T.J. Regional Health named among the top tier exemplary practices nationwide in rural healthcare transformation


In 2016, T.J. Regional Health published a Community Needs Assessment and Strategic Implementation Plan that identified five priority health issues — cardiovascular disease, diabetes, obesity, lung cancer, and drug abuse and addiction — and implemented a number of outreach programs and initiatives to address each issue and expand access to care. The results of those efforts have led to a letter of commendation from the Centers for Medicare and Medicaid Services.

“I personally commend your practice for producing significant results in achieving the aims of the Transforming Clinical Practice Initiative (TCPi),” as stated in the letter from Robert Flemming, PhD, director of the initiative from the Centers for Medicare and Medicaid Services. “Due to your superior performance, the National Rural Accountable Care Consortium Transformation Network certifies your practice as a TCPi Exemplary practice.”

Overall, Kentucky ranks 49th among states in America’s Health Rankings by United Health, with poor marks for obesity rate, physical inactivity, smoking and mental health. T.J. Regional Health began working with the National Rural Accountable Care Consortium (NRACC) in 2016.  As a client of NRACC, T.J. staff members were able to take advantage of programs and workshops to assist in reaching newly set goals to improve the five identified health issues.

In order to improve health outcomes, T.J. Regional Health set a primary goal of increasing the rate of Annual Wellness Visits (AWVs). Through education efforts and a heavy focus on improving AWV rates, the number of Annual Well Visits in 2019 have more than tripled from the number of visits in 2018.

The implementation of a Transitional Care Management (TCM) program, has helped to establish a good process to make referrals and close referral loops, with dedicated staff in place to make appointments for patients and perform follow-up calls.

In addition, the establishment of both a Patient Family Advisory Council and a Physician Advisory Council has resulted in involving all departments in quality improvement efforts, helping to incorporate them into the T.J. culture of patient-centered care.

NRACC’s educational outreach opportunities also led to improved measures in breast cancer screenings. By closely inspecting and tweaking processes, improvements were made to workflow and standardized documentation.

Overall, T.J. Regional Health showed significant improvements in quality measures that affect the patient health.  These measures included the documentation of current medications, control of diabetes, control of hypertension, screenings for breast and colon cancer, an increase in pneumonia vaccinations, an increase in tobacco screenings, and an improved number of fall prevention screenings.

A specific goal was set to increase colorectal cancer screenings from 23 percent to 25 percent by July 2018, and a plan was put in place to measure progress quarterly. With focused efforts on education and widespread adoption of the at-home colon cancer test, to date, colorectal screenings more than doubled to 50.8 percent, which is above the national average as compared to other practices.

Also as part of Transforming Clinical Practice Initiative (TCPi), T. J. Regional Health has created a Population Health Team which includes focused efforts on Transitional Care Management, Annual Wellness Visits, and Chronic Care Management.

As part of the Chronic Care Management effort to improve quality of care and health outcomes for diabetic patients, T.J. Regional health has been awarded a grant to utilize for improving diabetic patient education and self-management outcomes. This will be accomplished through a yearlong Diabetic Learning Collaborative (DLC) with University of Kentucky Regional Extension Center.

Francie Shelton, Practice Transformation Manager at NRACC stated, “Congratulations on the tremendous progress you have made during your time enrolled in Transforming Clinical Practice Initiative (TCPi). Your hard work has placed you among the top tier practices with National Rural Accountable Consortium (NRACC) on a nationwide scale.”

T.J. Regional Health, the parent system of multiple healthcare clinics, is anchored by T.J. Samson Community Hospital, a 196-bed acute-care facility with 16 skilled-care beds based in Glasgow that is fully accredited by the Joint Commission, and the T.J. Health Pavilion, which provides outpatient care and physician offices. T.J. Regional Health operates nine Rural Health Clinics in the South Central Kentucky region.


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