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Practice Spotlight: Bergen Geriatric Care

Odessa Hoinkis, MD, Owner


Bergen Geriatric Care is committed to providing patients with high-quality care in a variety of settings, including assisted living facilities and private residences. Based in Oradell, New Jersey, the practice delivers chronic and transitional care management, longitudinal home-based primary care (HBPC), advance care planning, and annual wellness and telehealth services, to more than 400 seniors. In this interview, Odessa Hoinkis, MD, Owner, shares her thoughts on HBPC and its role in helping patients achieve the best quality of life possible.

HCCInform: How would you describe your staffing model?

Hoinkis: We have one full-time and one part-time physician, one full-time and one part-time nurse practitioner, two medical assistants, one registered nurse, and one licensed practical nurse. Our staffing model also includes strong administrative support in the office.

That’s our team — we also have interns rotating in and out, along with a formal network of specialists and consultants on staff in the communities we serve. In addition, we have built an informal consultant network that helps co-manage our patients.

HCCInform: What recent challenges has your practice faced and how have you overcome them?

Hoinkis: The pandemic, of course, has been our biggest challenge as a geriatric practice in terms of the additional workload and the emotional burden. We’re all feeling it — the healthcare world is tired.

But even before COVID, the home-based model was a difficult road to navigate. Assisted living settings are particularly challenging from a logistical standpoint. Every facility has different protocols and mechanisms in place, so we’re constantly looking for ways to streamline how we gather information and communicate — how we can do things more efficiently and level out inconsistencies.

Specific to our practice, we recently switched our EMR system, which created some technology challenges, and there are always staffing issues as well. But we overcome obstacles by pulling together as a team and focusing on maintaining a positive outlook and energy. Being creative and communicating closely have been our best tools.

We are also utilizing technology more than ever. We use HIPAA-compliant teams messaging, email, and e-faxing. And we rely heavily on technology to help us manage patient care when we can’t be onsite. We bought and installed Amazon Echo devices for our facilities and private homes so we could drop in on patients and see what was going on.

One silver lining coming from the pandemic has been increased flexibility in televisits. We started facilitating televisits with specialists, which has provided our patients with increased access to specialist care. Through consultation with HCCI, we learned about the inter-consultation codes that specialists can use to bill for their time, which has helped build up our specialist network.

HCCInform: What makes you especially proud of your practice?

Hoinkis: Our team, hands down. Our team is strong and dedicated, and that’s what makes us special. Every team member — whether administrative, billing, clinical — takes personal ownership of patient care. All team members have a personal connection to the geriatric world, and it shows in their work ethics and dedication to our patients.

The feedback we get from staff, families, and patients is very positive — we often hear that it’s easy to communicate with us, that our staff is warm and caring. Every time I hear that kind of feedback, it makes me proud of what we do.

I am also proud of our clinical outcomes. We are proactive about having meaningful goals of care discussions, which reflects in lower hospitalizations and acute days. Per capita cost is below average, and our vaccination rates are high. Those are objective measures where we score well as a small independent practice.

HCCInform: What are some goals your practice is focused on right now?

Hoinkis: We have big plans! We were just accepted as a Primary Care First practice, so we are very focused on successfully transitioning from a traditional fee-for-service to a value-based system, which is a big shift. It’s exciting and necessary… and it’s also a little nerve wracking. But we’re excited because it supports our vision of providing good quality care while reducing the administrative burden. In addition, we just significantly expanded our home-based program, so building and maintaining that is also a goal we are focused on.

HCCInform: Is there anything else that you want to share with us about your practice?

Hoinkis: One thing that is unique about Bergen Geriatric Care is our large, assisted living patient population. We don’t provide geriatric services in a traditional office setting and limit our subacute patient base. The assisted living setting is a unique area within the long-term care spectrum that requires experience and some skill to navigate because each community is so unique and less standardized. I think we are somewhat specialized in that regard.

HCCInform: Why do you love house calls?

Hoinkis: It is challenging, and it is hard work, but there is so much to love about it. As a physician, I truly appreciate the medical aspect of house calls. Managing complex medical patients, trying to optimize and stabilize them without always having access to all the specialists is professionally challenging but very gratifying when you succeed at it.

And then there is the very personal side of house calls that I love. Caring for frail patients in their home setting, developing the plan of care with them, accompanying them on their whole journey — often through the end of life — is just such a great privilege. It is a very intimate journey, and when someone lets you into that space, it reaches far beyond the professional aspect of the relationship.


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