Pella Chronicle


December 2, 2011

New system to improve Chronic Care at PRHC

Pella — Pella Regional Health Center and its family of clinics in Pella, Bussey, Knoxville, Monroe and Sully has recently installed a patient registry system. The goal of the system is to improve the health care of patients with chronic conditions such as diabetes and cardiovascular disease by tracking and managing their care. The purchase of the system was funded in part by the Small Health Care Provider Quality Improvement (QI) grant.

Quality health care means improved disease management and better patient outcomes. It also means patients get the right care at the right time. There is a growing belief in the health care industry that creating a patient centered medical home with a dedicated health care team and the use of technology is the best way to give patients quality care and a better experience.

This patient registry system is another step in Pella Regional’s move toward a patient centered medical home. A medical home is a primary care practice in a clinic that uses a team approach and places the patient at the center of the team. The team can include doctors, nurses (health partners), pharmacists and therapists. They work together and use technology, such as the patient registry, to provide coordinated care to patients.

The new patient registry system will enable health care teams at Pella Regional to manage chronic illness in a proactive, organized fashion. The health care team no longer needs to wait for patients who are chronically ill to show up with an acute problem, and then address any chronic disease issues at that time or reschedule the patient for another visit dedicated to the chronic illness.

Diabetes patients are a good example. The registry will track all of Pella Regional’s patients with diabetes, including their required labs and preventive services, in order to manage the health and well-being of those patients. The registry also alerts the team if there are problems. By using this system, clinicians are able to increase compliance with recommended services.

The registry also helps to identify patients who need additional support and prompts care teams to provide further individualized education and support so patients and caregivers alike are armed with resources to help manage these diseases.

“We anticipate the outcome of implementing the patient registry and the other components of our patient centered medical home will be improved patient outcomes on clinical standards, decreased hospitalizations, and, ultimately, the identification of enhanced treatment strategies,” said Dr. Craig Wittenberg, family practice physician who also provides obstetrics services.

The patient centered medical home at Pella Regional is designed to keep patients healthy by providing primary care, coordinating any visits to specialists they may need and by taking steps to manage chronic diseases. The team partners with the patient to make sure they are making the right decisions for good health and keeping on top of any preventive care the patient needs. It might mean more frequent visits to the clinic or contact with the nurse—but the goal is to keep the patient healthy and prevent episodes that would require hospitalization or expensive medication.


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