For July, the Health is Primary(healthisprimary.org) campaign from Family Medicine for America's Health(fmahealth.org) is promoting how critical family medicine and primary care are in fighting chronic disease.
The team at Iora Primary Care's Seattle office meets in a morning huddle each day to discuss patients in the hospital, patients receiving post-acute care and those who have been discharged in the past 30 days.
To support this effort, the campaign developed a chronic disease toolkit for physicians with patient information sheets on hypertension,(healthisprimary.org) diabetes(healthisprimary.org) and heart disease(healthisprimary.org) -- with both English and Spanish versions available.
And when it comes to creative approaches to treating patients with these chronic conditions, Iora Primary Care has come up with some successful solutions.
Its Boston-based parent company Iora Health broke ground in 2010 and quickly expanded -- now operating 29 practices in 11 U.S. markets that serve about 45,000 patients, with plans to double in size in the near future. These practices did away with the fee-for-service payment model and instead cater to a range of businesses that pay a flat fee for their employees to get care, as well as to a large contingent of Medicare beneficiaries.
During an interview at the 2016 World Health Care Congress,(www.youtube.com) Iora Health CEO Rushika Fernandopulle, M.D., called the organization's approach "high-impact, relationship-based care."
- For July, the Health is Primary campaign from Family Medicine for America's Health is promoting how critical family medicine and primary care are in fighting chronic disease.
- To support this effort, the campaign developed a chronic disease toolkit for physicians that includes patient information sheets on hypertension, diabetes and heart disease.
- Iora Primary Care has found success using creative approaches to treating patients with chronic diseases.
"If we want to fix health care, we need to get rid of the transactions and refocus on relationships," he said.
This approach definitely has been driving the care delivered at the three Iora Primary Care-branded practices in the Seattle area, which serve Medicare beneficiaries 65 and older. These patients commonly present with a combination of chronic diseases such as diabetes, hypertension, heart disease, cancer, depression, dementia and arthritis/chronic pain, Carroll Haymon, M.D., medical director of Iora Primary Care's Seattle operation, told AAFP News.
Haymon said a key component to delivering quality chronic care is making sure it's team-based. "And to have a highly functioning team, you need the tools to help (team members) function well," she added.
Head Start With Huddles
One of the tools Iora Primary Care staff members use is meeting first thing each day to discuss the patients they are about to care for.
Haymon explained that this approach differs from traditional primary care, which is reactive -- that is, treating patients as they walk in the front door each day.
"We might be missing opportunities to care for people if we do so in a more reactive way," she said. "Instead, we are trying to move towards planned care and care that is intentionally about an entire population."
At these morning huddles, team members review the cases of everyone who currently is in the hospital, patients receiving post-acute care and those who have been discharged in the past 30 days. Then, as a risk stratification strategy, the group assigns a "worry score" to each patient designating whether that person is considered to be of low, medium, high or emergency concern.
A low-risk patient might be a healthy person with no significant chronic disease burden who comes in once a year for an acute health problem, Haymon said. A medium-risk patient might have chronic diseases, but his or her condition is under reasonable control. A high-risk patient, she said, is someone with acute illness, chronic diseases and a significant medical burden but also some type of additional personal stress -- incurable illness, homelessness or a personal crisis such as the death of a child -- that makes it difficult to manage their medical condition.
In addition, the team creates a "concerned list" of patients considered to be at the emergency level. "This can be because the person is in crisis from health but also from something going on in their personal life. 'Emergency' is someone who is hospitalized and of acute concern," Haymon said.
Team Shares Patient Care
Many times the barriers to treating chronic disease are outside of physicians' direct scope of care, such as social determinants of health and mental health issues, Haymon said. "Physicians aren't always the most expert in helping navigate those things, so we need some additional team members with expertise to extend our reach," she said.
That's why Iora Primary Care includes a behavioral health specialist in each clinic -- often a social worker who has mental health expertise that can be integrated into the clinics.
For example, anybody with a diagnosable mental health condition such as an anxiety disorder or depression or someone dealing with grief will be scheduled to meet with the behavioral health specialist for counseling sessions. "These aren't used for long-term therapy, but instead are a few sessions to help build awareness and understanding in our patients around their mental health," Haymon said.
Physicians at Iora Primary Care make frequent diagnoses of dementia, which often requires providing extensive education to family caregivers, and the behavioral health specialist provides this teaching. Typical questions include: "What does it mean to have somebody in your family with dementia?" "What's this new situation going to look like?" and "How am I going to take care of my mother?"
The behavioral health specialists also are experts on what mental health resources are available in the community so they can triage patients and ensure they continue to receive the level of care they need, Haymon said.
Additionally, Iora Primary Care uses health coaches who become experts in patients' lives and have strong, healing relationships with them. "So the health coaches are trained in techniques like motivational interviewing and behavioral change modeling, which allows them to help patients who wish to change -- quit smoking, walk more, eat better -- and work on these patient goals," she said.
Power in Numbers
Another important tool Iora Primary Care uses for its chronic disease patients is the group visit. The behavioral health specialists and health coaches run these sessions, which cover diverse topics such as stress management, stretching for back pain and walking as a group.
Carroll Haymon, M.D., medical director of Iora Primary Care's Seattle group, leads a monthly "What's Up Doc?" session, where patients can ask anything on their minds.
"We believe group visits and care are very therapeutic," Haymon said. "It's most effective to get people with a variety of diseases together and focus on healthy behaviors rather than subdivide them by disease. The principles of patient self-management support have been proven to change outcomes in those with chronic illness. Teaching those skills to patients both on an individual level and in a group setting is very powerful."
However, there are exceptions to this dual-approach rule, such as the diabetes self-management skills program.
"We're trying to teach diabetics what all these new words mean, what these medicines are for and what behaviors they can do to better understand their own illness," Haymon said. "This is much more fruitful in a group environment because people can really learn from each other and the teaching can be targeted at the community that you're serving."
Haymon leads a monthly group session titled "What's Up Doc?" that offers patients an opportunity to ask anything on their minds.
A recent question on antibiotic-resistant bacteria offered Haymon a great chance to remind the group why they might be denied antibiotics, such as when they request them for a viral infection.
"It's one of those conversations that every family doctor has had 10,000 times," she said. "To get to say that once and have 20 people hear it and then react to each other and talk about it was so much more fun than having that conversation 20 times in a patient room."
Integration of Advance Care Planning
One group visit at Iora Primary Care that's proved especially valuable covers advance care planning and includes instruction on advance directives and thinking about patient goals and values in end-of-life care.
"I've found (this topic) to be fun to do in a group environment," Haymon said. "Again, it allows patients to learn from and talk to each other about what their experiences have been with serious illness, what their fears are, what their hopes are and how we can help support them in their values."
One concept that Haymon said has been important in these discussions is that "more care isn't always better."
"One of the challenges for us in health care is to bring this (idea) forward for people to understand without having it feel like I'm withholding care from you," she said. "That's a tension that family doctors are conscious of a lot. That suspicion can be allayed much easier in a group."
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