Jake’s Journey: The Challenge of Primary and Personal Care Part IV

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Dr. Bob Crittenden serves as Cambia Grove Executive in Residence and brings a wealth of experience and knowledge as a practicing family physician and as a senior policy advisor. Dr. Bob’s blog series weaves learnings from his career while highlighting broader barriers to health care innovation and possible paths forward. Read more about Dr. Bob and his writings here.

 

When we think about health care we think about having services available when we need them and a personal physician who can help us through the wilderness of medical care. Our patient that we are following - Jake   - knows little about health care except what he reads in the news, but he has medical problems that need evaluation.  

A personal physician can have a wide range of training including, but not limited to, Family Medicine, Internal Medicine, Family Nurse Practice and Pediatrics . All of them are your front door into the health system: these physicians and nurses can sort out the problems you may or may not have, provide care for those amenable to treatment and if needed direct you to specialists for issues beyond their scope. Jake needs an entry into the health system and will probably find a personal physician - often called a primary care physician or a nurse practitioner. But finding that physician does not guarantee Jake the care Jake needs to be the healthiest he can be. 

Problem

Our understanding of effective primary care has changed dramatically in the past twenty years. The care in many US settings has only inched forward despite the fact most other developed countries have improved based on these learnings.

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We know a lot about what works to maximize the impact of primary care – the problem is the unsustainability of these improvements in the face of organizational and financial barriers slowing transformation.

We know that your care is better if there is a team in your primary care office that can actively manage any problems you may have. The office is most effective if it has prevention care, pharmaceutical management, behavioral health including mental health and substance use, and chronic condition support. The doctor or nurse practitioner must be an expert in helping you care for yourself – especially through changing harmful behaviors and finding community support. 

It is the primary care provider’s responsibility to actively manage this care, whether an intervention or medication change. 

Barriers to adopting team-based care include how we pay for care, culture, communications, and knowledge.

Payments – mostly fee for service - do not support a team-based approach. Paying for face-to-face encounters with doctors or nurse practitioners does not cover the expense of other team members who may stand in for the doctor. Nurse triage, pharmacy review and social work evaluation are all critical services not usually covered by fee for service. 

While many newly trained doctors and nurses support this model, there are many in my generation who are content with the current episodic care. Making this shift requires effort and barriers slow our progress. Doctors and nurses feel overworked and with the burdens of completing electronic records, increased responsibilities and low funding. Without needed support it’s no wonder they can be wary and resistant to further change.

Adopting team-based care requires communications internally and externally – usually using an electronic medical record that is populated with clinical information and connections to external information for internally unavailable services. There are no systems that make conversion to this kind of care easy and few EMRs provide the full package of information and connections needed. Information needs to be shared and acted on. All providers on a team may not be able to be in the same site or town especially in rural and less dense communities. And, much of this care may be better provided in an off-site location, not in a doctor’s office - like people with severe mental illness may need their care in their mental health providers offices.  

Possible Solutions

The good news is that there are examples where this team-based care is in place and making a difference. There are clinics in the U.S. that are modeled this way with good health outcomes and higher satisfaction ratings. One group has a patient turnover of 7% per year (very low) and most of those lost are from moving and death. But even these models may not be the primary care of the future.

There are many new concepts and technologies that enable a much different future for primary and personal care. 

Teams work better when there is contact, but can we have a virtual contact that enables the care we need without co-location? Do all patients have to come into the office for needed assessment and care? Can we make sense of the new diagnostic and data collection modalities that can overwhelm providers?

There are changes now emerging that can assist in resolving some of these questions.  Interoperability is emerging over the horizon, soon allowing the sharing of and access to a patient’s data in any setting. There are many examples of diagnostic tools and monitoring that can be done from home or work. And, there are examples of patient history taking that is done virtually. There are ways to maximize health and reduce errors using evidence supported approaches and artificial intelligence mechanisms that will improve over time. Future changes, beyond our current knowledge, may drastically shift our primary care direction in the future.

My simplistic vision of the future for primary care - based on what we know and can do now - includes the following: 

a.   We have a payment system that supports team-based care and rewards improvements in outcomes. 

b.   The primary care team is made up of all the needed providers and they communicate freely either personally or virtually as needed.

c.   The electronic medical record (EHR) is inclusive of the information provided by the provider and patient from many different settings and includes a digestible review of all relevant existing literature on the clinical issues identified. 

d.   The EHR has a portal that connects the care team to a broad array of providers and services in the community that potentially interact with any one patient.

e.   The providers are experts in helping you change behaviors that improve your health and you can access that provider in person and virtually as needed. 

f.     The team knows you and your issues and uses every modality to ensure you get the prevention, diagnostics and treatment as needed.

g.   You have a set of diagnostic tools at home that connect to your phone or computer that allow you to collect needed information - ranging from a device that checks the ear on a sick kid at night, to a device that actively monitors and/or manages your diabetes or congestive heart failure. 

h.   The patient – Jake - is clear on what prevention he needs and when he needs it. He knows he can access his team at any time needed. He can get a consultation at home or when traveling. The information about his health is available to his providers anywhere.  

 

All of this is possible right now – but rarely fully implemented. 

Next Steps

This will NOT be the future. There will be many additions to the possibilities outlined above. All need to be assessed to ensure they truly help Jake get healthier, improve customer service, are more convenient or save somebody money. We can and should start with the above changes that we now know improve care and outcomes. But, there are many new ideas being generated that may change the our current concept of the future.

My greatest concern is that we let payment structures and fear of change keep us from making Jake’s experience and access to needed care limited to the system we have at present. We must keep an open mind to improvements continuing to improve care into the future. More on these changes in future blog posts. 

At Cambia Grove we have a fireside chat series, an annual 5 Points of Health Care™ Conference and roundtable meetings discussing possible improvements and innovations like interoperability, the impact of needed changes and support for innovators. We are focusing on ways we can improve the payment system so we can stimulate innovation. We are supporting other groups who are working to improve primary care as well - some first steps to improving primary care.

 

About Dr. Bob Crittenden

Dr. Bob Crittenden joined the Cambia Grove as the first-ever Executive in Residence. He has practiced as a family physician for over 28 years in central and southeast Seattle with urban underserved populations, worked for the state legislature, been a Robert Wood Johnson Health Policy Fellow with Senator George Mitchell, was special assistant to Governor Gardner for health, and is a Professor Emeritus in the Departments of Family Medicine and Health Services at the University of Washington.

His work on projects at the local, state and national levels focuses on improving the access and effectiveness of health services for all populations. Most recently, he served as Gov. Jay Inslee’s Senior Health Policy Advisor, where he was instrumental in the implementation of the ACA in Washington state and the successful Medicaid Transformation Waiver. He has also played a key role in initiating the Kids Get Care program, actively participating in rural and urban underserved health systems improvements, and working with insurers, employers and providers in improving systems of care for chronic conditions.

Dr. Crittenden received his BA in Communications and Public Policy from the University of California, Berkeley and a diploma in Political Theory and Development Economics from Oxford University. He went on to earn his Medical Degree at the University of Washington School of Medicine and his Masters of Public Health in Health Services from the University of Washington. He loves any sport and enjoys his time on the lake or in the mountains.
 

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