Meeting scorecard measures for effective patient care yields rewards for patients and providers alike but making gains within a high-need population can be a real challenge. Family practice partners Dr. Jonathan Levyn and Dr. John Crawford of Levyn Crawford Medical have developed a noteworthy approach to serving patients in the Kensington and Northeast Philadelphia communities using a blend of well-honed practices and a patient-centered ethos.
Their Kensington practice, part of the Temple Care Integrated Network (TCIN), has scored high in multiple measures of the TCIN scorecard, particularly in the areas of social determinants of health (SDOH). The Network relies on its community-based partners to provide feedback on the strategies and resources that are working to meet the benchmarks of healthcare quality and cost, with the shared goal of better patient results.
Levyn Crawford Medical achieved patient outcomes in 2022 that scored above the average in six categories: The office screened 49.0% of patients for SDOH variables compared to the TCIN average of 17.2%; reported better blood pressure control at 81.8% of patients compared to the average of 56.4%; achieved 62.4% blood sugar control compared to the average of 58.5%; logged 14-day follow-ups after hospital stay at 37.8% compared with the average of 32.8%; and recorded 813 emergency department visits per thousand patients compared with the average of 845.
Whole Patient Approach
Over the years, Drs. Levyn and Crawford have instituted several measures to ensure their patients receive the care they need and are prescribed. As a smaller, privately owned practice, they can be flexible, trying new approaches and iterating constantly to improve practice standards.
The family practice’s holistic approach to patient care begins with staff trained to meet every patient – no matter what they came in for -- with a series of health screenings, including SDOH questions that uncover gaps in food security, housing, transportation, and other key variables. Staff are trained to be sensitive in the way they ask the questions. “Our staff are very careful to have a disclaimer that they don’t mean to be personal or invasive. It helps patients feel comfortable answering questions,” Dr. Levyn says.
Staff Ownership is Key
A motivated and trained staff is vital to success across the program, the physicians say. The staff are the ones who generate lists of patients with a positive SDOH need, contact them, and input information, including their zip code, into FindHelp.org, a help referral system like Temple Care Connect. The software tracks which patients staff referred to which services, as well as which patients utilized the services. If the patient does not connect, staff members follow up to address the need, says Lakisha Sturgis, Director Community Care Management. This level of consistency sets the practice apart and promotes higher rates of compliance.
Securing staff buy-in for the extra work has not been an impediment, says Dr. Levyn. “We let them know that this is a team approach, and their success is our success. We appreciate their efforts, both big and small, in these endeavors. They go into this field with the idea that they want to help people, so we find our staff are motivated to make a call or go through a questionnaire to help people if they need it.”
Patients have been equally receptive to the process, he adds. “Getting a call from us after being in the ER, our patients say they’re glad we called, and we’re pleasantly surprised at how receptive they are.”
Tracking Patient Data
Also key to Levyn Crawfords’ high standard of care are office tools, including Electronic Health Records (EHR) software that tracks patient data, including medical records and the SDOH details that could affect a patient’s health. The EHR helps providers and staff determine when to schedule follow-up calls and visits, when patients are due for routine appointments, and whether patients have followed through with outside health recommendations such as dental care.
“We look at our care gap reports on a monthly basis, and we make the effort to do outreach programs, whether it’s for mammograms, prescriptions, colorectal screenings, or helping them set up GI appointments,” Dr. Levyn says. “We send out dental lists with four or five dentists that they can attempt to reach for themselves or their kids. We continue our efforts even if we’re not necessarily seeing the return that we’d like to see. Our efforts are important to getting our patients the care they need. It never ends. We do this 12 months of the year.”
To ensure proper data tracking and recording, Levyn Crawford Medical is committed to coding client charts in the office—this allows them to ensure that no diagnoses are missed or recorded inaccurately. The providers post CP2R code “cheat sheets” in patient rooms throughout the office for handy reference.
Doubling Down on Key Conditions
The practice leans into preventing or controlling critical health conditions such as diabetes and high blood pressure in several ways. One is by having a diabetic eye scanner in each office. Staff are trained to take the pictures, download, and send them to the ophthalmologist. With this information, the office makes the necessary referrals to specialists and follows up with patients following care.
Similarly, the practice is aggressive about blood pressure control. “If someone is not controlled, they don’t get a three-month appointment, they get a three-week appointment, a two-week appointment -- we need to see them,” says Dr. Crawford.
Going the Extra Mile
Despite the software, assessment tools, and other aids, the bottom line to improving the numbers, the physicians say, is simply hard work and long hours. The practice is committed to seeing patients in a timely manner, even if it means adding hours to the day. They check the daily Temple University Hospital discharge reports to see if any of their patients have been discharged and follow up with them 7 days post-hospital if possible.
“We roll up our sleeves and work extra hard,” Dr. Crawford says. “That’s the only way we’re having success and positive results. We’re doing more and taking on more as providers.”
In addition to individual patient support, the practice takes a community-based approach to health, including hosting a community food drive to which everyone is invited, but for which patients with SDOH needs are particularly targeted, [Leticia last name] says.
The Work Continues
While Levyn Crawford Medical is currently one of the most successful partners within the Network, the practice is determined to reach 100% across the scorecard measures and patient satisfaction. As the Temple Care Integrated Network continues to focus on Population Health, Levyn Crawford Medical will be leading the way.
