NRACC Exemplary Practice Profile: Utah Partners for Health

July 19, 2019


Implementing new processes around Chronic Care Management and Annual Wellness Visits has helped Utah Partners for Health get our patients invested and actively involved in managing their health. Making full use of NRACC resources has empowered our practice to establish a strong foundation for providing quality care that considers that unique needs of our patient population.

About the Practice

Utah Partners for Health operates from the community of Midvale, Utah. We are a 501(c)(3) organization and rely on our numerous partners – including community organizations, businesses, churches and individuals – to support us in our mission to provide “compassionate, comprehensive, quality care to empower under-served individuals, families, and communities in a patient-centered medical home.”

Our organization was established in 2002 in response to the growing number of uninsured adults and children in Utah. According to County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation program, 10% of the state’s population is uninsured. To provide services to those in need, we began by partnering with for-profit healthcare clinics, which donate an average of 68% of their customary billings. In addition, we started operating mobile clinics that now work with 32 community-based organizations in our service area of Salt Lake and Tooele counties.

We established our own clinic location, the Utah Partners for Health Mid-Valley Health Clinic, in 2013, and it is staffed by one doctor of osteopathic medicine, two nurse practitioners and two physician assistants, as well as a registered nurse/case manager. The clinic expanded in 2016 to include the Utah Partners for Health Behavioral Health Clinic and the Utah Partners for Health Dental Clinic – which employ a dentist, a hygienist and a licensed clinical social worker – allowing us to provide a full suite of health care services to our patient population.

The majority of our patient population, 64.3%, is Hispanic or Latino (the balance is 23.3% white, 4.0% African American, and the remaining 8.4% is a mix of other races). Our mobile clinics enable us to take medical care to those grappling with cultural, language and transportation barriers, as most of our practitioners are bilingual.

The Utah Partners for Health Mid-Valley Health Clinic is a Federally Qualified Health Center and provides primary health care services for all patients regardless of their ability to pay. We accept Medicaid, Medicare, PCN, CHIP and other health insurance plans. For those under 200% of Federal Poverty Level who can provide proof of income, we offer a discounted sliding fee schedule.

We joined NRACC to enhance our treatment program for chronic diseases and to get our patients actively involved in managing their health. One of our community’s biggest health challenges is controlling diabetes, and we looked to the NRACC for assistance in developing processes that would help us and our patients address associated risks, such as high blood pressure.

The Transformation Process

Our transformation process involved adopting and successfully completing Plan-Do-Study-Act initiatives for Chronic Care Management and Annual Wellness Visits. Our CCM PDSA revolved around care of patients with high Hemoglobin A1c levels. We took the opportunity to enroll with the American Association of Diabetes Educators to leverage their tools and resources to augment our efforts. We developed a comprehensive care program that incorporated educational materials, classes and nutrition information, providing patients with a complete view of how the disease impacts various aspects of their health and how they could take an active role in managing it. For instance, any patient with a high Hemoglobin A1c reading is referred to a diabetic dietitian.

For AWVs, we completed our PDSA and applied the nurse-led model we learned from NRACC. Today, 100% of our visits are conducted with this model, with our nurse facilitating screening and testing. Each month, we establish goals for how many AWVs we want to complete, and we have been meeting our targets. Our AWVs and regular check-ups are an important part of our Transitional Care Management, as we are focusing on providing critical patient education and high-quality care daily to help patients avoid hospital admissions.

We believe that Patient Family Engagement is crucial to positive health outcomes, and we have taken steps to incorporate PFE into our workflows. Although we initially adopted NRACC’s Patient Satisfaction Tablets to survey our population about the quality of their care, we have transitioned to surveying through our patient portal. Approximately 50% of our patients make use of our patient portal, checking on features such as lab results, diagnoses and recommendations, as well as completing patient care surveys. Additionally, our providers are engaged in medication management, working with patients to understand and monitor use of pharmaceuticals. We achieved an approximate 44 percentage point improvement in our documentation of current medication, rising to 62.0% from 17.7%.

Providing Patient-Centered Care

Participating in TCPI has resulted in six improved quality measures and significant cost savings, chief among them from depressing screening and Hemoglobin A1c poor control. We improved our depression screening about 16 percentage points, from 43.8% to 60.1%, and we realized an associated cost savings of $759,979.


As noted, we expanded our practice in 2016 to include behavioral health, and we begin depression screening with age-appropriate tools for patients aged 12 or older. On the date of the encounter, we refer patients to a specialist, either in our practice or in the community, and we follow-up to ensure patients receive care. We have two referral coordinators who connect our patients with the appropriate resources.

We achieved a modest improvement in Hemoglobin A1c poor control, from 48.5% to 45.3%, resulting in cost savings of $9,782. Our comprehensive, patient-centered approach is making a clear impact. For instance, a male Hispanic patient visited the clinic for a physical in November 2018 and was found to have a blood sugar level of 198; a follow-up appointment was scheduled for December, at which time his A1c level was too high for the machine and blood sugar was at 196. He was diagnosed with Diabetes Mellitus, prescribed medication and referred to a case manager, who provided diabetes education encompassing the importance of diet, physical activity and medication. At his January 2019 check-up, the patient had lost 20 pounds, dropped his blood sugar to 102, and reported more energy and motivation to continue improving his health. At a two-month follow-up, his weight was down another seven pounds, and the A1c was at 5.4. He received further education on weight control and was referred internally for eye and dental exams, receiving total care from our clinic’s practitioners.

A well-defined process and plan for treating hypertension has also contributed to quality improvement and cost savings, with controlled blood pressure contributing $6,542 in cost savings. In 2014, we established a goal of having at least 55% of adult patients diagnosed with hypertension achieve a blood pressure reading of less than 140/90. We achieved that goal and continued improving throughout our relationship with NRACC.

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Consistent Application of TCPI Learnings

Once Utah Partners for Health exits TCPI, we will continue to apply our learnings from the NRACC to how we implement and refine new processes and workflows. We are focused on improving population health and will continue to embrace a patient-centered approach that delivers a wholistic plan of action for patients to own with our full support.