Jennifer Robinson

GLASGOW — An initiative launched in 2016 by T.J. Regional Health to improve community health by expanding access to services and encouraging people to be proactive in seeking preventive care has garnered the medical organization national recognition.

The Centers for Medicare and Medicaid Services recently issued a letter of recommendation for T.J. stating the organization's directive, known as the Transforming Clinical Practice Initiative, or TCPi, has received "exemplary" distinction.

“I personally commend your practice for producing significant results in achieving the aims of the Transforming Clinical Practice Initiative (TCPi),” said the letter from Dr. Robert Flemming, 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.”

T.J. targeted five priority health issues — cardiovascular disease, diabetes, obesity, lung cancer and drug abuse and addiction — following its publishing of a community needs assessment in 2016. Jennifer Robinson, director of clinical informatics, CDI and and population health at T.J. Samson Community Hospital, simplified the strategy by comparing it to how most drivers maintain their vehicles.

Instead of waiting until there's a problem, drivers routinely have their vehicles serviced to prevent them from shutting down, she said.

"If you're not getting your body checked with wellness visits, then you could shut down and stop working as well," Robinson said.

For example, if breast cancer is detected at an early state through a regular checkup, a medical team will have a better chance of fighting the disease, which will lead to a better outcome for the patient.

One goal of the 2016 initiative was to increase the rate of annual wellness visits, which are a primary defense for patients when it comes to discovering disease or for learning about health concerns before they worsen.

"We can keep you healthier longer, and if you do have something that's a chronic condition, we can treat it faster and better than if you wait," Robinson said.

T.J. has worked with the National Rural Accountable Care Consortium, or NRACC, for the past three years. The partnership allows T.J. staff members to take part in NRACC training programs that address the health issues the organization identified as priorities in 2016.

"We've really taken it running because we wanted whatever help they could give us to improve our outcome with patients, because our ultimate goal is to make our community healthy," Robinson said.

A major component of the project has been community outreach and education. T.J. has emphasized the need for wellness visits and preventive care.

Another part of the initiative known as the Transitional Care Management 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," a news release issued by T.J. this week said.

T.J. also implemented goals to increase colorectal cancer screenings, established a physician as well as patient-family advisory councils and, through NRACC's educational outreach opportunities, improved measures for breast cancer screenings.

The organization has also launched a chronic care management effort focused on improving health outcomes for diabetic patients. T.J. has received a grant that will allow the organization to partner with the Kentucky Regional Extension Center to help achieve the goal.

There are obstacles to overcome. Transportation for wellness checkups is an issue for some. There's also the continual need for public outreach to ensure people understand the importance of preventive care, which is generally covered by medical insurance at no cost to the patient, Robinson said.

The staff of 10 that's dedicated to population health for T.J. deserve a lot of credit for the improvements that have been made and the initiative goals that have been reached, Robinson emphasized.

"Every one of these people play a very important part in making sure we are successful," she said.

The T.J. administration has been dedicated to achieving the goals of the initiative since it began, which has included staffing employees to address the aim of improving community health, Robinson continued. She specifically thanked T.J.'s chief financial officer, Mei Deng, for her support of the initiative.

NRACC Practice Transformation Manager Francie Shelton congratulated T.J. on its accomplishments in a statement provided in the news release.

"Your hard work has placed you among the top tier practices with NRACC on a nationwide scale," Shelton said.

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