Ann Hwang, M.D., decided to change the script of caring for her patients by making home visits. It was the best way to understand the patient perspective, she said recently during a panel discussion on scaling team-based primary care.
Adrienne White-Faines, CEO of the American Osteopathic Association, left, moderates a discussion of team-based primary care during the Patient-Centered Primary Care Collaborative Fall Conference with a panel that includes Lisa Stewart, M.A., of Family Medicine for America's Health and the Patient-Centered Outcomes Research Institute, center, and Marie Brown, M.D., senior physician adviser for the AMA's professional satisfaction and practice sustainability group.
Hwang's approach entails role reversals in the physician-patient relationship that begin when she requests a time to visit that is convenient for the patient. On entering the patient's home, Hwang asks whether she should remove her shoes and where to sit. In the home, the relationship becomes more of a partnership.
"You become a guest," she said. "You feel that shift in the balance of power."
Hwang shared her experiences as a panelist at the Patient-Centered Primary Care Collaborative(www.pcpcc.org) Fall Conference, held here Nov. 9-11, in a discussion of successful team-based care and how it might look in the future. Other speakers outlined ways a broader community-based approach to primary care differs markedly from the traditional office visit.
Hwang said that despite the benefits of her new approach to patient care, payment and performance measurements have not kept pace with innovation in care delivery. Hwang, director of the Center for Consumer Engagement in Health Innovation for the Community Catalyst health care advocacy organization, recalled a patient who struggled with addiction, was receiving methadone treatment, had attempted suicide and was living in a truck. The only metrics in the patient's health record subject to performance improvement addressed colonoscopy and blood pressure, she said -- hardly appropriate measures given the patient's condition.
- Panelists at the Patient-Centered Primary Care Collaborative Fall Conference discussed successful team-based primary care.
- Team care can allow physicians to spend more time with patients, returning to what one physician on the panel called the "golden moment."
- Panelists described community projects that show how expanding primary care into areas with limited access requires being sensitive to the needs of residents.
Hwang and other panelists emphasized the importance of team-based care that allows physicians to make the best use of their time with patients. For instance, Hwang said, a nurse or a medical assistant might be able to handle a patient's questions about medication.
Spending more quality time with the patient and delegating more to the medical team will allow physicians to return to the "golden moment," according to Marie Brown, M.D., senior physician adviser for the AMA's professional satisfaction and practice sustainability group. She described physicians entering the exam room, making direct eye contact, shaking the patient's hand and saying they care. They ask about the patient's health and listen, neither interrupting nor looking at a computer screen.
"We have to change what we do," Brown said. "We want that. The patients want that. But with the computer, the regulations and all the interpretations required by institutions, we've added another 200 clicks on the computer."
Brown identified several measures that could preserve a physician's time with patients. One hour would be saved each day if all medications for chronic care patients could be prepared for a full year without having to continually update prescriptions, she said. Another 15 minutes would be saved if computers and tablets had a "tap and go" feature instead of requiring physicians to sign in with a password every time.
Physicians who have more time with patients will be able to ask questions such as why those who are nonadherent are not taking their medication, thereby perhaps preventing a stroke or dialysis treatment.
Brown noted that despite hurdles, practices are taking steps to address larger population health goals through a team-based approach.
"The missions are aligning," Brown said. "We care about blood pressure being 150 over 90. We're starting to get control of A1cs. We're starting to think, 'Maybe we do need that diabetes educator on the team.'"
Although regulators and insurers are consumed with collecting more data, Brown argued that information already exists to trigger change.
"I think we have enough data," Brown said. "The question to ask is, 'What do we want to improve?' The team has to make that decision."
Panelists shared stories about team-based community programs that show how expanding primary care into areas with limited access requires first being sensitive to the needs of area residents.
One was a project undertaken by Drexel University to open a medical clinic in an underserved part of Philadelphia where the average annual income was $15,000. Early in the planning, residents asked for help addressing stray dogs that were biting people, speeding cars that contributed to accidents, and a lack of resources for nutrition and exercise, said Maryjoan Ladden, Ph.D., R.N., a senior program officer with the Robert Wood Johnson Foundation.
University leaders initially tried to brush aside concerns they saw as unrelated to their goal, but residents were insistent. So to build trust, health officials worked with others to address the problems.
Now, Stephen and Sandra Sheller 11th Street Family Health Services of Drexel University(drexel.edu) is equipped with a fitness center, a garden, integrated behavioral health services and an art/music therapy program in a wide-ranging approach to primary care.
"It took several years of talking with residents to establish the health center," Ladden said. "The answer is not just going into a community with answers but saying, 'Now let's work together.'"
Such an attitude was evident when officials in Hayward, Calif., decided to open the Firehouse Clinic adjacent to a fire station in 2015. The clinic, which offers primary care, mental health services and health care navigation, was built after surveys showed that firefighters and emergency medical services personnel enjoyed high trust in an area that reported low levels of access to care and poor health outcomes. Residents feel safe visiting the facility, a collaboration of organizations including the city, Alameda County and local health systems.
"Officials looked at the data and used it," Ladden said. "It was built outside the usual primary care sites. They asked, 'How can we build it so they will come?'"
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