NW Family Physician staffNorthwest Family Physicians staff members, including clinic administrator Heather Steinert (third from left).WICHITA—Patient-centered communication helps improve health outcomes. At Northwest Family Physicians, patient-centered communication has led to nearly all of their diabetic patients bringing their condition under control, said clinic administrator Heather Steinert.

"Now we have a very small percentage of diabetics who are over 9 (not under control). I can think of only three patients currently—and that's fantastic," Steinert said, noting the clinic has more than 2,000 diabetic patients.

However, getting there took time, she said. “It's been a long journey. This isn’t something we established overnight. We have been working on this for more than nine years, since we started working to become a PCMH (Patient-Centered Medical Home).”

Part of that journey was working to help the clinic’s diabetic patients to more faithfully follow their physician’s guidance.

Performance Story Snapshot
Northwest Family Physicians, Wichita

  • How many patients do you care for? 30,000 active patients.
  • What is a subgroup of patients that have seen significant improvement in outcomes? About 2,000 of our patients have diabetes.
  • The performance measure for this sub-group; and the standard for it: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%). The 2018 CMS Benchmark Average for Claims, EHR, and Registry/QCDR was 22%, 49.4%, and 34.8% respectively. Note: this is a reverse measure.
  • What has been the practice's performance?

2018 Quarter 1 : 71.37%
2018 Quarter 2 : 62.84%
2018 Quarter 3 : 40.94%
2018 Quarter 4 : 38.39%

Source: FIGmd

  • How exceptional is this performance?

“[We started with] better communication with patients—following up with them more. We developed a tracking system and implemented care coordinators. By just communicating with the patients better, giving them encouragement, and giving them a diet plan to follow, it’s made a big difference.”

“Patients are more likely to follow guidance when they understand what is going on,” she said. “Essentially we just started better communication with patients—following up with them more. We developed a tracking system and implemented care coordinators.”

“By just communicating with the patients better, giving them encouragement, and giving them a diet plan to follow, it’s made a big difference,” Steinert said.

Northwest Family Physicians has been recognized as a “Pinnacle Practice,” one of just five physician organizations in Kansas to receive the distinction in 2019, which comes with a $12,000 award.

Pinnacle Practices have excelled in efforts to steadily improve health care quality, safety, and value with patient-centered, evidence-based interventions. For example, they have employed person and family engagement, encouraging the patient and their family to partner with the medical staff in their care. Pinnacle Practices also have incorporated additional quality metrics and utilization metrics for national comparison and evaluation.

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Northwest Family Physicians also improved proactive communication beyond its diabetic patients by “closing the referral loop,” said Steinert. Typically, when a patient is referred to a specialist, a follow-up appointment is scheduled with their primary care physician to discuss the specialist’s notes.

NW Family Physician staffNorthwest Family Physician staff members, including clinic administrator Heather Steinert (far right).

“Before we had a structure in place, it could be very frustrating because you didn't necessarily get those notes back from the specialist. Being proactive makes the process much more efficient,” she said.

Steinert said working toward the many comparable goals of being a Patient-Centered Medical Home has been aided by the clinic’s partnership with the Kansas Healthcare Collaborative (KHC) and their KHC Quality Improvement Advisor, Mandy Johnson.

“Working with the KHC has been great because it has kept us on track and kept us accountable. It’s easy to get distracted from keeping the practice on task with the goals of our PCMH. But every month I meet with my quality improvement advisor and we review where we’re at and where our goals are,” Steinert said. “We’re an independent practice but this gives me somebody to be accountable.”

2019 Kansas
Pinnacle Practices

Read more about each practice:

Dr. Bradley BarrettDr. Bradley Barrett, Neodesha


Hiawatha Community Hospital Family ClinicHiawatha Community Hospital Family Practice Clinic


Horizons Mental Health CenterHorizons Mental Health Center, Hutchinson


NW Family PhysiciansNorthwest Family Physicians, Wichita


Women's Health CenterWomen’s Health Center, Chanute


• • •

Northwest Family Physicians is among 180 practices in the Kansas Practice Transformation Network (PTN), which is administered by KHC and awarded the distinction.

Rosanne Rutkowski, Program Director at KHC, said the Pinnacle Practices exemplify—each in their way—scalable successes in improving health care quality, safety, and value.

“Northwest Family Physicians and our state’s other Pinnacle Practices are among the leaders in Kansas working on patient-centered initiatives that improve quality, safety, and value,” Rutkowski said. “Their experience is scalable and worth emulating.”

The Kansas PTN is part of a regional network called Compass PTN, which is one of 29 regional PTNs nationwide. Together they are part of the Transforming Clinical Practice initiative (TCPi), a program of the federal Centers for Medicare & Medicaid Services aimed at:

  • Promoting broad payment and practice reform in primary care and specialty care;
  • Promoting care coordination between providers of services and suppliers;
  • Establishing community-based health teams to support chronic care management; and
  • Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation.

PTNs are peer-based learning networks designed to mentor and assist practices in improvement in the broad areas. A “Pinnacle Practice” is among the top 5% of enrolled practices based on reporting and phase progression.

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Founded in 2008 by the Kansas Hospital Association and the Kansas Medical Society, KHC embodies the commitment of these two provider groups to act as a resource and continuously enhance the quality of care provided to Kansans. For more information visit KHConline.org/clinical-quality-improvement.