates.

Working closely with the state’s largest payer, Blue Cross Blue Shield of Louisiana, the practice addresses these health concerns and improves care for patients with chronic disease. In 2013, the payer created a program, Quality Blue Primary Care (QBPC), to improve primary care throughout the state.

Blue Cross Blue Shield asked The Family Doctors to participate in QBPC. “We had a good EHR we could extract data from, and we’re one of the largest primary care practices in the state,” Administrator Lisa Britt, CMPE, said. “It made sense for them to include us.”

QBPC targeted four chronic conditions: diabetes, hypertension, chronic kidney disease and/or vascular disease. The payer and provider collaborate to help coordinate care for patients with those diseases, and payment is based on performance in core clinical quality measures. Providers use the payer’s analytics software to evaluate data from the EHR.

Achieving better coordination and outcomes

“What’s great about this program is the coordination we have with other providers to help manage patients with complex conditions,” Britt said. “If a patient sees an orthopedic surgeon in a multispecialty clinic across town and has lab results, our primary care doctors can see that, too. We couldn’t do that without Professional EHR.”

In 2015, QBPC’s second year, the program included 658 primary care physicians treating 187,209 patients across the state. Data collected from January to September 2015 show improvement across quality measures, including 25% for diabetes, 40% for vascular disease, 31% for hypertension and 69% for chronic kidney disease.

The program also recognized 58 physicians for achieving results in the top 10th percentile for each chronic condition. Physicians at The Family Doctors earned 26 of these awards.

“We’re proud of these awards, because it means our physicians are performing high-quality care,” Britt said. “With data from the EHR, our physicians were able to see trends over time and improve outcomes for patients.”


Editor’s note: Physician practices can also bring population health management efforts together with Allscripts CareInMotion™. It’s the comprehensive platform that delivers care coordination, patient engagement, connectivity and data aggregation and analytics. Learn more about the CareInMotion suite of solutions on our website.

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