Northwell Health

JoAnne Gottridge, M.D., Northwell Health

JoAnne Gottridge

Patient-Centered Medical Homes

Editors’ Note

Dr. JoAnne Gottridge completed her internal medicine residency in 1983 at North Shore University Hospital (NSUH) and has remained with the health system ever since. Most recently, she served as executive vice chair of the Department of Medicine at NSUH and Long Island Jewish Medical Center. She was also the division chief of general internal medicine in the Department of Medicine and program director of NSUH’s Internal Medicine Residency Program from 2002 to 2008. She earned her bachelor’s and medical degrees from Case Western Reserve University in Ohio.

Would you describe your key areas of focus at Northwell Health?

Two years ago, we were asked to put a team together to direct and oversee patient-centered medical homes transformation for our service line. A lot has been accomplished in two years.

For 40 primary care practices, which include a dozen pediatric sites, we have been moving forward to complete a multisite application to the NCQA (National Committee for Quality Assurance) for level 3 patient-centered medical home recognition.

Primary care is the bedrock of any highly functioning, integrated healthcare delivery system. It is the first point of entry for most patients.

Responsibility for promoting health and wellness, optimally managing chronic illness and helping people maintain a good quality of life and prevent unnecessary hospitalizations, lies with primary care.

Our development of a large network of practices has occurred over a relatively short period of time. We took the opportunity to look at patient-centered medical home application as a way to bring some standardization for workflows, processes, and quality across the expanse of our primary care network.

The criteria that must be met in order to be designated a patient-centered medical home are important, and we used the opportunity to leverage many other parts of the organization to get needed support. This includes major IT initiatives.

We have developed enhancements to the IT platform for primary care with the team. We developed a whole series of new notes to make it easier to document and capture data.

We developed clinical snapshots, which give a quick view of how patients are doing and whether they’re meeting metrics or not.

We’ve enhanced interoperability between inpatient and ambulatory EMRs (electronic medical records) and are undertaking the development of a major data registry for primary care.

We’ve also worked closely to integrate behavioral health into our primary care practices, for which we’ve had a lot of support.