Jake's Journey: Improving Care
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 series writings here.
Patients expect the care in the U.S. to be the best in the world. As we’ve described in previous posts, we are improving, but have fallen behind our peer countries. What do we need to do to improve the care here in America?
Some of this is due to the tighter organization and relationships. Some have more organized ways to implement and pay for new innovations. Most have greater clarity and prioritization of their goals and direct their investments into changes that have the greatest impact on health and longevity.
We all want to honestly tell a patient like Jake, who we met in Making Our Health Better, that the care he and his family gets is the best in the world and that he will have the best chance to be healthy. To do that we need to make changes. Innovation is being implemented daily and yet there are many areas of opportunity yet to be realized. Innovation is a continual process and in the past few years health care has seen that process accelerate. Its direction is always changing, but in order to be adopted, individual innovations will need to improve our health at an affordable cost that won’t hinder equitable delivery and improvement to our overall system of health care. Successful ones will restrain the growing cost of care; the best ones will decrease it.
The work of health innovators working in a broad range of areas – from administrative to clinical and from system improvements to artificial intelligence – provide optimism for positive change. This is momentous considering our basic model of care in the U.S. has remained unchanged over the past 50 years, with a few exceptions as described below.
We have talked a lot about changes, but the organization today is very static. We have separate hospital, outpatient clinics and behavioral health providers. Many of the doctor’s practices have been purchased by hospitals, but the models of care are similar to the care provided in 1970. The biggest changes have been in the digitization of the clinical setting, the adoption of electronic medical records, and targeted improvements in medications.
In hospitals we have improved the systems of care mostly for specific disease states. Stroke care, reversal of myocardial infarction and continual advances in cancer treatments have been highlights of these improvements.
Behavioral health is mainly outpatient and almost entirely separated from outpatient and inpatient medical care except for the relatively rare hospitalization in a general hospital for severe mental illness.
The broad adoption of electronic health records (EHR) - accomplished through carrots and sticks – is now almost complete and provides great opportunities. Interoperability is well underway and will greatly enhance the benefits of the EHR.
The most effective health systems in the country have integrated medical and mental health care with solid connections between outpatient, inpatient and behavioral health. The best care follows evidence-based guidelines that transcend the borders of in and outpatient care. Records are integrated, and monitoring measures processes AND outcomes over time to track the overall impact of interventions.
In high functioning settings care is provided by interdisciplinary teams of providers working to their maximum scope of training, close communication focused on individual patients and constant process improvement in the systems of care. All appropriate and effective care is provided to patients like Jake in one stop - including services such as mental health and pharmacy consultation. The clinical setting is interconnected with other community services such as pharmacy, mental health, food, housing, dental, transportation and other needed service providers. Today’s In these settings, patients are actively managed. Instead of doctors waiting for patients to present, doctors ensure their patients are getting the care they need through outreach, coordinating care and behavior change. These changes present in current health systems are proven to improve global outcomes, but are mostly absent in the United States (very few existing).
The implementation of innovations known to benefit patients is spotty.
Inflexible payment systems and fragmented care across different payers, different clinical settings and systems, different electronic medical records can easily derail new solutions. Our organization of medical services leaves no room for important health-adjacent services - like food, housing and transportation - that affect our wellbeing.
Some innovations are being implemented nationally. New services such as telemedicine are spreading. More sophisticated remote monitoring with new devices are coming. Also, care that once had to be provided in hospitals is being provided in clinics and at home. One challenge is how to get this waterfall of new information into a form that it can be well used by the provider or providers to make timely interventions.
There are innovations coming that will change the care of individual diseases with tremendous progress being made in the care of different diseases from diabetes to cancer. Strokes can be treated remotely. Glucose levels in diabetics can be adjusted by the minute. Other advances are coming through the development pipeline and need to be assessed and, if cost-effective, adopted. Some of the innovations are one-offs and some are system changes.
Many of the system changes mentioned above have been adopted in other developed countries and account for much of their better health status compared to the United States.
In our next blog posts we will discuss the needs for innovation in primary care, pharmacy, rural health and social determinants of health. Improvements in these areas are needed to help make Jake and his family as healthy as anyone in the world. To succeed we need to develop innovations and integrate them into the systems of care so that everyone in America can access services that are highly effective and people like Jake and his family can get the care they want and expect.
Cambia Grove’s goal is to catalyze solutions and is focusing on many of these challenges. Through events such as the fireside chat discussions (like the recent interview with Dr. Ali Mokdad of IHME), the Interoperability Summit, the 5 Points of Health Care™ events and various Roundtables, these important issues are being explored and we would like innovators to see these as achievable challenges that can improve health and outcomes.
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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