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Welcome to this edition of AMC.

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Tell you how I got better. I'm glad to be

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here, but a mission

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to. Well, I think that we're, we're talking, we're gonna

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talk about everybody's Arkansas is

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the 2nd highest prescriber.

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Welcome to AFMCTV. I'm Robin

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Ledbetter. Thank you for joining us.

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Today I have with me Angie Walker, and she's the office

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administrator of Walker Family Practice Clinics.

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Angie, thanks for being here today.

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Thanks for inviting me.

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So we're talking about rural healthcare and

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your practice, and can you start by

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telling us about your clinic in Duqueen and

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the population that you serve in Sevier

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County? Certainly. So, um,

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we basically have 4 locations.

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Um, I'll start with the main location. So

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we have 4 locations, we have um

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9 nurse practitioners and 2 medical

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doctors. And so, uh, for

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the main clinic here in DeQueen, the, the biggest

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location, we're open Monday through

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Sunday 7 a.m. to 7 p.m. with

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after-hour triage, and then we also have

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a home-based schedule and a nursing home

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schedule for this clinic.

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Um, we have a pediatric clinic still in Dequeen.

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It's Monday through Friday 8 to 5, uh,

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certified pediatric nurse practitioner who's

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Fantastic.

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Um, we also have a school-based clinic,

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Leopard care clinic. It's Monday through Friday,

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7 to 4.

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This year is actually the first year that we made it

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year-round and so we're super pumped about that.

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Um, but it also, um, manages

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our school-based clinic and then also handles

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all of our chronic care management and also

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some home-based patients too.

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Um, and then we have, um,

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another satellite clinic in Derricks, Arkansas,

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and it's open Monday through Friday 8 to 5.

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And what specific health challenges or needs

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does your community face and how has your

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clinic adapted to meet them?

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Uh, I would say we, we face the

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same as all other rural clinics

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and I'm sure even some, um, urban clinics

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as well. Um, so for us,

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um, we, our city population

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boasts 6000 with a county

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population of 17, which is absolutely

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wrong. Um, our city population

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is probably closer to,

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I would say 10 to 12,000,

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um, and our county population is probably

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closer to 2500. 00.

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We are probably 65%

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Hispanic, I would say at least just

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based on some demographics in school. Um,

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and we also have a Marshallese population of

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about 300.

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So, um, we, we

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battle housing issues, uh, lack

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of housing issues, we bought, we battle

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transportation, um, we've also

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got, um, a poverty level

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that, that's kind of up there and then also some

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food insecurities too.

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Your clinic has made notable success

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with immunizations. What has

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been the driving force behind that?

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Uh, so I think for us, um,

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it's probably been the partnership with the

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school, um, you know, just some of the things

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that those school nurses have to deal with on

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a day to day basis, that's tough, um,

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you know, once we started kind of integrating in

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and and learning everything that they were managing

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on a daily basis, it was insane

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to me,

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um, and so of course when COVID hit and

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everything shut down,

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we had AAFP screaming, you've got to

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keep everybody immunized and what have you and so

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I think that jumped us off in there along

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with the school,

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um. So we just kind of have this motto, we're

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checking everybody and we we're doing it right

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now. If we, if we got to meet you at Walmart, we're coming

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to Walmart. Um,

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we also partner with one of our local

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restaurants here and so on the kids' side,

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you know, if they come in and get their shots and they get a free

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mini pizza, um, same thing

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on at any of our clinics if they do that.

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And so I think it's just one of those things

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that we decided it was gonna be a quality

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improvement project, you know, mostly

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for the school, the school nurses, but it kind

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of just exploded and and just

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went clinic wide.

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And you, you touch a little bit about outreach

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and what kinds of outreach aside from

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meeting them where they are, is there a reminder

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systems that have worked best in your area to

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improve those immunization rates too?

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So we do, of course we send out

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reminders and reminders and clinical works.

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Um, we make it a point to be

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on site for every school register.

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Um, every school registration

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that we are either inside that

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county or inside that district or we're

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touching that district. So we will

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be on site at Casaat when they do kindergarten

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round up and catch everybody up. Um,

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we go to Horatio, we're, we're at

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every registration, um, for the

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the Queen School District, and that's primary

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elementary. High school, middle school,

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um, we just try to make sure that we,

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we're there and we're showing up at

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everything that we can show up at, and that's the first

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thing that we're taking, uh, especially if

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we're doing smaller kids, we want to make sure

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they're kindergarten ready, you know, we're doing their

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vision and their hearing and we're trying to

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identify those problems early so

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that we can catch them and get them resolved.

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And do you work with aside from schools as churches,

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employers, are they involved in

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some of this as well?

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We do. So, um, we currently partner

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with Pilgrim's Pride here which is our biggest

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employer at about 1500, and

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so we have a nurse on site there,

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uh, 1 to 2 days a week and so

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come cold and flu season we're gonna be on

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site doing flu shots. Uh,

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we also, um, partner with our

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college, um, CCCUA

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has campuses here,

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uh, Nashville and Ashdown. We're going to do the

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same thing as soon as cold and flu hits, we're

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going to be at every campus, um, offering

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flu and pneumonia shots. Um, same

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thing if if they've got nurses or students

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or what have you that are behind on immunizations,

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then we're bringing those with us as well.

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Um, and pretty much just any

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churches, the same thing, we're getting ready to kick off

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a huge children's health fair. We'll see

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about,

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uh, probably 400 to 500 kids.

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Um, it's actually gonna be this year, um,

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the Queen Church of Christ has given us space

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and so we'll be there doing immunizations.

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Haircuts, uh, vision screenings, hearing

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screenings, you know, with the, the big goal

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being

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everybody's ready for school. And again,

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our, our ultimate goal is to reduce

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that workload off of that school nurse, you know, there's

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other things that they could be looking at versus

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chasing kids for immunizations.

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And Sevier County has seen a very

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low measles outbreak compared to other

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parts of the country.

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I mean, much of this, this push for

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vaccinations has contributed to that

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success. Uh, I would

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say we, we stay at about 95-98%

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within the school district,

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and even our whole clinic as far

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as keeping, uh, kids immunized.

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And so, and, and I'm talking about those

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tried and true immunizations, the ones that we

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know that have been around that are required by the

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state. And so, um, we,

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we try to, I mean it's a quality improvement

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project for us and so it's just one of

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those things that's just always in the forefront

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of our mind, making sure the kids are ready, prepared

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and vaccinated.

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Are you seeing vaccine hesitancy locally

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and how have you effectively addressed that?

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Uh, I think when any time you come

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into a rural area, you are

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always gonna have that hesitancy and

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again that's OK. I mean it,

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this is America, you get to choose what you want to

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do and so um for us it's

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just an educational thing and so we

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try to make sure that we're providing all up

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to-date information. We're very honest

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about if we don't know, we don't know,

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um, and so. So I think we just,

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you know, we, most of these folks

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are our neighbors, we go to church

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with them, we, we grocery shop with them

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and so I think um just

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making sure they understand where we're at,

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what, what we agree with, what we think

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that is appropriate or what we know

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information about, we're gonna share that information

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and then we're certainly gonna respect anybody that

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has a difference of of opinion. Um,

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and then for us what we've seen, you know, used

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to it was HPV,

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you know, no one really wanted to deal with HPV

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and so we did a pretty big um

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push on screening for, for different

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kinds of things and I think that that was a

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real eye opener for us again in a rural

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area and so I think once we

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were able to jump in and do some of that education,

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I think we've even seen. Those numbers increase.

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So I think it's,

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I think it's all about education and then

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meeting that patient where they're at and if

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they're hesitant,

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that's OK, we'll continue to have

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that conversation

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until we resolve that and that resolve is

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I'm, I'm not going to do it or we've

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provided you with enough education so that

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you can make a good decision.

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And what specific team work flows, protocols,

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and even quality improvement practices have made

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a measurable difference in your clinic's outcomes.

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Um, so for us, anytime we're seeing somebody

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under the age of 18, we're pulling Web

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IC immediately. We're looking at

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or do you have everything that you need? Is

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everything covered? Same thing anytime they're

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coming in for a wellness visit, we're

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immediately pulling that WebIC and making

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sure that we've got that.

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Um, we're kind of a little bit on the

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border. Um,

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a lot of our folks are Oklahoma and

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back or they're Texarkana and back,

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and so, um, we spend a lot of time

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cleaning up immunization records as well

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because we, we don't chat with each other.

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And so, um,

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You know, for us it's just

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it's a priority and so

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um with the and it we especially

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it took a whole another level, uh, a

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whole another stance once we brought in the pediatric

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clinic.

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Um, we've had the pediatric clinic for about

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2 years and so I think that

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that was a very big um.

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Educational thing for Nick. It was very

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important to him and so again, you're,

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you're leading by example, you're, you're

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showing folks and you're educating and you're providing

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information.

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And so,

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you know, other than it's just constantly

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on our mind and we're constantly trying to figure out

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how to improve it.

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Yeah I don't know.

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Well, measures are noticed for sure

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and taking it a step further, how do you train

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and support your staff to maintain high

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standards in preventive care?

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Uh, so for us, um, we sit

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down once a year and look at all of our metrics.

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Um, we follow probably about 30

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metrics in the clinic that are spent or

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split amongst different departments.

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So the front desk has a metric set,

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uh, lab and allergy has

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a metric set, the nurses have a

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metric set.

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my providers do and they cross reference

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so there's not just one or one

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department working on anything and so

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we pull those metrics on a monthly basis

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at the beginning of the year we set them, we

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identify them, we agree on them, we

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set our benchmark for July and then we

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set our final benchmark for December

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and so um.

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and we've got to meet those if we don't, because

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we bonus twice a year, we bonus in July

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and we bonus again in December and so

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if we're not meeting those benchmarks, it hurts.

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Um, it doesn't just hurt the provider, it hurts all

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the way through the staff and so um

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I think that has really helped us as far

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as um keeping an eye on. Things

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and because as

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me myself, I can't manage

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30 metrics through 75

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employees in 4 different locations. They

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have to have that buy-in.

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And so I think just us sitting down

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meeting, talking about them and then

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agreeing on what those look like.

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It is huge. Like we had our meeting this

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morning about July or June, we cut it

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off June 30th and so we've hit some

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and we've hit them really good.

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And so I told the group, I said, well, I'm actually

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gonna move the December metric

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because you're exceeding it by 7

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to 8 points. It seems crazy to leave

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it that low if we're already exceeding it.

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They weren't happy about that, but they did

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understand. And you know, that constant need for

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that upward trajectory. So

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have you implemented any technology or data

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tools that have helped your clinic stay on top of immunizations?

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So for us, we have a a bi-directional

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with WebIZ

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and so and that's for all the providers, all

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locations. So the minute we give an immunizations,

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it's immediate. It's, it's immediate. into

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the system. Um, I would say the same

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thing for us when we are on site for registrations,

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you know, used to you did not take technology

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with you, you didn't take it out of your office,

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um, now that's more mobile for us,

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you know, if we're gonna be on site, we wanna

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be looking at that

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mom right then and there and saying, oh, so

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and so is missing this, this and this, and

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we've got it, we can do it right now.

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And I think again, you're

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meeting the patient where they're at, you're not,

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you're not requiring them to take additional time,

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take time off work or any of that, and

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I think that helps. And I think the same thing

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on the clinic side, once we went

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to 7 days a week, um, with

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a 12 hour day, folks

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do not have to miss work and

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so it makes it a lot more accessible

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to them when they don't have to take that point.

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Or they don't have to take that day off work.

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Same thing on the student side, you know, the

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clinic, um, the school-based clinic is right

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there on campus, the teachers can go on

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their, on their, um, lunch

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break, they can go on their free period, you

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know, no one has to, um,

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miss work or miss school. And how have

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you built partnerships with other community stakeholders

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like local government, you mentioned

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schools, nonprofits to strengthen public

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health.

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Uh, I think for us

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we're always gonna say yes. And

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so my, my, my crew will sometimes roll

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their eyes and be like, oh my gosh,

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um, but I think in a rural community,

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you have to have that partnership. You have to

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have that one

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organization that you can count on and

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for us, to me, I want us to

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be that. want us to be that very

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first phone call that somebody makes when

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they need something,

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uh, when they need to coordinate something or they need

[00:13:14.835]
to get a hold of somebody and so,

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um, while sometimes that can, that

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can be absolutely tiring, I think it's also

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absolutely rewarding and then it

[00:13:23.514]
it really strengthen strengthens

[00:13:25.955]
the relationship that you have.

[00:13:28.769]
And what can other role or

[00:13:31.029]
resource limited clinics learn from your experience?

[00:13:34.960]
Um,

[00:13:36.330]
I would say just get out

[00:13:38.519]
there, uh, you know, a lot of times we feel

[00:13:40.609]
like. Monday through

[00:13:42.649]
Friday 8 to 5, I'm doing all that

[00:13:44.649]
I can do. Um, I think once

[00:13:46.769]
you start to peel that onion and you

[00:13:48.769]
start to look at things like social

[00:13:51.048]
determinants of health,

[00:13:52.529]
um, you start to understand, you know,

[00:13:54.769]
for us it was an eye opener. We had a patient

[00:13:57.570]
who we were just having a horrific issue with an

[00:13:59.570]
A1C.

[00:14:00.529]
Well, come to find out they didn't have a refrigerator.

[00:14:03.479]
So guess what?

[00:14:04.798]
Their A1C was not their primary concern.

[00:14:07.399]
Um, we've had patients without running water,

[00:14:10.038]
OK? If, if they don't have running water, they really

[00:14:12.158]
don't care whether or not they picked up their blood pressure medicine.

[00:14:14.879]
And so again,

[00:14:15.918]
I think you always have to meet that patient

[00:14:18.798]
where they're at and for us, um.

[00:14:21.500]
Our, our big motto is, you know,

[00:14:23.700]
quality team-based care has to be

[00:14:26.538]
performed at the right time,

[00:14:28.580]
um, at the right moment, and it's

[00:14:30.619]
that moment that belongs to the patient, it's

[00:14:32.700]
not your moment. It's not Monday through Friday

[00:14:34.820]
8 to 5. It's not, oh well we have an appointment

[00:14:37.099]
in 2 weeks, it's when that patient

[00:14:39.298]
needs you.

[00:14:40.229]
And so, um, the same

[00:14:42.359]
thing that we want, we want to do as far as being

[00:14:44.599]
available for our community when they need us

[00:14:46.649]
at the time they need us, we want to do the

[00:14:48.678]
same thing for our patients and so,

[00:14:50.710]
uh, we, we were looking at things yesterday

[00:14:52.859]
and identified that um we're open

[00:14:55.109]
access and so 71%

[00:14:57.678]
of our patients walk in the same day

[00:15:00.399]
and, and we like that.

[00:15:02.219]
It, it

[00:15:03.320]
keeps it exciting.

[00:15:05.710]
So before we close, if you could

[00:15:07.750]
send one message to healthcare leaders, stakeholders

[00:15:10.389]
watching, and what would it be?

[00:15:12.700]
Uh, I think that for

[00:15:14.820]
us we're primary care

[00:15:17.288]
and, and we're rural primary care and

[00:15:19.418]
so my biggest push

[00:15:21.418]
would be, I think we've got to really start

[00:15:23.779]
looking at um

[00:15:25.739]
some of these reimbursement policies and

[00:15:27.820]
they need to match what's actually

[00:15:29.899]
going on.

[00:15:30.849]
You know, once COVID hit, and I hate to keep

[00:15:32.928]
saying COVID, but a lot of things got pushed

[00:15:35.019]
back on the primary care, things that we never

[00:15:37.210]
would have done, but now we are

[00:15:39.379]
doing them and excelling at them

[00:15:41.379]
and that patient is, is

[00:15:43.500]
used to coming in here and getting that done. And

[00:15:45.940]
so I think we have to really start

[00:15:48.899]
looking at primary. Care and

[00:15:51.125]
understanding what that whole gatekeeper mentality

[00:15:53.904]
looks like

[00:15:55.264]
because a lot of times we are the first stop for the

[00:15:57.423]
patient, even when they go to the specialty,

[00:15:59.585]
they're coming right back in going, I don't understand

[00:16:01.634]
what do I need to do next. And so

[00:16:03.783]
I think we're going to have to start looking at

[00:16:06.024]
some reimbursement policies

[00:16:07.984]
that match.

[00:16:09.548]
The performance of work you're doing,

[00:16:11.840]
um, and also the medical complexity

[00:16:14.178]
of work that you're doing. Well, Angie, thank you

[00:16:16.219]
so much for sharing some valuable

[00:16:18.859]
information about practice management

[00:16:20.940]
meeting the community where they are.

[00:16:23.658]
Thank you for talking about the success

[00:16:25.700]
of what your practices are doing. Thanks for being

[00:16:27.859]
here too, too. Thank you. And that's

[00:16:29.899]
it for this episode of AFMCTV. Thanks

[00:16:32.029]
for watching and have a great day.