By Dale Shaller and Susan Edgman-Levitan

Grant Community Clinic

222 W. Amelia St.
Cassville, WI 53806
608-725-2321
www.deancare.com

Please click on the image above to watch a slide show of photos of The Grant Community Clinic.

Grant Community Clinic is one of 12 primary care practices featured in Commonwealth Fund case studies of patient-centered practices. The site visit was conducted by Dale Shaller.

Key Personnel Interviewed
Robert J. Smith, M.D., Family Medicine with Obstetrics
Mary Esser, R.N., Nurse
Mary Jane Uppena, C.M.A., Office Manager and Receptionist
Matthew R. Bagley, Region 1 Director, St. Marys/Dean Ventures, Inc.
Betty Schwarz, Project Management Specialist, Measurement Resources, Dean Health System

Additional personnel interviewed as part of the Dean Health System in Madison, Wisconsin:
Thomas J. Hirsch, M.D., M.S., Vice President of Medical Affairs, Dean Health Plan
Jonathon A. Hess, Administrator of Operations, Dean Health System
Scott M. Lindblom, Director, Medical Affairs, Dean Health System
Jack Bowhan, Administrator, Medical Practice Improvement, Dean Health System
Steve Wilkes, Administrator for Primary Care, East Region, Dean Health System

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Overview

The Grant Community Clinic in Cassville, Wisconsin, is one of 12 primary care practices included in this case study project of high-performing, patient-centered primary care practices. Practices were selected for study from a sample of more than 2,000 sites on the basis of their exceptional patient experience survey scores across multiple domains. The purpose of the case studies is to document models of high-quality, patient-centered care, and to extract lessons regarding the organizational factors and specific processes used by these practices to achieve favorable patient experiences.

The Grant Community Clinic

The Grant Community Clinic, part of the Madison, Wisconsin–based St. Mary's/Dean Ventures, Inc., scored well above the 95th percentile on each of the American Medical Group Association (AMGA) patient survey domains related to access, doctor–patient communication, and interaction with office staff. Several attributes of the clinic appear to contribute to these exceptionally high scores. First, the small scale of the practice allows for a level of interaction between providers, staff, and patients that is uncommon in larger practices. The practice's only physician, Dr. Smith, and the other staff have known many of their patients for years, and often their families and friends as well. A supportive work environment has fostered a team approach that has, in turn, led staff to treat each other and their patients very well. Each member of the team is knowledgeable about each others' functions and responsibilities and stands ready to pitch in when needed and job share as appropriate.

The small scale and rural location of the Cassville site also contribute to several challenges, including difficulty maintaining consistent hours of operation when providers are called away to cover at other St. Mary's/Dean Ventures clinics. Retaining clinical providers is also a challenge in such an environment.

An important structural feature that has enabled the clinic to thrive is its connection to a larger health care system. As a satellite practice within a network of clinics, the Cassville site has relative autonomy in making decisions that affect the local practice (e.g., hours of operation, scheduling, and workflow). Yet, it is able to take advantage of important support services provided through its parent health system.

Characteristics of the Local Market

Cassville is a town of approximately 1,100 residents on the east bank of the Mississippi River in Grant County, Wisconsin. It is a picturesque community that promotes river tourism along the scenic bluffs leading into the rolling farmland of southwestern Wisconsin. The residents primarily work in local commerce and farming or are retired.

The Cassville Clinic is the only medical facility in town. The nearest hospital, the 15-bed Grant Regional Health Center, is 20 miles away in Lancaster, which is also home to the SMDV Lancaster Clinic. The nearest major medical center is in Dubuque, Iowa, a 45-minute drive on the other side of the river.

History, Structure, and Governance

The Cassville site of Grant Community Clinic is a small primary care practice located in rural Grant County along the Mississippi River in southwestern Wisconsin. The practice dates back to the 1950s, when it was started as a solo practice by a local physician, "Doc David," who was renowned for his close involvement in the life of the community. Dr. Robert Smith arrived in Cassville and took over the practice about 15 years ago, when Doc David retired. Dr. Smith is currently the sole part-time family practice physician at the clinic, supported by a part-time physician assistant, nurse, and office manager/receptionist.

In 1993, the Grant Community Clinic became part of a joint venture between the Dean Health System (DHS), a multi-specialty integrated health care system based in Madison, Wisconsin, and the Sisters of St. Mary's (SSM), a St. Louis–based hospital system that owns St. Mary's Hospital in Madison. This joint venture, called St. Mary's/Dean Ventures, Inc. (SMDV), consists of a regional network of about 30 primary care clinics located throughout the predominantly rural counties of southern and central Wisconsin.

The regional clinics in the SMDV primary care network operate fairly autonomously within the overall system. The Cassville site is a satellite clinic of a larger clinic in Lancaster. The SMDV network is divided into four regions and each region is assigned a regional director. Regional directors are responsible for the operations of each clinic under their purview. All clinics receive support from the SMDV corporate office, including human resources, compensation, marketing, billing, collections, and an evolving information system using the EpicCare electronic medical record (EMR) platform. While EpicCare is fully operational in various primary care and specialty departments in the Dean Health System, it has not yet been fully implemented in more regionally dispersed SMDV sites, including those in Cassville and Lancaster.

SMDV maintains its own board of directors, composed of an equal number of members from the two parent companies plus two physicians from the SMDV clinics. At the regional and site levels, the regional director convenes monthly meetings with the physicians, physician assistant(s), and nurse practitioner(s) to review both system and site-specific issues. A regional operations committee meets bimonthly. In addition to the regional director, a reimbursement coding specialist, clinical specialist, and practice management specialist are available to support the regional clinics as needed.

Payer Mix and Patient Population

As self-described, the practice has the following payer mix:

The practice averages 1,500 to 1,700 patient visits annually.

Physical Characteristics of the Site

The Cassville Clinic is located on the city's main street near the downtown center. The clinic occupies half of a single-story brick building. The common front door opens to an entryway with an interior door that leads into the reception area. Patient parking is either on the street or in a rear parking lot.

The clinic includes two exam rooms, a larger emergency room, a nurses' room with lab facilities, and an office shared by Robert J. Smith, M.D., and Kelly Muench, a physician assistant (PA) in family medicine. A storage room houses the clinic's paper charts, which are not yet entered into the EpicCare EMR.

All facilities are neat and clean. Furnishings are modest.

Physician Staff

As noted previously, the physician staff members are Dr. Robert Smith and Kelly Muench, who works two days each week (four half-day sessions) when Dr. Smith is not in. Ms. Muench was not present for the site visit.

Dr. Smith is board certified in family medicine, having received his M.D. at the University of Alberta and completed his internship and residency in family practice at the Royal Alexandra Hospital in Edmonton, Alberta, Canada. He works three half-day sessions per week at the Cassville Clinic and spends the balance of his time at the Lancaster Clinic. He has been a Cassville resident for 15 years, since moving from his practice in Canada in the early 1990s. He generally schedules 15-minute visits but allows more time as needed for special cases and physicals.

Dr. Smith describes the legend of Doc David as a mixed blessing; it is a formidable legacy to live up to in terms of patient and family relationships. He believes the key to the current success of the practice is the office staff. Both the nurse and office manager/receptionist have been at the practice for more than 20 years and know most of the patients and their families by name. He credits a strong commitment to customer service by all clinic staff as the foundation for successful patient care, and believes the key to customer service is a commitment to meeting the needs of the staff and working as a team. This commitment to staff well-being is carried out in several ways, such as by involving staff in planning, incorporating their needs and preferences in the design of the practice, and by proactively addressing any conflicts or concerns.

Dr. Smith perceives strong advantages to working as part of a larger system. The infrastructure support provided by SMDV, such as financial management and human resources, "takes a lot of pressure off the practice." He has mixed views of the EpicCare EMR, which he values for providing ready access to patient information online but which he thinks is too rigid and difficult to customize. He chooses to dictate his notes via the telephone, which are then transcribed in a digital system to become part of the EMR. A hard copy of the dictation is placed in the paper chart because the organization is currently in a transitional period between paper charts and a full EMR. Dr. Smith is somewhat reluctant to move away entirely from a paper chart, which he can skim easily for written notes. He does not use e-mail with his patients, and the "MyChart" patient portal of the Epic system is not yet available at this clinic site. (MyChart is a Web-based system that allows patient conversations to take place in a secure environment.)

Dr. Smith takes the performance review system of the Dean Health Plan, known as the Physician Incentive Model (PIM), quite seriously. The PIM currently includes two metrics for monitoring performance: 1) use of generic prescriptions and tablet splitting (which are both cost-based measures), and 2) patient satisfaction scores. Patient satisfaction is being measured using a modified version of the Consumer Assessment of Healthcare Providers and Systems survey, which is mailed to Dean Health Plan members at their homes. Results are sent quarterly to each clinic site, and individual physician scores are compared with clinic and system norms.

Other Staff

In addition to Dr. Smith and the part-time PA, the Cassville Clinic employs a part-time nurse and a full-time receptionist/office manager.

• Mary Esser, R.N., has been with the Cassville Clinic for 20 years. She attributes the clinic's high patient survey scores to the fact that "we know our patients really well." The small size of the clinic and its proximity to patients' homes contribute to the close relationship between patients and staff. She believes they "can do things that larger clinics can't do," such as delivering medicines to patients' homes. She personally takes the time to "call everyone," routinely calling patients with lab results rather than having them access results through a voicemail system. The on-site lab allows her to draw blood and, through a courier service to the Lancaster site, quickly obtain and report results to patients, often on the same day.
• Mary Jane Uppena, the receptionist and office manager, has been with the Cassville Clinic for 24 years. She attributes the success of the practice to the ability of the small staff to function as a team. Since she is trained as a certified medical assistant, she is able to escort patients to examining rooms and perform other basic services as needed. She and Mary often trade-off duties that are appropriate to their respective clinical expertise; they know each other so well that they can anticipate what needs to be done and do it. She also believes that the small scale of the practice makes it easier for staff to accommodate patient needs, such as scheduling changes.

Systems Supporting Patient-Centered Care

• EpicCare EMR: Although all features of the EpicCare system have not yet been implemented at the Cassville Clinic, Dr. Smith and the support staff are using the system for accessing patient data online, dictation, internal communications (with other clinic sites, specialists, and SMDV and DHS locations), scheduling, ordering, and charging.
• SMDV Liaison and Support: As noted, SMDV provides support through its regional director and specialists in coding and practice management.
• Regular meetings: Matt Bagley, the SMDV regional director, meets monthly with Dr. Smith and Ms. Muench.

Human Resource and Compensation Policies

All human resource functions are managed centrally through SMDV, although individual clinic sites retain control over staff hiring and firing decisions. Physician compensation is based on a productivity formula according to professional services billed. Physicians, physician assistants, and nurse practitioners have the ability to earn additional compensation through a Dean Health Plan Physician Incentive Model (PIM). PIM is a pay-for-performance program concentrating, at this time, on diabetic care of Dean Health Plan members.

Conclusions

The Cassville site of the Grant Community Clinic possesses several important characteristics that appear to contribute to patients' satisfaction, such as its small size and a supportive work environment that encourages teamwork. The Cassville site's relative autonomy within the larger SMDV system gives the clinic latitude in making certain decisions about issues such as workflow, yet at the same time enables it to take advantage of important support services provided through the SMDV system.

Nonetheless, the small scale and rural location of the Cassville site entail several challenges. Providing medical services in a rural area with limited patient volumes and growth potential makes it difficult to offer extensive office hours and a broad scope of services to meet the needs of the community. For example, since Cassville is considered a satellite clinic, providers are periodically required to work at the Lancaster clinic. Even though efforts are made to limit this from happening, it has been occurring more frequently (due to the loss of a physician in Lancaster). The concern is that such scheduling changes, which force the clinic to close during normal office hours, will lead patients to choose another clinic. In fact, over the past several years, Cassville has experienced a decrease in patient volumes.

Another major challenge faced by the clinic has been retention of providers. Dr. Smith has been with the clinic for more than 15 years; however, in the past 10 years, the clinic has had five different advance practitioners.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.