Bend Memorial Clinic’s transition to a medical home meant that the physician practice had to expand its focus beyond only treating patients who present at its doors. 


Bend Memorial ClinicA 55-year-old man in good health who hadn’t been to a doctor in more than a decade recently had a colonoscopy performed at Bend Memorial Clinic (BMC), a multispecialty clinic in Bend, Ore. The test revealed that he had Stage 3 colon cancer. During the staging of that cancer, his care team discovered that he also had renal cell carcinoma. Fortunately, both malignancies were caught in time for effective treatment. 

One straightforward preventive screening saved this man’s life—twice. But why did he decide to have a colonoscopy when he hadn’t seen a doctor in 10 years? Because he received a message reminding him about his overdue screening, thanks to the clinic’s commitment to identify and engage patients who were lacking recommended care.

Between April 2012 and March 2013, BMC has contacted almost 95 percent of patients with an identified healthcare gap, such as overdue immunizations, blood pressure or Hba1c readings, and screenings for colon, breast, and cervical cancer. The response among patients has been remarkably high: 87 percent have responded to BMC’s outreach efforts with a confirmed visit.

Bend Memorial Patient Outreach Campaign

Developing a Medical Home for the Community

In 2009, BMC transitioned to managing its population of patients under the patient-centered medical home (PCMH) model. The clinic’s leaders restructured its practice and processes to align with the seven Joint Principles of the Patient Centered Medical Home, developed by four physician associations: 

  • Enhanced access to care: Practices must use systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.
  • A personal physician: Each patient must have an ongoing relationship with a personal physician trained to provide first-contact, continuous, and comprehensive care.
  • Physician-led team-based care: A patient’s personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. 
  • Whole person orientation: The personal physician is responsible for providing all of a patient’s healthcare needs or taking responsibility for appropriately arranging care with other qualified professionals, including acute care, chronic care, preventive services, and end-of-life care.
  • Coordinated and integrated care: The practice must coordinate care across all settings (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public, and private community-based services).
  • Quality and safety: This principle covers a number of requirements such as:
    • Advocating for patients to support the attainment of optimal, patient-centered outcomes
    • Using  evidence-based medicine and clinical decision-support tools to guide decision making
    • Enlisting the active participation by patients in the decision-making process
    • Using IT 
    • Attaining third-party certification of a practice’s patient-centered capabilities
  • Payment reform: Payment to providers must appropriately recognize the added value provided to patients who have a PCMH.

Realigning Patient Focus

The clinic partnered with a local payer, PacificSource to establish an innovative reimbursement model that included traditional fee-for-service payments, a capitated care management fee, and eligibility to participate in bonus pools based on quality metric scores and overall shared savings. 

BMC leaders understood that to succeed in this value-based care arrangement, they needed to expand their focus beyond treating patients who presented at the clinic with symptoms. An integral part of this strategy was to find a better method to help patients stay on track with routine and follow-up care. 

Scaling Patient Communication

With more than 75,000 active patients to track for preventive care, BMC needed a system to help care managers reach their highest-risk patients in a consumer-friendly way that would produce high rates of response.

The clinic used a web-based automated population health management system to mine information from its electronic health record and practice management system to create a patient registry. The registry identifies individuals who have gaps in care, such as missing tests or lab work.

The system then triggers automated outbound communications to patients by phone, email, text message, or a blend of all three. Clinic staff schedule the messages to be sent at a certain time each day. 

Many patients prefer the automated process for routine appointments, and BMC has been able to manage its population without adding dozens of new case managers. 

Planning for the Future

Moving forward, BMC plans to broaden the scope of its outreach program to include specialty areas, such as cardiology and pulmonology. That will improve care coordination for patients who see multiple providers and will, ultimately, result in better quality of care, patient satisfaction, and lower total cost of care.  

M. Sean Rogers, MD, is medical director and compliance officer at Bend Memorial Clinic. 

Publication Date: Monday, January 27, 2014