Dan Prince

Ever since I first heard the phrase ‘medical home,’ I have been entranced with the concept.

Since I haven’t lived in an era where doctors make house calls, I hope I live to see the era where care teams, healthcare technology and the right reimbursement models will come together to create a primary care system that will enfold me in a little cocoon . . .

• where my records will be coordinated and accessible to every provider I see
• where every provider on my team will care enough about me to actually read those records, and will consult and collaborate with others on my care team
• where everyone will apply evidence-based guidelines as they make decisions about my care

. . . and, as a result, get me safely out of the woods whenever I need acute care or go the distance with me if I need care for a chronic condition.

What is a patient-centered medical home?

The ‘patient-centered medical home’ is defined in the white paper “NCQA Patient-Centered Medical Home 2011” (available at http://www.ncqa.org/tabid/631/default.aspx). It’s a companion to the Patient-Centered Medical Home (PCMH) standards NCQA issued in January.

“A patient-centered medical home is a model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has a relationship with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient’s health care needs and arranging for appropriate care with other qualified clinicians. The medical home is intended to result in more personalized, coordinated, effective and efficient care.

“A medical home achieves these goals through a high level of accessibility, providing excellent communication among patients, clinicians and staff and taking full advantage of the latest information technology to prescribe, communicate, track test results, obtain clinical support information and monitor performance.”

The concept is, according to one of the organizations that has promoted ‘medical homes’ for years as a model for primary care, the American Association of Family Practice (AAFP), “An Idea Whose Time Has Come . . . Again.”

“The medical home . . . is both old-fashioned and thoroughly modern – a blend of the personalized, comprehensive care that family physicians have been offering for decades and coordinated care that capitalizes on new technology and helps patients make sense of the increasingly complex health care system.”

One of the hurdles: teamwork

There are so many hurdles, though. Making primary care staffs gel as care teams is one. I have a vision of a care team like a band of ministering angels, solely focused on me and on how best to integrate their disparate skills to provide me with the best care, the best experience possible. (This band of angels is pictured on the cover of the NCQA white paper, shown here.)

From the cover of the white paper "NCQA Patient-Centered Medical Home 2011"

There are over 1,500 NCQA Recognized Patient-Centered Medical Home sites in the US, but I’ll bet that even in these distinguished practices, teamwork is still something they have to work on.

Thinking about the future of healthcare professionals’ cooperation and collaboration, I ran across a paper about how some institutions that educate healthcare professionals are trying to make inter-disciplinary cooperation part of the curriculum. The article is “Educating the Care Team,” by Brian Schuetz, Erin Mann and Wendy Everett, published in Health Affairs in 2010.

The authors write, “Team-based primary care offers the potential to dramatically improve the quality and efficiency of care, but its broader adoption is hindered by an education system that trains health professions in silos. Collaborative models that educate multiple practitioners together are needed [as are] changes in professional cultures, organizational structures, clinical partnerships, admissions, accreditation, and funding models . . .”

Interest in collaborative education in healthcare first blossomed in the 1970s, and some major institutions, including Ohio State University, Indiana University, and the Universities of Minnesota and Miami started programs. But as grant funding dried up in the 1990s and 2000s, so did the programs. Today, most doctors, nurses, NPs, PAs, and therapists graduate from programs that reinforce “the traditional hierarchical structure that considers physicians to be the primary decision makers and relegates others to a secondary status,” according to Schuetz, Mann and Everett.

The cultural divide that starts in college has to be bridged in the physician practice or it’s not going to be a very happy ‘medical home.’

The changes required to live up to the care team standard in the NCQA PCMH guidelines are just as foundation-rattling as the ones needed for integrating technology in the practice workflow, tracking and reporting patient results, population health management and instituting appropriate payment systems.

Hard as it’s going to be to create the new medical home, most of what the NCQA guidelines call for will be table stakes for practices that expect to survive into the 2020s and 2030s when the baby boom generation is truly the “old old” and the principal consumers of healthcare services. It will be great if the healthcare system really makes us feel at ‘home’ when we get there. But following the NCQA guidelines will at least make the system functional.

Dan Prince

I haven’t had much personal experience as a patient lately (Knock on wood!), but I have spoken several times to a friend whose 85-year-old father has been in and out of hospitals a lot in the past four months. Her experience of staying with him in the hospital for a week in early August was the subject of one of my blog posts a few months ago, Fear as Part of the Patient Experience.

Recently, her father has been making a very slow recovery after another seven-day hospital stay followed by a 14-day nursing home stay. He was in the hospital because his primary care physician attributed his 102-degree fever to an infection resulting from a catheter procedure his urologist had recently done. So, rather than treat him with antibiotics at the local hospital, she sent him to a hospital in Cincinnati, 60 miles away, where his urologist is based and, according to my friend, “washed her hands of the situation.”

My friend’s father was in the hospital for seven days – even though his fever came down almost immediately. He saw the urologist once in those seven days, for about 5 minutes.

My friend’s father has very weak legs, and he uses a walker. Seven days flat on his back in the hospital made him even weaker and made a two-week ‘layover’ at the nursing home necessary before he could go home. He’s been home for a week and a half now, but he fell last week and was back in the ER briefly. My friend told me he was pale and glum and didn’t eat much at the Thanksgiving dinner table last week – and hasn’t eaten much since.

All this, in my friend’s mind, is because his primary care physician wouldn’t take the trouble – or the responsibility – to confer with the urologist and work with him to figure out what was causing the 102-degree fever and what would most effectively bring it down. If my friend’s dad had to be hospitalized, she thought the primary care physician should have realized that the local hospital would have been a better venue. His PCP could have kept an eye on him and maybe gotten him released when his fever went down after a couple of days. His wife and family could visit more often and for longer periods, if the trip to the hospital was three miles instead of 60.

My friend is probably judging her father’s doctors too harshly. I mentioned the story to a doctor friend of mine, and he said he would have done just what the primary care physician did. People with catheters are prone to infection; infections can get out of control in a patient whose immune system is not strong to begin with; the urologist is the best one to assess the situation and deal with it.

But I think there is still a problem with the PCP’s choices in handling this patient. Whether she was in the right or not clinically, she didn’t – at least in the view of the family – show the proper consideration for the patient’s recent health history and his weakened condition. She didn’t take the time to explain their father’s risk or her decision to the family, so it felt to them like the brush-off – shuttling Dad off to the big city just because he had a little fever.

To me, the whole story underscored one of the central points we’ve been trying to make in this blog: A healthcare professional can make the right calls from a clinical standpoint, but to really be a healer, you have to take into account the patient’s experience and the experience of the family network of which the patient is a part.

What do you think? Comment on this post or send me a message at dan.prince@catalysthcr.com.

Dan Prince

A lot of my reading lately is taking me back to the theme of how the healthcare system needs to move out of hospitals, doctors’ offices and insurance company headquarters and into the community if it’s going to make a real dent in society’s biggest health problems.

The problem of obesity is a good example. We reported in our Living in Denial white paper a few months ago on Americans’ strong sense that the country is in the grips of an obesity crisis – and their adamant denial that their own personal obesity is contributing to it.

A recent National Public Radio (NPR) series on obesity included a piece about new research on how our hormones fight us when we try to lose weight.

It reported some emerging insights into why losing weight slows metabolism – which makes it hard to keep losing, and very hard to keep the weight from creeping back on.

NPR’s Patti Neighmond wrote, “For example, if you weigh 230 pounds and lose 30 pounds, you cannot eat as much as an individual who has always weighed 200 pounds. You basically have a ‘caloric handicap.’ And depending on how much weight people lose, they may face a 300-, 400- or even 500-calorie a day handicap, meaning you have to consume that many fewer calories a day in order to maintain your weight loss.”

One of the interesting links in the NPR piece was to a study by the American Journal of Clinical Nutrition of 784 people (629 women and 155 men) who had succeeded in losing weight and keeping it off. These folks were, years after losing weight, still eating less than other people who had never had to lose. In particular, they were eating less fat.

The other secret to their success was exercise. The group exercised in a variety of ways, but the researchers calculated their average caloric burn and said it was the equivalent of walking 28 miles a week – four miles or about an hour a day.

I mentioned these statistics to a friend of mine who is a weight loss success. She found them interesting because they matched her experience, but she had always thought she was unusually cursed – especially by the way she still has to curb her caloric intake – 10 years after losing the weight.

Just how hard it is to lose weight and keep it off is not a news flash, but I don’t think it’s something our society and our healthcare system have fully internalized. Obesity is tied to the most dangerous chronic conditions and a root cause of much of the cost of American healthcare.

If healthcare reform and the ACO movement succeeded in its mission to shift more of the healthcare system’s focus to wellness and prevention, doctors and hospitals would have a new motivation to look beyond the acute conditions that bring people into their facilities, to help them work on making better day-to-day choices as to how they eat, drink, sleep, move – live.

Taking better health out to the community

Taking better health to the streets was the theme of another piece in the NPR obesity series: ‘Secret to a Long, Healthy Life: Bike to the Store.’

Physician Jonathan Patz and a team of researchers at the University of Wisconsin-Madison studied the health impact of making short trips by bike rather than car. They gathered up data sets for 11 Midwestern cities on obesity, automobile pollution and pollution’s health effects. They estimated that, in those 11 cities, with 31 million people, 1,100 deaths influenced by overweight and pollution (heart attack, strokes, asthma) could be avoided every year, and $7 billion a year in healthcare costs could be saved.

I found particularly thought-provoking a short comment by Dr. Patz at the end of the piece. He’s a dedicated bike commuter in Madison, and he can do that because Madison is a bike friendly city with 87 miles of bike lanes, 116 miles of bike routes and features like ‘bike boxes’ on the streets – painted rectangles at intersections where bikes can move in front of cars, to protect bikers from drivers making right turns.

Dr. Jonathan Patz. Photo by Jean Patz.

Dr. Patz commented that when he lived in Baltimore, a city not set up for biking, he didn’t bike-commute. “I tried it about three times, and realized this could be very hazardous to my health.”

If he still lived in Baltimore, Dr. Patz might not be the picture of health he appears in the NPR blog.

One of the thrusts behind the government push for Accountable Care Organizations is the desire to make healthcare professionals and hospitals broadly responsible for the health of their community – not just treating its illnesses, keeping it healthy.

I think a healthcare professional like Dr. Patz, looking beyond the clinical setting, at where patients live day to day, sets a positive example for the healthcare system and suggests some of the ways that healthcare could be truly “accountable” to its community.

What do you think? Comment on this post or send me a message at dan.prince@catalysthcr.com.

Dan Prince

National Public Radio has been running a series on obesity. I have found the segments on the radio and the related articles in their blog very interesting, particularly in light of the findings we reported in our Living in Denial white paper a few months ago.

In the NPR piece “Workplaces Feel the Impact of Obesity,” author Jennifer Ludden writes that obesity costs U.S. employers $73 billion a year. And that doesn’t cover everything. Ludden said companies are having to use pickup trucks as company ‘cars’ to accommodate plus-size drivers. They are having to replace toilets when wall-mounted ones collapse. They are having to spend big money on big office chairs. A spokesman from chair manufacturer ErgoGenesis told Ludden that sales of their ‘bariatric’ chair, for workers up to 600 pounds, are brisk.

A custom chair ErgoGenesis made for a customer too big for its <600 lb 'bariatric' office chair. The custom chair cost $1,800. The regular bariatric chair costs $1,300.

Pete Gaffney of ErgoGenesis is quoted as saying that the intended users of these chairs are sometimes offended by them. “I’ll kid around with the ladies sometimes,” he says. “They’ll say, ‘Well, that’s too big for me! It’s too wide!’ I’ll say ‘Look, when you go home everybody likes to get into a nice pair of comfortable jeans. Just consider the few extra inches as a nice comfortable pair of jeans. You’ll thank me.’ ”

They do thank him, Ludden writes.

The large ladies who look at the chair and say “That’s too big for me!” reminded me of many of the respondents in our “Fitter or Fatter” study, the substance of our Living in Denial white paper. We did an online survey of 1,500 adult Americans. With all the media and public health attention that has been paid to the obesity epidemic, we wanted to see if it was having any effect. Were people trying to get in shape? Did they think they already were?

We didn’t recruit for the study based on weight, but it turned out our respondents mirrored the general population. Based on BMI measurements, 60% of our respondents were overweight or obese.

Many of them seem to have just as faulty a self-concept as the ladies who think they’re too small for the ErgoGenesis bariatric chair.

Among the overweight or obese respondents to our survey, 11% said they were in “excellent” health; 61% said their health was “good.” Yet excess weight contributes to almost every malady that plagues us as a nation, from diabetes to heart disease. And our respondents, at least on some level, know that. When asked what America’s number one health issue is, 60% of them said, “Obesity.” (The health issue that came in number two in the voting, “Cancer,” was cited by just 16% of respondents.)

Who is going to break the news to these people, that they are part of the obesity epidemic? Employers avoid the issue. Family members do, too. And too often, so do doctors.

“A physician’s behavior is the strongest predictor of how they will counsel patients around preventive health behaviors,” according to Harvard Medical School professor Dr. David Eisenberg, quoted in a blog called Obesity Discussion. The post cited a 2003 study that found doctors who watch their own weight are more likely to advise and encourage their patients to lose weight. It cuts the other way, too. A heavy doctor was quoted as saying she felt like a hypocrite if she counseled patients to lose weight when she had her own weight problems.

I found a vintage 2004 statistic (from a study published in the Annals of Epidemiology) that 44% of male physicians were overweight and 6% were obese. (No stats were available for female physicians.) If doctors are trending like the rest of us, I would guess that half of them are overweight by now. That would suggest that very few of us with weight problems are likely to get straight talk from the professional we would trust most on the matter – our physician.

The conclusion would seem to be, ‘Doctor, heal thyself’ – so you can give the rest of us the help we need to get our weight under control.

What do you think we should be doing about obesity? Comment on this post or send me an email at dan.prince@catalysthcr.com.

Dan Prince

Colleen Sweeney has found that 96% of people suffer from “clinicophobia,” a term she coined to describe patient’s fear of hospitals, providers and the healthcare system. She has data to back that up – from a 1,080-person survey she conducted for Memorial Hospital and Health System in South Bend, Indiana. Colleen is Director of Ambassador and Customer Services at Memorial, and she has made many presentations on patient fears and why the healthcare community needs to know more about them. She was the speaker at a Beryl Institute webinar on the topic August 16.

The interesting thing to people outside of healthcare is that this is news to the people inside healthcare.

But Colleen, who has worked in hospitals her whole career, says you get inured to the sights, sounds and smells of the hospital, and you don’t perceive it the way patients do. As Colleen said, “We see dead people. We see people naked. After a while you stop realizing this isn’t normal.”

Colleen is on a mission to help hospital insiders see the place the way patients do. Her own consciousness was raised when she walked down to admitting with a woman who had come in for surgery. “The woman was shaking uncontrollably,” Colleen said. “I asked her what the trouble was. She said, ‘The last three times I’ve been here to visit people, they died.’” It occurred to Colleen that every patient had some variation of that same fear – “and they weren’t telling us!”

Colleen conducted research to confirm that intuition, including a postcard request to the community to tell the hospital what their fears are. Responses ranged from “I’m afraid I’ll see a dead person” to “I fear white walls – why do you do that to us????” (This, shortly after the hospital had spent $25,000 to paint the walls white.)

She also commissioned the 1,080-patient survey, and the results have enabled her to compile and rank her “Top 11 Patient Fears” list. I won’t share Colleen’s whole list (Be sure to see her next time she speaks on this topic!) but the top 5 are: 1) Infection, 2) Incompetence, 3) Death, 4) Cost and 5) Medical Mix-up.

The list won’t be a big surprise to people who manage and work in hospitals. What Colleen is doing at Memorial is sensitizing hospital staff to the human faces, the emotion, behind these broad, abstract categories. For example, she puts senior staff – the CEO and VPs – at the front door of the hospital for two-hour shifts every day of the week so they can have the same experience she did – walking people down to admitting, finding out what they’re there for and why it scares them.

Colleen says her biggest challenge is hiring people who “care enough to ask the question: What do you fear?” I agree with Colleen that that’s a very big challenge. But the biggest is really taking the nurses, doctors, PCAs and everyone else who’s already on board – and making them “care enough to ask the question.” An idea on how to do that will be the subject for my next post.