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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. Today I have

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with me Brittany Branson. She's an RN

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and the chronic care management

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coordinator at Randy Walker's clinic

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in practice there in Sevier County

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in DeQueen. Britney, thanks for being here today.

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Hey, it's good to be here.

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So can you start by giving us an overview of your role

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in chronic care management at Doctor Walker's

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clinic in the patient population that you serve?

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Yes, so the population we serve right

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now is about 380

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patients, uh, within our practice.

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Um,

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with those patients, we consider high risk

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and we do home visits

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on them if they're not able to come into the clinic,

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you know, we monitor blood pressure.

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We, we do things in the home so that,

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to keep the patients out of the hospital.

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or from being readmitted to the hospital

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is what our goal is.

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And for providers are familiar with rural

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chronic care outreach, how would you define

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the scope and purpose of chronic care management

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in a setting like the Queen?

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So, um, like I said, you know, we do

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have a hospital here now. We've,

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you know, we just recently got one back. We haven't

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had one for a while, so.

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We try to keep the patients in our area

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out of the hospital if they

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need a home visit, we have a provider

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that goes out and sees people for home

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visits. Um, if they need

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monitoring after that, blood pressure

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checks, their medication boxes filled

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so that they don't miss. Any of those,

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um, I, that's kind of where I fill

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in. I fill in the gaps where the providers

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need me and basically I, I

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take it day by day and whatever the patients

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need,

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I go out and do to keep them

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in their home and healthy

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and keep them out of, out of the hospital.

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And what clinical criteria or social

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determinants do you use to identify patients

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for chronic care management? Is it particularly

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those that are homebound or high risk?

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Um, both. So we actually have

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screeners when they come into our clinic or when we

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go out and do a home visit on them. We

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screen those patients then and you know, we

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can tell if, if they need food, we give them

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food then

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in the clinic or in the home, we try to

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keep the bags with us if we do home visits,

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um, so they can have something right now. Then

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we also have resource guides that we

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give out to the patients with other resources

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like churches,

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you know, things like that in our community that do

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things, um.

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And then we decide if

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they have trouble with transportation,

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you know, we decide right then and

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you kind of flag those patients and they'll send me

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a referral

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or

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send me a message on our EMR and

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we just kind of keep a list of those. Well then I

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contact that patient after that

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and we kind of get.

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You know, figure out where they are based on

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what they're gonna need and then go from there on

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treating them.

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So you, you touched a little bit about the

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the structure of your home visit program.

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Is this something to where you reach

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out to the patient? Is it like follow up, hey, we

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haven't seen you in the clinic, um, or

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is this where they, they reach out to the clinic

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and say I can't make it in. I need someone

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to come to me?

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So both um if. There's someone,

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you know, the providers are worried

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about or that they deem high risk

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when they come in and it can be acute or

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it can be chronic.

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Um, they will contact me and I will

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contact the patient or you know, we have patients

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that call the clinic and they've only been in a couple of

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times or never been in, and they

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don't even know that we have this program, but

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they reach out to us and as soon as

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they call, you know, they. and send them

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to me and we figure out,

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hey,

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you know, they need a home visit. We try

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to get them to come into the clinic for their first

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visit,

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but

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after that, if we deem them, you know,

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they're, they can't, they're homebound

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and they can't get out. We go out and

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we see those patients and we try to schedule those

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every 2 or 3 months. If they need labs,

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anything we try to do in the home.

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And you mentioned food, so food

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insecurity is a part of, of the community

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too, but it's not

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just blood pressure monitoring,

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this also carries into medication

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management, education. So it's

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really an in-home care model.

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Yes, so, um, I

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mean,

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really,

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anything they need,

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we, we have, you know, feed local

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here in Dequeen that is

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a nonprofit organization and you

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know, they keep

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churches stocked with food. They

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kind of, you know, they'll help with our food pantry

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for chronic care management.

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Um, that's another, you know, we have that that we

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can

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go to here in town to help with people,

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but um.

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We, I mean, we do everything. We have transportation

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and that's also me if.

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You know, they need a ride and we try to exhaust

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churches

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and family members first, but if that's not

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possible, then, you know, we have

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a waiver they sign. I go out,

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they sign the waiver, I transport

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them to the clinic and then take them back home

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after. If they need medicine,

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we will stop by the pharmacy on our way home and

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grab that if the pharmacy don't deliver, you

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know, we are fortunate here and we have a

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couple of pharmacies that do deliver to

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patients.

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Have you seen measurable improvements in

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health outcomes um among the patients

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that you serve?

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Yes, we have, um, you know, the med

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boxes I feel a lot of those patients,

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they, they have a hard time reading their medicine

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bottle or they don't understand. They don't

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have family members that take care of them.

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So I go out and I fill

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those boxes, but a lot of those patients, they don't

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they. They won't take their medicine,

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you know, and so that keeps them

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out of the hospital. It keeps them from

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having issues and having to come back into

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the clinic and kind of manages their,

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you know, chronic problems that they have.

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So we have seen, you know, quite a bit of

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improvement with that.

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What is your care team look like? How do you coordinate

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with with the providers within

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Doctor Walker's clinic to ensure continuity

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and documentation of care?

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So, you know, we're there 7 to 77

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days a week. Um, there's always a

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provider there that I can call and communicate

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with, um.

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I have Devin Russell, which is a nurse

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practitioner at our school-based clinic,

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but she also does all of our telehealth. So

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if there is not a provider in the home,

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then I will assess the patient

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in telehealth back with her

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so that we can get the patient seen. We

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have one EMR that all of our documentation

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goes into and so every

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provider at the clinic can see everything I

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do, I can see everything they do,

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and

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We kind of stay on the same page but,

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I mean, everything's right there so we can all

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access it. What are some of the biggest challenges

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you face in maintaining or scaling this

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level of personalized care in a rural

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environment?

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Um,

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really, it's the ones

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that

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go to the ER and are used to just go into

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the ER for those kinds of issues,

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you know, trying to

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retrain them and to

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understand that we, you know, we're 7

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to 7.

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You can call, I have a direct number to me. They

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can, you know, call me and contact me

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instead of,

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you know, going into the ER like I

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can. Just teaching them that

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we do have this and that it is

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there for them to utilize and that we can come

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out and fix those

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issues or adjustments and you know, communicate

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with the provider out of their

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home. And from a reimbursement or

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funding perspective, how does this currently supported

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or Are there value-based models, grants

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or different billing mechanisms in place?

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Um, well, right now as far as

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our, you know, our food pantry, we do

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all of that in-house. Transportation

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is the same way, you know, it's just not,

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we don't do enough that it's just,

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you know, we're overwhelmed with it right now we can

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manage the population that we have.

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Um, so we, we manage

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most of it, or all of it inside,

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inside our clinic. And then when we,

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when we go out and see the patient do the home visit,

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you know, it comes back to the providers.

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So we're either doing an office visit

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or a nurse visit, and we're able to

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document those things in their chart and just

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bill accordingly to what the service is.

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So for other clinics, um, health providers

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looking to implement or expand similar

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chronic care outreach,

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what would be your recommendations?

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Start small.

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I mean, you know,

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everybody has 10 or 15 high-risk

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patients that they can pick out and start

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to manage. And then once you

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get that down and you can manage

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those patients and you start noticing

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the decrease in the ER visits for

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them, call, I mean. And several

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times a day, you know, you're, you're able to

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get those patients managed and

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get better care,

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then you can grow from there

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and then grow your team. I mean, it started out

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as just me and

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uh one other provider in the chronic care management

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program and just this past year, we've added

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one more person because we've gotten big enough.

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We contact all 380 of

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these patients every month.

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So,

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We're either contacting them at least once

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a month and then some of them, you know, when they

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need us, they know to call us and they'll call us

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directly and we'll take care of whatever it is they

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need. Well, Brittany, thanks so

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much for talking to us today about

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this important information and

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really amazing effort that

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your clinic and this program is

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doing for the residents of Sevier County.

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Thank you.

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Thank you so much for having me.

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And that's it for AFMCTV. Have a great

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day. Thanks for watching.
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