South Huntington Team-Based Primary Care Practice Marks First Anniversary

Ana Maria Brandao takes patient Dawn Pulley’s blood pressure.

Boston resident Dawn Pulley learned that she had type 2 diabetes when she was just 19 years old. Diabetes runs in her family; her parents and grandparents had it, and two of her three siblings are also diabetic.

"It was different for all of us," said Pulley, who is now 47. "I was a teenager when I found out about it, so it was hard for me to believe. I wasn't paying close attention to it, which, as a result, led to significant health problems for me, even though I knew some of the risks of the disease."

At age 25, Pulley began to take her health more seriously and started going to another hospital for insulin shots. But her health didn't improve, and she eventually suffered a massive stroke at age 40, leaving her paralyzed on one side of her body. 

After her stroke, Pulley continued to receive treatment to manage her diabetes. But it wasn't until last year, when she became a patient at Brigham and Women's Advanced Primary Care Associates, South Huntington, in Jamaica Plain, that Pulley finally began to feel more in control of her health. 

The practice is celebrating its one-year anniversary this month. Created as a "learning laboratory" for team-based care as one component of BW/F's primary care strategic commitments, the South Huntington Avenue practice has seen tremendous growth since it opened its doors, expanding from 500 patients in its first month to roughly 3,300 patients today.

"With the support of the hospital, our goal was to implement a practice that most closely resembled a fully-functioning ‘patient-centered medical home' in order to identify those successful components that we could then ‘export' to our other 13 practices," said Joseph Frolkis, MD, PhD, vice chair of Primary Care. "Even after a year, that investment is showing an impressive return in terms of improved outcomes, patient satisfaction and increased access. The practice has assembled a terrific and committed team that is truly ‘walking the walk' of team-based care."

Pulley, a former special education teacher for Boston Public Schools, says she didn't know the specifics of diabetes until coming to South Huntington. 

"I began seeing Dr. Barnett and Dr. Pollack there, and they took the time to talk with me about it," she said.

In addition to visits with physicians Michael Barnett, MD, and Stuart Pollack, MD, South Huntington's medical director, Pulley's personalized care plan has included sessions with full-time, on-site dietitian Mara Sansevero, RD, CDE, pharmacist Sonia Freitas, PharmD, and social worker Lara Sullivan, MSW, LICSW, who recently helped Pulley get a new wheelchair. 

"My blood glucose levels have been low, and my cholesterol is down," said Pulley, who has monthly appointments at the practice. "I am feeling great. The team continues to provide wonderful care to me. The doctors and other members of the team monitor me every step of the way, and everyone is so friendly. I love them like they're my family."

Pulley is an example of how population management and care coordination have improved outcomes for diabetic patients at the South Huntington practice. The practice has 158 diabetic patients who have been with the care team long enough to have undergone more than one A1C test, which provides information about one's average blood sugar level over a three-month period. Thirty-one percent of the 158 patients had blood sugar levels that were extremely poor upon coming to the practice. When tested three to six months later, that poorly-controlled group fell to 24 percent.

Asaf Bitton MD, MPH, South Huntington's assistant medical director, has been evaluating the implementation of the model as well as health information technology approaches for improving patient engagement and clinical quality, including diabetic patient management. 

"We have seen success in disease management among our diabetic patients at South Huntington in a relatively short period of time," said Bitton. "We are finding that ‘care teams' lead to more personalized approaches to patient care and healthier patient outcomes."

Pollack also believes that the success of the site, and the model in general, lies in its integrated, team-based approach.

"The care is delivered by a team of clinicians all in one place and mixes professions together for synergy and different expert viewpoints," Pollack said. "We find out what's important to each patient; different members of the team get to know different patients well, depending on who the patient builds a relationship with and which member of the team has the knowledge to help the patient do the hard work of managing their own chronic disease. Once you make an investment in people, they really respond and their care improves as a result." 

Pollack added that the site recently began holding group education visits for pre-diabetes and other health conditions, another element of population management that the team hopes to build upon.

The patients are responding. Pollack and practice manager Linda Jo Stern, MPH, say the practice has been scoring in the 90th percentile on patient satisfaction surveys. Many patients did not have a primary care physician before coming to the practice.

"South Huntington was also the highest-rated choice for training among BWH primary care medical residents this year," Stern added.

Looking ahead to year two and beyond, Pollack, Stern and other members of the South Huntington care team expect to see continued growth, as the demand for primary care continues; the practice has the capacity to see 10,000 patients.  

As for Pulley, she plans to keep receiving care from her South Huntington team.

"Since they've been working with me, I feel much better," she said. "I am really grateful to my team there."

Read the Sept. 23, 2011 BWH Bulletin story announcing the opening of Brigham and Women's Advanced Primary Care Associates at BWHPikeNotes.org. For more information about the practice, visit www.brighamandwomens.org/southhuntington.