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A journey toward a rural patient-centered primary care home



Cascades East Family Medicine Center has always had a team approach for its patients with high health care needs. Now it has expanded this patient-centered approach to all patients across the clinic.

Cascades East Family Medicine Center, Klamath Falls

Cascades East Family Medicine Center has always had a team approach for its patients with high health care needs. Now it has expanded this patient-centered approach to all patients across the clinic.

The rural Klamath Falls health center has about 7,900 patients with about 450 to 500 patient visits per week. Cascades is a joint project of Sky Lakes Medical Center and Oregon Health & Science University's Family Medicine Residency program. This health center will be part of the provisionally certified Cascade Health Alliance, LCC, a coordinated care organization.

Cascades East was recently recognized by the state as a patient-centered primary care home for  providing coordinated, patient-centered care to promote better health for its patients.

Some of the innovations for better care at Cascades East include:

Creating patient care teams;
Developing specific care plans for their high-needs patients; and
Expanding access to care by making more appointments available, even during evening hours.

"With this patient-centered, team approach, the outcomes for patients are so much better," said Faith Koepke, R.N., director of clinic operations.

The care teams consist of a registered nurse, a medical assistant, medical residents and faculty physicians. There is always a team member available for patients; the resident and faculty physicians do home visits and team members are available by phone if needed as a way to prevent health emergencies.

"For example, a patient with diabetes can call the nurse on his team if he has a question about his blood sugar and he'll get an answer right away. This can prevent a more serious issue," Koepke said.

Switching from being mostly a walk-in clinic to encouraging patients to proactively schedule appointments provides more consistent care.  

"We would have the same person walk in four or five times a week and they would get a different provider each time. Now that we've changed to a team-based model, patients can come in and see someone on their team who knows them even when their doctor is not available," Koepke said.

Cascades' patient-centered care approach hopes to reduce hospital use by increasing use of their clinic. It is also a more efficient use of health care, Koepke said.

"We are able to take care of issues that would otherwise bog down the emergency department," she said.

Koepke said that their journey towards the patient-center centered care model is a continuous process at Cascades East. They are still adding services to meet their patients' needs and recently hired a family and marriage counselor.

 "We are always looking at different ways to best serve our patients," Koepke said "The important thing is that we meeting our patients' needs. That's our goal."

Learn more and find out if there is a Patient-Centered Primary Care Home in your area.