Letter from Dr. John Cruickshank, Chief Medical Officer of Lovelace Health System Regarding Coordinated Care Models and Patient Centered Medical Homes

I want to share with you a few updates pertaining to Lovelace Health System’s continuous efforts towards improving the health of our members and community. We have made significant progress over the past few years and we’ve recently added additional services to ensure access to quality, preventive and timely care. 

For the past two years, Lovelace Health Plan (LHP) has introduced coordinated care models through various innovative programs, as well as partnering with different provider groups around the state to advance Patient Centered Medical Homes (PCMH). Some of the provider groups we have partnered with include First Choice Community Healthcare, Santa Fe Family Health Center, Corazón Family Health, and BCA Medical Associates in Roswell.

These models organize care around the patient, allowing clinical teams to better coordinate and track care. PCMH models provide a central medical “home” for the patient instead of focusing solely on providing episodic care. Offices that adopt PCMH typically have same-day access, extended hours of care, focus heavily on preventive care, want to see their patients for annual well visits and work closely with other providers like pharmacists and dieticians to ensure that all aspects of care are addressed through the medical home.

As part of a coordinated care model, LHP has established a Medicare program that sends providers into the homes of patients that are homebound or too ill to physically see their doctor on a regular basis. This program has improved the quality of care for the most frail and elderly and has eliminated many of their health complications. The providers get a good view of the patient’s living conditions and work with the patients’ primary care physician to ensure appropriate care is delivered. The providers are on-call for the patients so emergency department visits are reduced, thus saving the patient considerable costs. Currently, we have visited more than 4,500 patients, including one-time home assessments.

Another addition LHP recently implemented is state-of-the-art predictive modeling. This program assesses all the patient’s encounter data and identifies opportunities for improvement in care. The system is used to help recognize clinical gaps in care such as mammography or colon cancer screenings. The LHP team reaches out to these members to encourage them to seek services and their primary care physician is also informed for appropriate follow-up.

LHP has also created a very robust medication therapy management program. This program takes information from the patient’s pharmacy prescription history and filters it through a sophisticated decision support tool looking for opportunities for improving care. The program helps to eliminate medication complications, find opportunities for drug cost reductions for the patients, and identifies individuals on critical drugs that are not taking them as often as needed.

Clinicians work with patients’ providers to ensure medications are appropriately coordinated and dispensed. Additionally, our Lovelace Retail Pharmacies call patients who haven’t picked up medications for chronic conditions, such as diabetes, to help improve the patients’ adherence to medication therapy.

As part of expanding our coordinated care model, Lovelace Health System recently purchased Southwest Medical Associates. This acquisition supports a new physician model for Lovelace, a hybrid network of employed and community physicians who work together to provide care. This hybrid model will benefit patients through better coordination of care, improved communication between facilities and providers, and improved patient flow throughout our comprehensive, integrated health system.

Additionally, this week Lovelace Health Plan opened a new coordinated care family clinic called Lovelace Family Health, which is available exclusively to Lovelace Health Plan members. The clinic offers family medical services, health screenings, preventive exams and wellness education. No appointments are needed and walk-ins are accepted. The clinic is located at 101Hospital Loop, NE, Suite 109, and can be reached at 923-4646.

Lovelace Health System is proud to have been chosen by the Centers for Medicare & Medicaid Services (CMS) for a demonstration project, Acute Care Episode (ACE). The selection was based on quality outcomes and efficiencies and affords Medicare beneficiaries, with select orthopedic and cardiac procedures, the ability to share in cost savings. The Heart Hospital of New Mexico at Lovelace Medical Center, Lovelace Medical Center, Lovelace Westside Hospital and Lovelace Women’s Hospital are the only hospitals in New Mexico that were chosen


Dr. John Cruickshank
Chief Medical Officer
Lovelace Health System


For more information on Patient Centered Medical Homes, please visit the National Committee For Quality Assurance at www.ncqa.org.