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    Patient engagement remains cornerstone of primary care's future

    The future and success of primary care may rest on its ability to engage patients in entirely new ways.

    Driven by cost containment, adoption of technology, the need for patient transparency, and a kind of re-engineering of the healthcare team, David Judge, MD, founder of the Ambulatory Practice of the Future at Massachusetts General Hospital (MGH) in Boston, is betting on primary care and has built a kind of learning laboratory to test models to improve the quality of care and build teamwork. Long-term, Judge believes the efforts will help lower costs to his patients by reducing hospitalizations and visits to emergency departments.

    Judge, an internist and co-program leader in clinical systems innovation at the Center for the Integration of Medicine and Innovative Technology (CIMIT), believes that primary care needs to be reinvented to improve its economic base and solve some of the most vexing problems confronting it, such as physician and nurse burnout, dwindling shortages of primary care physicians (PCPs), and low reimbursements at a time when healthcare is moving to improve care, juggle more patients, and still remain economically viable.

    Judge should know. He built a busy internal medicine practice and concluded there simply had to be a more effective way to deliver care than in 15-minute time slots.

    His answer is a 7,200-square-foot primary care practice, costing more than $2 million, built on the premise of testing different business and clinical care models in an attempt to redefine the rules of patient engagement. He also is looking to contribute to the growing body of evidence supporting the premise that if you engage patients in their healthcare, it will improve their health status and ultimately reduce long-term healthcare costs.

    Leaders within MGH bought into the concept, and the practice opened in 2010 in collaboration with the Mass General Physicians Organization, the Stoeckle Center for Primary Care Innovation, and the CIMIT.

    Patient engagement not only is a critical component of healthcare reform, it is a cornerstone to the concept of a Patient-Centered Medical Home and accountable care organization, according to a Health Affairs report titled “What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs” by Judith H. Hibbard, et al.

    Although the report states that not a lot of evidence exists to date about the impact of costs associated with an engaged patient, Judge believes his practice is showing some evidence of bending this cost curve.

    So what is a primary care practice of the near future?

    Imagine a time when you are conducting 35% of your follow-up care appointments through video conferencing, or patients are booking their own appointments through an open-source network. Imagine building a “living room” as patients enter your clinic that is so Web-enabled patients that can review their records, educate themselves on their health, and even conduct research about their own conditions in the clinic. Imagine a time when patients can access all of your notes about their health, even if they have a poor diagnosis or prognosis. Imagine a time when a health coach sits down with your patients and shows them how to safely exercise with cardio machines and weights. And imagine a time when the primary care clinic facilitates support groups with other patients in the practice with the same chronic conditions, such as diabetes, or when the practice truly manages the health of that patient population whether in a primary care setting or referred on to specialist consultations.

    And although many of these concepts are in play in practices across the United States, their integration into the service mix and practice workflow could help position primary care from mostly delivering episodic care to facilitating wellness among the majority of its patients.

    The Ambulatory Practice of the Future treats employees and spouses of Massachusetts General Hospital, but its findings are definitely transferrable to private, office-based practices, Judge adds. In fact, that is one of the goals. Test it, and if it works share the information with the profession to help improve internal medicine and make practice more satisfying for physicians. This arrangement offers the practice some flexibility in adapting technology and trying new approaches to care delivery, he adds.

    Here is a closer look at how the practice currently is structured.

    MEET THE TEAM

    With 15 examination rooms and one treatment room enclosed in a 7,200-square-feet space, the practice is made up of three healthcare delivery teams, each including a physician, a nurse practitioner (NP), a nurse, a health coach, and a medical assistant (MA).

    Typically, a patient enters the practice and initiates a check-in through a computer-based kiosk. A greeter is available at the entrance. The waiting room, or “living room” as the practice calls it, showcases computer workstations and a host of health-related reading material overlooking a Boston cityscape.

    When the healthcare team is ready to engage the patient, a member escorts the patient back to the examination room to begins to record vital signs and initiate the health evaluation.

    The practice’s MAs have been “trained up” to begin a detailed inquiry about a patient’s health status, Judge explains. “They will do a lot upfront to learn about you, your medications and known allergies, and those kind of things.”

    The role of the MA is to gather as much information as possible to help set up the encounter for the doctor or others on the healthcare team. In fact, like a baton, the electronic note is passed over to the physician to complete the health assessment.

    When appropriate, the practice also is experimenting with ways to gather diagnostic data before the visit. In fact, if screening blood tests or urine samples are required, the idea is to schedule this prior to the encounter. Having data available to drive the discussion and help build a health plan is useful for the physician, Judge says, and it helps educate patients about the results or health-related issues they face.

    Within each examination room, computer workstations for two people are positioned around a large, mounted flat-screen monitor. The design allows providers and patients to sit together to enter and edit data into the electronic health record or review diagnostic results.

    “We are trying to engage patients in new ways,” Judge explains, “and it is a key part of the design of the examination rooms. It’s not me peering down at you as I type information into your record or me looking in another direction as you are talking, it is us—patient, provider and team—sharing information together,” he says.

    “Until technology provides us niftier ways of getting information into the medical record, this is a good way of doing it,” he adds.

    This technique, Judge says, helps teach patients how to read the note, because they will have time to go back to the Web portal to view it later.

    Interestingly enough, he also believes that this strategy has improved the accuracy of the record, because patients are collaborating in its creation and helping to revise the record as data are being entered into it.

    To accomplish this task, the physicians are trying to build in more time for these initial visits, and it typically takes 1 hour per encounter. Although subsequent visits are much less time-intensive, this initial assessment is extremely important, Judge adds, because the goal is to create a working health plan for the patient that will be referred to frequently and updated as necessary by the entire healthcare team.

    “In the flow of a day, we are trying to build more time into the schedule to meet, talk, build trust, and learn what we are all about. You just can’t do that in a 10-minute visit, which we have tried to do in primary care for a very long time.”

    When it comes to scheduling, the practice uses the team’s five examination rooms to alternate longer initial assessments with shorter follow-ups, virtual examinations, or urgent-care visits at the same time.

    Typically, Judge sees two to three patients per hour, and that rotation usually creates space in the schedule for urgent or unexpected care.

    IN PURSUIT OF WELLNESS

    At the end of the consultation with the physician, the baton is passed back to the MA, who schedules time for the patient to visit with the NP, nurse, or health coach.

    The patient may meet the nurse if he or she has high blood pressure or diabetes. And the NP’s role has a particular focus on chronic illness and managing those conditions. The health coach works with patients to help execute results of the health plan.

    “Our health coach’s background is in exercise physiology, health, and nutrition. Coaching is the science of motivating you to change behavior, so we have a person who really owns that role.”

    THE ROLE OF TECHNOLOGY

    When an initial encounter concludes, the team has crafted a working health plan for the patient. It’s available on a Web portal and will be referred to frequently. Technology also is creating entirely new ways for physicians to communicate with patients. In fact, patients may even feel more comfortable discussing a health problem or concern through an e-mail. Video and audio conferencing are opening other channels of communication that are time-efficient for both doctor and patient, and they create new avenues for building this kind of engagement.

    “When you are managing a big population of patients, much of what you are doing does not always require you to come here,” Judge says. “It requires reinforcing a plan, checking in, and building that relationship, answering questions, education, coaching. All that stuff does not have to be face-to-face.”

    THE BUSINESS MODEL

    “When we designed this model, we knew that we wanted to try to package all of this stuff together or explore the types of services that would not totally depend on the traditional visit,” Judge says. It might be a physical visit, a virtual visit, or a videoconference or telemedicine encounter.”

    Although the business structure and financing is notably different because it is operating under the umbrella of a major health system, the practice has a billing mechanism to collect and analyze claims data, “which is useful in understanding impact of overall cost,” he explains.

    “In terms of what is transferrable to any population—put the self-insured aside—I think there is a business model here, and we are on our way to figuring out what that is. There is an incremental cost per patient to provide this kind of care. And there is a savings to the payer. If the savings is greater than the cost, well, great. If it is relatively neutral, I still think what you are doing over time is helping patients get healthier and that reduces risk.

    “And it has been well-documented that many of the risks that drive employer healthcare costs are being seen and treated within primary care. It’s about depression. It is about hypertension, diabetes, obesity, physical inactivity, stress, smoking. It’s about all the stuff that we want to help manage,” he says.

    “If you are doing the early coaching and aggressively managing patients in primary care, I think that there are additional savings going beyond that. It’s something that we will be uniquely be able to learn more about over the next few years with the way we are approaching care.”

    Although this model might be directly transferable to a self-insured organization, pieces of it could be transferable to office-based practices, Judge says, including the way you configure a team, train a staff, engage patients in the examination room.

    “When you put healthcare in the context of a patient’s own life and really delve into the barriers of getting healthier—that is really hard work,” he says. “Many [PCPs] are being driven away from engaging patients at that level simply because they are seeing too many patients in a day. We have to come up with creative ways to change it.”

    VIDEO TELLS THE STORY

    David Judge, MD, believes that primary care physicians can engage patients about their healthcare in entirely new ways.
    In fact, he is putting some techniques into practice. In this video, Judge talks about the goals of the Ambulatory Practice of the Future. See www.MedicalEconomics.com/APF.


    CLINIC SUMMARY

    Location:  Boston, Massachusetts

    Opening date: May 3, 2010

    Size: 7,200 square feet

    Number of exam rooms: 15

    Number of treatment rooms: 1

    Number of care providers:  3 physicians

    Encounters per hour:  2 to 3

    Average patient cycle time: 1 hour


    THE PLEDGE

    The Ambulatory Practice of the Future has a pledge to make about its service, team, and community. In fact, it is framed, signed by the entire healthcare team, and visible to all of its patients.

    “We are not only in the healthcare business serving patients but also in the people business supporting health and wellness,” it says.

    Here is an excerpt from the practice’s pledge to patients about service.

    Together we will:

    • invest in getting to know our patients;

    • share information with our patients in a prompt, appropriate, and personalized manner;

    • provide timely access to care;

    • proactively support our patients in their effort to reach their personal health goals no matter where they fall on the healthcare continuum’

    • be transparent with our patients in their care;

    • explore and practice new and better ways to communicate with and support patients;

    • provide excellent service and seek feedback from our patients;

    • apologize if we make a mistake;

    • be efficient in our communication;

    • empower our patients to guide their own care; and

    • honor each patient’s unique perspective and goals.