Health care leaders in South Central Pennsylvania are turning patients into partners in their own care, taking them behind the scenes at local medical practices to get their insights on how to create a better health care system. Participating patients work with medical practices as advisers, consultants, and collaborators, with the hopes that their insights will improve relationships, raise engagement, and even lift clinical outcomes. Participating patients report higher levels of “activation” than other practices, while medical practices are getting unique feedback into how to improve the way they deliver care. There are now 65 patient partners working with medical groups in the area, with 11 more in training. Eventually, if every practice recruits two patient partners, there will be around 100 in total. And there could be room for even more.

"I see them as giving us a window into our practice," said Whitney Almquist, business manager at the White Rose Family Practice in South Central Pennsylvania. 

Effective handoffs help to reduce medical errors that may result from miscommunication. Many physicians, nurses, and other providers are involved in a patient’s care, so effective communication is critical. AF4Q South Central Pennsylvania’s Nurses Council initiated a pilot project in 2012 to enhance communication during handoffs in which hospitals and skilled nursing facilities adopted a modified version of a communication technique called SBART (which stands for Situation-Background-Assessment-Recommendation-Teach-Back). SBART standardizes the information that should be communicated about a patient’s condition during any interaction between clinicians. It also includes a “teach back” component in which the recipients of information are expected to repeat the information they just learned in their own words to demonstrate they understood it.

“Super-utilizers” account for only five percent of patients, but they accrue more than 60 percent of health care costs. These patients make frequent trips to hospital emergency rooms or have repeated inpatient hospital stays, resulting in costly health care, but not necessarily good-quality care. Super-utilizers often have multiple chronic medical conditions and social complexities that make their care difficult in a fragmented care setting.

AF4Q South Central Pennsylvania wanted better for area patients. Clearly, emergency room visits for acute episodes would not address the larger issues that repeat visitors face. By enhancing primary care, emergency room overuse and costs would decrease. AF4Q South Central Pennsylvania also aims to improve the quality of care and reduce re-hospitalizations. Since beginning the super-utilizer initiative in 2013, Wellspan Medical Group has enrolled 40 patients. For these 40 patients, average monthly hospital charges have decreased by 60 percent. Inpatient event frequencies have decreased by 74 percent.