This article was published in our 2015 Annual Report.
Dr. Milt Fowler and physician assistant Leslie Osterman
For Dr. Milt Fowler and physician assistant Leslie Osterman, teamwork is the key to continuity of care.
Dr. Milt Fowler had just completed his residency when he arrived at Gifford in 1976.
He and his wife were eager to leave the city and wanted to be part of a small community.
He’s still practicing at Gifford forty years later, and now he faces another major life transition: easing into retirement.
“I’m having a hard time cutting back. I’ve known some of my patients for 35 or 40 years,” he said. “There’s a deep richness and joy in practicing primary care in a small community. Once you’ve shut the door on the chaos and paperwork and sit to connect with a patient, the office is like a sacred space.”
Providers at Gifford often say that an ongoing patient relationship is the most satisfying part of their work. For family physicians, the bonds can grow especially strong: it is not unusual for long-time primary care physicians to have treated several generations in a single family.
“I see my role as being a positive influence, someone a patient can come to for help—not just with medicine, but with other issues as well,” said Dr. Ken Borie, who has been practicing family medicine at Gifford since 1980. “Family doctors can build trust in ways a specialist can’t. That’s what’s valuable about being a primary care physician—it’s one of the intangibles that you can’t put a price on.”
Across the country a shortage of primary care physicians is forcing rural community hospitals like Gifford to look for alternatives to this traditional model. As a generation of long-time physicians starts to retire, fewer new providers choose a career in primary care.
Many factors have contributed to this shortage: primary care pays less than other fields and many medical students, burdened with student debt, specialize in other areas. Those who do practice primary care are in demand, and are much more mobile than the providers who settled in Randolph years ago. Rural communities are especially hard hit, since salaries are much higher in urban areas.
To respond to this primary care recruitment challenge, Gifford has implemented a team model, often pairing a physician with a physician assistant or nurse practitioner. These healthcare professionals have been specially trained to diagnose and treat a variety of conditions, prescribe medication, order and interpret tests, counsel, and manage patient care.
Fowler works closely with Physician Assistant-Certified, Leslie Osterman. The arrangement shortens a patient’s waiting time for appointments, but also helps to make sure that patients have quality time with a provider during visits.
“There are not enough MD/DO’s to care for everybody—we have to find new models,” said Fowler. “Leslie and I work really well together. She’s taken over much of the acute care and the preventive and health maintenance visits like annual physicals and cancer screenings. I tend to manage care for patients with more complicated needs.”
Osterman previously worked as a respiratory therapist but found she wanted to be more involved in patient care. She saw that the physician assistants she worked with could focus on preventative medicine, and shared knowledge and decision-making as a team. She returned to school, received a Masters of Physician Assistant studies from Franklin Pierce University (she completed three of her nine rotations at Gifford), and came to practice at Gifford in 2015.
“Milt introduces me to his long-time patients and they see us working together. If their next appointment is with me, I won’t be some random person they haven’t seen before,” said Osterman. “Continuity of care is really important to people.”
The new team model increases patient access to primary care professionals while preserving a quality provider/patient relationship. Like the long-term providers they work with, physician assistants and nurse practitioners say they specifically chose their roles because they wanted to build ongoing connections with patients.
“I trained as a physician assistant because I had seen that many doctors weren’t able to spend extra time with patients discussing concerns or preventive care,” said Osterman. “Sometimes patients need extra time for education or explanations, and I wanted to help fill this need.”
The following article appeared in our 2014 Annual Report.
Dr. Martin Johns
One evening when I was on duty, a 911-call patient was brought into the emergency room. The patient was unresponsive and unable to communicate.
I pulled up the electronic medical record and was able to see that he had been given a new medication when seen at a Gifford clinic earlier that day.
Clearly he was having a delayed allergic reaction, and because I could see exactly what medication he was given, I could immediately give him the appropriate antidote. If I had not had access to the information in EMR, I would have had to guess and start trying different medicines to counteract the reaction.
When another patient was confused about what medications they were taking, I pulled up their most immediate office note on EMR and made adjustments based on what had been done within the previous 24-hour period.
An important aspect of the new EMR system is that it allows medical information to follow the patient through transitions of care across all Gifford platforms: inpatient care, outpatient care in community clinics, radiology, and emergency room visits.
In the past, important information could be unavailable or even lost during these transitions—a clinic might be closed for the day, or important information not yet added to a patient’s record. Now, anyone caring for a patient can view important information and also update the record (adding a newly developed allergy or immunization) or note changes in clinical status.
The following article appeared in our 2014 Annual Report.
Gifford completes its upgrade to electronic medical records (EMR). Throughout the year, Gifford primary care and specialty care outpatient practices moved from paper to electronic records as part of a federal initiative.
Gifford and the White River Valley Chamber of Commerce collaborate to hold the only local candidates’ debate for Senate and House of Representatives candidates.
Gifford employee Teresa Bradley and her niece, Krista Warner, once again hold a bowling tournament in memory of Teresa’s mom and Krista’s grandmother, Ruth Brown. Money raised supports Gifford’s Woman to Woman Fund and brings awareness to the importance of mammograms.
Gifford announces it has met its state-approved operating margin for the 15th consecutive year.
Gifford loses one of the greatest heroes of our time, Major Melvin McLaughlin. Affectionately known as “the Major” and “Major Mac,” he spent the last 40 years volunteering at the hospital, encouraging staff and patients with words of love and friendship. He will be greatly missed, but never forgotten.
Hannaford Supermarket in South Barre presented Project Independence with a gift certificate worth $1,500. The gift is used to offset the cost of groceries for the program which provides a daily breakfast, lunch, and snack for roughly 38 participants. When the store manager asked staff which nonprofit they should contribute to, the adult day program was at the top of their list.
Pediatrician Dr. Lou DiNicola receives the Green Mountain Pediatrician Award from the American Academy of Pediatrics Vermont Chapter. He was acknowledged for over 38 years of service as a Gifford pediatrician. Along with a plaque, Dr. DiNicola was presented a 7-foot-long handwritten scroll describing what makes him special.
Gifford once again invests $40,000 into the regional economy through the Gifford Gift Certificate program.
The following article appeared in our 2014 Annual Report.
Flashback to March 2014. Gifford’s switch to electronic medical records, the industry standard, has been in the works for a couple of years. The challenge: To complete the transition before spring 2015, when government penalties are due to kick in. For the shift to occur, providers—doctors and other medical professionals—will have to learn to use the system. This learning will be put to the test in front of patients. A prevailing sentiment: “I was really hoping I’d retire before we got around to doing this.”
“EMR came out of the Affordable Care Act as a sort of a mandate for us,” says Gifford Administrator Joe Woodin. “We had some electronic files and file management in the past, as many hospitals do, but now there’s a clear mandate of completing that loop, and the government has given us economic incentives to do it, as well as economic penalties if we don’t. So like every other hospital in the country, we’ve been passionately working on this for a couple of years.”
When we think of doctors, we think of clipboards and script pads and cheap ballpoint pens. We think of scrawly handwriting. With the shift to EMR, doctors who were used to scribbling notes on charts and sending them to medical transcriptionists were being asked to give up those tools and plug in the data electronically. VP of Finance Jeff Hebert likens the task to mastering Excel when you’ve been doing spreadsheets by hand for years.
“To add more complexity,” says Hebert, “the product was a brand-new one for our hospital vendor; they redesigned it and we were the first to be going live with it. So in addition to my Excel analogy going on with our providers, CPSI was introducing us to a product that they weren’t that familiar with because they had just created it.” Across the health-care system, a piecemeal electronic infrastructure that lacks standardization—unlike, say, the banking system—did nothing to make the task easier.
By March, pediatrics was trained and ready to go. The first wave of physicians began walking into exam rooms hugging their new laptops. Office visits slowed.
“A lot of organizations have found that transitioning to EMR affects their productivity and some of their morale,” says Woodin. “It asks a lot of the providers and the patients. The challenge would be equivalent to going metric or if you were asked to speak a different language.”
Over the summer, primary care joined the campaign. Neurology, surgery, and other specialists stepped up in the fall.
Meanwhile, providers and patients were starting to experience the benefits of the new system.
“Electronic medical records will allow our organization to be fully integrated across the continuum of care, from inpatient to outpatient to pharmacy—the whole thing. And it’s going to allow us to better care for you. If you walk into the ER and you’re a patient in our Bethel clinic, the ER can pull up your record from this morning—it’s already there,” says Rebecca O’Berry, vice president of operations and the surgical division.
“So if you’re a poor historian—meaning, for instance, that you can’t remember what pills you take or whether you’ve had your gall bladder out—or you just know that you saw somebody today and you still don’t feel well, they can pull it up, whereas before we had nothing. If it’s seven o’clock at night, you can’t call Bethel and say, ‘Hey, I need you to pull this record and read to me what happened.’ There’s no delay, no lag time waiting for dictation. For somebody who has had care and needs more care within the next day or two of their last visit, everything’s there, and that’s the beauty of it.”
By the end of the year, providers were settling into their new routine and at least some of the kinks had been worked out of the new system.
“We’ve done a good job,” said Woodin. “We’re working through it. There are always improvements to be made.”
The following is an excerpt from our 2013 Annual Report: A Recipe for Success.
This has been another successful year for Gifford, and it is due to our continued ability to take care of so many different patients, from so many different communities. Ultimately that is our mission and focus, and for me constitutes our Recipe for Success. We continue to offer treatment and services over a wide geography, and “how” we do that is as important as “what” we do. We strive to bring personal attention into the clinical delivery system through relationships and flexibility. Sometimes we do these things very well, and sometimes we learn and grow from our experiences and shortcomings. In all instances we are indebted to the many communities and friends who utilize us and give us feedback and support.
A Gallon of Leadership
This has also been a year marked with stress over health care reform and the roll-out of both a national and state-wide insurance product (i.e. Vermont Health Connect). Although the state has done a better job than the federal government in implementing the insurance exchange, there is still much uncertainly about these new programs, with people looking for answers and assurance that this is the “right direction.” That uncertainty, however, does not find its way into our planning for the future. Gifford has always relied upon a simple understanding that if we focus on patient care, quality and insuring access to everyone, regardless of their ability to pay, we will be successful. Maybe it’s that three-ingredient recipe that has helped sustain us over these past 110 years (since our founding in 1903). While others are employing sophisticated forecasting techniques and prediction models, we are just trying our best to be your medical home and guide.
I hope you enjoy this report, and the many stories that highlight our efforts this past year. We are grateful for the legacy we have inherited, and continue to build upon that
success each and every year.
The deadline to sign-up for health insurance through the state’s new online marketplace – Vermont Health Connect – is March 15.
To help more of this region’s residents meet the deadline, Gifford Medical Center has organized two special days – March 6 and March 13 from 9 a.m. to 4 p.m. – when extra “navigators” will be available to help people sign-up for insurance.
On hand will be navigators from Gifford’s Blueprint for Health team, Gifford’s Health Connections office (which is part of the Vermont Coalition of Clinics for the Uninsured), and from Bi-State Primary Care.
“For those who haven’t already signed up, the deadline is looming, meaning people must act now. We have been signing people up for months and will continue to do so until the deadline, but wanted to make this extra push to help those who haven’t yet chosen an insurance plan,” said Health Connections caseworker Michele Packard.
For Vermonters not offered insurance through their employer, Vermont Health Connect is how insurance is now sold in the state. This includes Vermonters who:
do not have health insurance;
currently purchase insurance for themselves;
have Catamount or Vermont Health Access Program; or
are offered “unaffordable” coverage by their employers.
Signing up for health insurance is a requirement under federal health care reform efforts. Those who do not sign up may face a federal tax penalty.
Appointments at Gifford’s special March 6 and 13 events are preferred, but walk-ins are welcome. Call the Health Connections office 728-2323 to sign up for an appointment. On the day of your appointment or when walking in, use the main entrance. Private one-on-one discussions are being held in the primary care doctor’s office area. Look for signs and ask for directions.
Gifford Administrator Joe Woodin wrote the following as an introduction to the 2012 Annual Report, segments of which we’ll be featuring on our blog:
It’s interesting to be working in an industry that continues to be under the microscope of the political process, with people wanting more control over the cost of health care. Frankly it can be a bit exhausting, but I can understand and agree with their concerns.
“What can we afford?” is becoming an uncomfortable theme both locally and nationally; although we can all relate to this in our daily lives when we go shopping for food or services. There are now so many involved in helping to “fix” the health care system that it becomes a daunting task just to stay focused on the basics: providing quality patient care with compassion and kindness.
This report highlights a few of our providers who have remained focused and undistracted by all of the changes in health care. As the years have ticked by, they have not lost their love of the profession, nor have they been dissuaded by all of the changes, paperwork, and new requirements. Their work has become a calling, and they have touched many of our lives when we have been in need of medical help.
The more we try to understand and solve the complicated aspects of health care, the more I am reminded that at the end of the day, there are still patients in beds or in clinic exam rooms awaiting care. They are usually anxious, at times scared or upset, and always hopeful that someone can give them answers and help them through the next step. Our role is to ensure that we have a provider willing to enter into patients’ lives, helping to answer questions and even hold their hand when the news is “not good”.
So regardless of where we end up with “health care reform”, hopefully Gifford will always be there with physicians and staff members who reflect the values of the professionals highlighted in this report. Many things will change moving forward, but unchanged will be our commitment to you and our communities.
RANDOLPH – For more than 40 million Americans, Medicare provides their health insurance. Across the nation and here in Vermont, more Americans become eligible each day, leaving big questions about the federal insurance program and just what it covers.
Gifford Medical Center is aiming to help answer some of those questions for its employees and the public in a free talk this April.
“Medicare – Ready or Not… ” is being held on April 11 from 6-7 p.m. in the Randolph hospital’s Conference Center. The talk will feature a presentation from Acadia Benefits Inc. health insurance specialist Scott McKee on Medicare parts A through D, eligibility and resources. Continue reading →
The following is an excerpt from our 2011 Annual Report.
Information Systems Director Sean Patrick sits amid the old way of keeping patient records – paper files – and the new way to come – electronic medical records updated by providers via new laptops or even iPads.
As lawmakers embark on an ambitious schedule to create a health care exchange required under the federal Patient Protection and Affordable Care Act by 2014 and a Vermont single-payer system by 2017, Gifford is mindful of its role as a community care provider.
The laws seek to bend the health care cost curve, in part through information technology, advanced primary care and payment reform.
Through the implementation of Vermont Blueprint for Health initiatives, Gifford is embarking on reform initiatives including care coordination for the chronically ill and recognition of Gifford’s five primary care practices as Patient-Centered Medical Homes.
The medical center has chosen an electronic medical record (EMR) vendor and is progressing toward both the installation of an EMR system and meeting federal requirements for “meaningful use” of electronic health records (EHRs). EMRs are internal electronic medical records. EHRs can be viewed by appropriate outside entities, including specialists and providers from other hospitals.
Gifford’s modest budget requests and responsible spending also align with reform, notes Trustee Paul Kendall, who actively follows reform legislation.
But the non-profit community medical center is by choice not at the forefront of reform efforts.
Gifford Administrator Joe Woodin likens health care reform to a passing ship. Where others might be quick to jump on – appropriately, the region’s larger health care providers – Gifford is waiting to ensure the medical center commits to the best choice for
Gifford’s size, patients and rural area.
“Gifford is more inclined to stay on the dock and wait for the boat to come around on health care reform,” Joe says. “It takes a lot of fortitude to humbly wait for the boat to make a reiteration.”
“We continue to be watchful of what’s going on and gradually position ourselves to do
what is right and appropriate,” agrees Paul, noting some initiatives like information
technology upgrades can require huge investments of time and financial resources.
Gifford also strives to be a voice in discussions leading up to reform legislation. Leadership is suggesting cost-saving ideas the state could pursue now. They continue to set a standard
for financial stability and maintaining strong relationships with other hospitals, state and federal lawmakers, and health care organizations, like Bi-State Primary Care and the Vermont Association (VAHHS).
VAHHS represents the state’s nonprofit hospitals before lawmakers and the Green Mountain Care Board, which was created by the Legislature in 2011 to oversee the creation of a single payer Vermont system. Bea Grause, VAHHS president and chief executive officer, sees small hospitals’ role in health care reform as one of preserving local access to high-quality care.
“Hospitals are seeking to create reform opportunities by working with the Green Mountain Care Board and federal lawmakers that will balance the need to contain costs with the need to ensure sufficient revenue that will help hospitals meet their local missions,” she says. “Issues such as recruitment and retention of physicians and other health professionals, improving quality, ensuring access and long-term financial sustainability are just a few of the challenges small hospitals will face as Vermont and the entire industry prepare for a decade of continued change on all levels.”
Gifford’s work with Bi-State Primary Care in part addresses the recruitment piece.
Bi-State Primary Care is a nonprofit membership organization of Vermont and New Hampshire rural health care providers working to support primary care practices in medically under-served areas. Its members represent more than 175,000 Vermonters. This equates to one in four residents, or 46 percent of Medicaid enrollees and 52 percent of the state’s uninsured.
The organization is working on Gifford and small, rural primary care practices’ behalf to improve access by recruiting providers to underserved areas. They are also working on health information exchanges and quality improvement initiatives.
The ultimate challenge the state – and likely hospitals by default – will face for successful health care reform, however, will be answering the question: “What can we afford?”
“There are a lot of uncomfortable issues with health care reform that we don’t talk about. The most common issue is ‘what can we afford,’” Joe says, hoping lawmakers will address that question. If they don’t, it will fall on hospitals, which will be given limited funds to provide care. They will have to make tough choices on what care they can afford to
The following is an excerpt from our 2011 Annual Report.
What is a Medical Home?
A medical home is an approach to providing comprehensive primary care that builds partnerships between patients, their physicians and, when appropriate, their families.
The American Academy of Pediatrics was at the forefront of the medical home movement, detailing decades ago that every child needed a place where care was accessible, ongoing, patient and family-centered, of high quality, coordinated, and compassionate.
Today, those philosophies have been expanded to adults as they’ve been adopted by family practice and other health care associations.
In fact, the National Committee for Quality Assurance, a non-profit dedicated to improving health care quality, is now recognizing qualifying medical practices as Patient-Centered Medical Homes.
Bethel Health Center family physician Dr. Terry Cantlin talks with patient Eileen Strickland-Holtham of South Royalton during a routine exam. The Bethel Health Center is one of five Gifford practices recognized as a Patient-Centered Medical Home.
Patient-Centered Medical Homes
Achieving the Patient-Centered Medical Home recognition is part of the Vermont Blueprint for Health’s goals for all primary care providers in the state.
The hope is to improve primary care so patients are getting regular needed care and other supports to maintain their health before facing more costly emergency or inpatient care.
“The medical home adopts a ‘whole person’ approach to primary care, encompassing medical, behavioral and self-management support,” says Gifford Blueprint Project Coordinator LaRae Francis. “It’s the entire health care team wrapping its arms around the patient to provide the support and resources he or she needs to manage his or her health
“It aims to keep people healthier, enhance their quality of life and benefit them financially, both through reduced health care costs and secondary costs such as missed work.”
In 2011, each of Gifford’s primary care practices – the Gifford Health Center at Berlin’s pediatrics practice, the Bethel Health Center, the Chelsea Health Center, Gifford primary care in Randolph and the Rochester Health Center – was recognized as a Patient-Centered Medical Home following inspections by the National Committee for Quality Assurance.
The health centers, which serve a total 21,540 patients, each formed quality improvement teams to address expectations for a Patient-Centered Medical Home, primarily through honing and streamlining systems. Among those expectations, or standards, were access to care, communication, such as through timely callbacks to patients and tracking referrals and tests, such as lab results to ensure they are communicated back to the patient.
The process, says Vice President of Medicine Teresa Voci, allowed the health centers to identify and correct problems. It’s all work done behind the scenes, but also all work that makes care more timely for patients.
Labs, X-rays and referrals to specialists are all now better tracked to ensure the patient and the primary care provider know the results of those exams, notes Chelsea Health Center site manager and nurse Travis Worthen. Providers are also more often meeting with patients to go over results.
And the patient is increasingly a bigger part of the health care team.
“Historically, medicine has always told patients what to do and now medicine is really turning toward engaging the patient in a partnership for health outcomes,” Teresa explains.
Blueprint Project Coordinator LaRae Francis has headed up efforts to implement the Vermont Blueprint for Health at Gifford and in the larger Randolph Health Service Area.
The work doesn’t stop with Gifford.
With the medical center’s primary care locations now all recognized, LaRae, as Blueprint coordinator for the Randolph Health Service Area (a Blueprint-defined area spanning from Randolph to White River Junction), is now looking outside of Gifford. She’s reaching out to White River Family Practice in Wilder and the South Royalton Health Center.
She hopes to help these private health centers also earn the recognition, further improving patient care in our region.