Practice Innovation Q&A

Stephen Tierney, MD

Southcentral Foundation Anchorage Native Primary Care Center, Anchorage, Alaska
PCMH Components: Integrated Team-based Care, Same-day Visits and Patient Access to Phone/Email/Text

Q. Describe your practice or clinic.

Dr. Tierney: Southcentral Foundation provides full spectrum primary care from cradle to grave. It is part of the Alaska Native Medical Center campus and is the PCMH component paired with an acute care community hospital on the same campus.

Q. Describe your community.

Dr. Tierney: We are the primary source of care for the Alaska Native/American Indian community in Anchorage, AK, and the surrounding areas. We act as a multidisciplinary specialty practice that includes a PCMH but also has OB/GYN, complementary and alternative medicine, health education, behavioral health, dental, and optometry.

Q. What led you to work on innovation in your practice?

Dr. Tierney: We were using the emergency room for our same-day access and the resultant high admission rates and costs drove change. There was also a lot of provider dissatisfaction, as in “I never see my own panel of patients.”

Q. Give us specific examples of 1-2 innovations the clinic incorporated that provided positive outcomes for both the patient and the physician.

Dr. Tierney: Adding an RN case manager position for every primary care physician and having an in-clinic integrated behavioral health specialist for every four to five PCP teams. This allowed providers to comfortably shift work of office visits onto a trusted colleague assigned to them and also allowed for the immediate referral and evaluation of mental health problems with same-day, direct feedback to the referring provider.

Q. Give examples of how a patient-centered approach has changed your motivation and enthusiasm for primary care practice.

Dr. Tierney: Sustainability of treatment plans goes way up when you adjust your medical interventions to the life context of the people you serve. While they might now always want to do exactly as you would chose, they are far more likely to continue a co-created approach. At least you know what the plan/expectations are for the patients you serve.

Q. What surprised you most about your patient involvement in patient-centered care?

Dr. Tierney: Believe it or not, patients most often opt for less invasive, less costly and leaner interventions. When asked, “What is it you need from me?” the answer is invariably, “Just tell me I am going to be OK and this is not a really bad thing.” We often answer questions that are not asked in health care with overdesigned interventions or work ups. This shortens my day.

Q. Tell us a story about how you and your staff approached patient-centered care.

Dr. Tierney: Twelve years ago we changed to a same-day access system. This meant you could schedule an appointment literally every day with your primary care provider or team. While over 95 percent never did this, and did not alter their traditional use of health care resources, suddenly the top five percent of utilizers were in the clinic multiple times per month. We liked that same-day access had dramatically cut our ER visit rate and hospitalization rate so we were not rushing to abandon the approach, but something clearly had to be done. We started experimenting with “ways other than visits” to connect with this top five percent. We changed our business cards to reflect all four members of our integrated care teams (the provider, RN case manager, medical assistant, and clerical assistant). We put email and voicemail on the card for all, and cell phones/text for the RN case manager and provider. We encouraged patients to “get in touch when you have questions, do not immediately call the front desk” (who will just book an appointment). We found that many times patients simply wanted to ask basic questions for advice, or just reassurance. These previously burdensome appointments were now shifted to email/text/phone. When offered rapid connection to the PCP team, the complexity of questions/problems dropped. Previously, if forced to come in, they would pile on lots of other issues. We sharply dropped recurrent wasteful visits.

Q. What would/do you tell an undecided medical student who is considering family medicine about the new model of care and the future of primary care/family medicine practice?

Dr. Tierney: “Primary care” right now is a rapidly changing concept. The range of how this discipline is executed in the real world is so rapidly moving that it will be about 10 years before it really redefines itself. All that said, it is also the highest growth area, with the most dynamic change in medicine. If you like being on the leading edge, if you enjoy destroying all prior premises with a chance at real radical innovation, this is the place to be. In the next 10 years, it will be primary care that integrates social media, virtual relationships in health care, and population health together in ways that will completely redefine the rest of the industry. If you think of yourself as an innovator, this is the ONLY place to be right now.

Joseph M. Kim, MD

Quincy Family Medicine Residency Program, Quincy, Illinois
PCMH Components: Evidence-based Medicine, Team-based Care, Same-day Access

Q. Describe your practice or clinic.

Dr. Kim: We have the “Office of the Future” at the Quincy Family Medicine Residency (QFMR) Program. The goal is to utilize everyone to the top of their license. The number of innovations we put in place include: scribing, co-location of physicians and staff, and a morning huddle. Incorporation of these innovations allows the “Office of the Future” to function more efficiently with greater satisfaction from patients, staff and clinicians.

Q. Describe your community.

Dr. Kim: We are small, rural city in southern Illinois with a population of 50,000. However, we draw patients from a 50 mile radius. The practice and new innovations serve the community well because we are a rural health clinic and see many underserved patients.

Q. What led you to work on innovation in your practice?

Dr. Kim: The QFMR was looking for innovations to change the way we serve our patient base in a more efficient way without sacrificing quality. Extra space became available next to our practice. This provided an excellent opportunity to design the “Office of the Future” from the ground up.

Q. Give us specific examples of 1-2 innovations the clinic incorporated that provided positive outcomes for both the patient and the physician.

Dr. Kim: First, the practice employs medical assistants to act as scribes during clinical encounters. This allows the clinician to stop constantly referring to the computer and helps establish a stronger patient-physician relationship. Furthermore, the documentation is done in real time, alleviating further time spent on documentation by physicians. Second, the medical assistants also work at the top of license by being “health coaches” for patients. They are trained to educate the patients on healthy lifestyle choices and chronic disease management (e.g., hypertension, diabetes, etc.).

Q. Give examples of how a patient-centered approach has changed your motivation and enthusiasm for primary care practice
.

Dr. Kim: QFMR is certified as level 1 NCQA PCMH. As we redesigned our practice according to the principles of PCMH, we are able to serve our patients with same-day appointments. The greater access to physicians alleviates the needs of patients to visit the emergency room and helps decrease the cost of care.

Q. What surprised you most about your patient involvement in patient-centered care?

Dr. Kim: Each patient brings something unique to the practice. The greater access helps with motivating the patient in lifestyle changes, including smoking, exercise and diet. Often times, it is the patients who will bring these issues and seek the advice on how to change their lifestyle. The patients are more motivated to change and sustain the change within patient-centered care because they are an active participant and partner in their health.

Q. Tell us a story about how you and your staff approached patient-centered care.

Dr. Kim: The entire staff and faculty members at QFMR are champions for PCMH. However, our department chair, Dr. Jerry Kruse (also the president of STFM), is the biggest champion for change and we couldn’t do it without his support.

Q. What would/do you tell an undecided medical student who is considering family medicine about the new model of care and the future of primary care/family medicine practice?

Dr. Kim: There will be many changes coming to family medicine, and primary care in general. The changes are designed to help transform how primary care is practiced in the U.S., which in turn will improve the health status of your community and the nation. We sincerely believe that this is the only way to change the health of the nation. Furthermore, primary care is getting the recognition, importance and fiscal boost it deserves. This is going to be a great decade to be a primary care physician.

Peter Anderson, MD

President, Team Care Medicine
Retired: Hilton Family Practice in Newport News, Virginia
PCMH Components: Quality Measures, Team-Based Care and Patient Engagement

Q. How long have you been a family physician?

Dr. Anderson: I started a solo practice in family medicine in 1982 in Newport News, Virginia.

Q. Do you have any additional training?

Dr. Anderson: I completed a one-year fellowship of ambulatory medicine at the University of Virginia.

Q. Describe your practice or clinic. How did it originate? What is its scope of care?

Dr. Anderson: I started a solo private practice in a suburb of a small city in 1982. I treated all typical patients. I delivered babies and saw adolescents for 10 years. My patient population grew older as I did.

Q. What led you to work on innovation in your practice?

Dr. Anderson: In 2003, after about 20 years of successful practice, I realized my practice was drowning. That year I was about $80,000 in the red, I was working 10 to 14 hours per day, and my patients were always frustrated because I was never available to them. My staff was stressed out. I hated medicine, and worst of all I had become a ghost to my wife. Because I was too old to try a different profession, I decided to try a different way to deliver primary care.

Q. Give us specific examples of 1-2 innovations the clinic incorporated that provided positive outcomes for both the patient and the physician.

Dr. Anderson: The innovation that was a game changer for me, the nurses, and our patients was teaching my nurses to collect and document all of the patient’s current and relevant medical data needed to accomplish a successful patient visit. The efforts of 1) collecting all the relevant medical data and 2) documenting the entire patient visit led to a dramatic transformation of my medical practice. The quality of our care became the highest I had ever produced. When I resigned, our HEDIS measures were in the national 90 percent of excellence for colorectal screening, mammogram rates, all 9 of 9 benchmarks for diabetic care, and hypertension goals. Our patient satisfaction was one of the highest because we could see ALL our patients when they needed to be seen. Our collections rose by more than $200,000 per year because I was free to see so many more of my patients. My workday dropped back to 8 to 10 hours per day. I loved medicine again, and my wife and I had free time.

Q. Give examples of how a patient-centered approach has changed your motivation and enthusiasm for primary care practice.

Dr. Anderson: Being able to give patients both the quality of care they need and the availability of this care from their familiar provider created real joy again in the practice of primary care. In 2003, the doctor-patient relationships were just about gone because the patients had learned that I most likely would not be available when they needed me. It is amazing to realize that teaching my nurses these skills literally restored the doctor-patient relationship for me and my patient panel (which was 3500).

Q. What surprised you most about your patient involvement in patient-centered care?

Dr. Anderson: As patients learned to trust our office again, the pleasure they had and the patient compliance that the relationship generated caused the atmosphere in the office to change. The frustration that was so prevalent in early 2000 was replaced by fulfillment.

Q. Tell us a story about how you and your staff approached patient-centered care.

Dr. Anderson: In 2003, one of my nurses of 20 years told me she was going to have to go back to the hospital because her son was going to college and she needed more money – that was the straw that broke the camel’s back. I could not afford to depend on another nurse, so I talked her into staying and trying this new idea. We all realized the system we were using in 2003 was desperately broken, making the buy-in fairly easy for my team after the decision to change was made.

Q. What would/do you tell an undecided medical student who is considering family medicine about the new model of care and the future of primary care/family medicine practice?

Dr. Anderson: This is the best time to be in family medicine in the history of our discipline. As primary care is rebuilt, it will become the backbone of our health care system again. When I said good-bye to my patients the last quarter of 2011, I realized by being in primary care, I had been given the best medicine has to offer. Twenty- to thirty-year relationships are the treasure of primary care. No other field of medicine can create this so frequently. It was very hard to say goodbye for both me and my patients, and for that I am deeply grateful!