Speeding past the farm fields of central Illinois, you’ll find the exit for Litchfield. The 7,000-person town is home to Litchfield Family Practice, an innovative rural health system that just achieved a Level 3 Patient-Centered Medical Home (PCMH) Certification from the NCQA.  It scored an impressive 97.5 out of a possible 100 points.

In this video, the team at Litchfield Family Practice describes how it is advancing population health in a rural community.


“Small step” approach leads to success

It all started in 2009, when Litchfield Family Practice and the local hospital, Hospital Sister’s Health System (HSHS), explored the medical home concept. “We felt the PCMH model was similar to the way that we were already practicing medicine,” said Daniel Wujek, MD.

Litchfield is home to seven busy practices under one roof. While they had worked as a team for decades, there were still many different approaches to documentation. For example, clinicians didn’t always measure the patient’s height to calculate a Body Mass Index (BMI), a key health indicator. Litchfield team members wanted to become even more patient-centered, more consistent and improve the way they shared information with each other.

During the 18-month process to apply for PCMH certification, Litchfield used “small steps” to stay organized and move forward. For example, two physicians met every Tuesday afternoon to review progress and plan next steps. And four times each month during a two-hour window, the practice’s IT manager led repeating 15-minute, drop-in training sessions for staff on specific topics.

These and other practical steps helped Litchfield tackle the lengthy PCMH certification process. “It can be overwhelming reading the principles,” said Pat Bickoff, practice manager at Litchfield Family Practice. “But once we got into it, we were surprised at how well we were already doing.”

Litchfield’s progress with population health management

With help from HSHS, Litchfield now offers patients access to a care coordinator, called a Nurse Navigator. “Patients love the extended time they have with her – for free – to learn about their conditions and work towards manageable goals,” said Bickoff.

Allscripts Professional EHRTM helped the practice add specific medical home terminology to documentation to enable targeted, comprehensive reporting. “The reporting is one of the most beneficial things for us,” said Dr. Wujek.

For population health management, the practice performs a review of diabetic care twice a year and set up reminders for breast cancer and hypertension screenings. “This reporting capability gives us an ability to be much more proactive in our patient management,” said Dr. Wujek.

Litchfield hopes that payers will soon begin to offer incentives for medical homes in rural Illinois. Until then, it continues to focus on providing great family medicine through an independent group of physicians to about 350 patients every day.  According to Bickoff, the team also enjoys the bragging rights that come with the practice’s outstanding PCMH certification score.

To learn more about Litchfield Family Practice’s success, you can read a case study or watch a video. You can also learn more about the process in another recent blog post, 10 tips for achieving Patient-Centered Medical Home (PCMH) certification.

Tags: , , , ,

About the author

Libby Moore is a healthcare IT executive with more than 25 years of industry insights and experience in developing winning strategies, driving business results, and focusing on client satisfaction. She began her healthcare career in finance and eventually transitioned to defining, developing, and delivering solutions that span the healthcare IT arena. She is passionate about building extraordinary client relationships and leading healthcare transformation. Libby first joined Allscripts in 1995 and has served in senior leadership roles that included Product Management, Product Development, Professional Services, Client Support, and Operations. Leveraging her vast industry experiences, Libby assumed her current role as Vice President of Physician Practice Solutions in 2012. She now devotes her time to defining and delivering comprehensive portfolio offerings to physician practices, value-based care (VBC) organizations, and accountable care (ACO) groups.


Your email address will not be published. Required fields are marked *