Transforming Clinical Practice

Dr. Emil Avanes (second from right), alongside office staffers Kristina Davtyan and Evana Grigorian display Certificates of Achievement for their exemplary outcomes in TCPI, presented by Project Director Kerry Nelson and Sai Vodela, LACare/LAPTN.

There is a dramatic improvement in the way patients with chronic health-related conditions are being monitored and receiving care, and it’s happening in Glendale and surrounding neighborhoods.

Adventist Health Glendale (AHGL) is part of a growing network (Los Angeles Practice Transformation Network) of primary care physicians and clinics working to transform the delivery of care to hundreds of thousands of adult patients.

Through a Medicare-funded grant, the Transforming Clinical Practice Initiative (TCPI) is completing its fourth year. The initiative strengthens the quality of patient care which helps practices spend health care dollars more efficiently, according to Project Director Kerry Nelson. The outcome is better coordination in treating patients with diabetes, depression, mental health, obesity and other chronic health-related conditions.

“TCPI is also benefitting communities by saving millions of dollars in fewer hospital readmissions and a reduction in emergency room visits by chronic users,” Nelson explains, “but the most important beneficiaries are the patients themselves — they’re leading healthier lives!”

At-risk patients are routinely engaged and undergo periodic assessments for key health-trend indicators, and their data is maintained in electronic medical records (EMR). The practice team then generates comprehensive reports which are reviewed regularly for any changes.

“What’s the old saying? ‘If you can’t measure it, you can’t manage it,’” says Emil Avanes, MD, one of about 16 medical practices and 24 AHGL physicians whose practices are participating in the project. “The most important thing is that it keeps us monitoring our patients in the same categories. By measuring the numbers, it indicates whether modifications are needed for improvements.”

Each of the 16 participating practices has recently been designated by Medicare as a “Medicare Exemplary Practice,” and the initiative’s process has become a model for other practices in communities across the U.S.

Dr. Edmund Lew (right), Lew Medical, and members of his staff also are TCPI honorees.