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The growing number of patients with chronic illnesses and conditions is forcing primary care practices to become more creative with the way they treat such patients.
Editor's note: This article is part of the Medical Economics Business of Health: Chronic Disease resource center.
Chronic disease is a leadin =g cause of death in this country, accounting for seven out of 10 deaths, according to the U.S. Department of Health and Human Services (HHS). About 133 million Americans–45% of the total U.S. population–live with a chronic condition. By the year 2020, it’s expected that number will rise to 157 million Americans.
The increasing prevalence of chronic disease is felt acutely in the primary care physician’s (PCP) office. “The work of primary care over the last 20 to 30 years has shifted considerably,” says Michael L. Parchman, MD, MPH, director of the MacColl Center for Health Care Innovation with the GroupHealth Research Institute in Seattle, Washington. Today, Parchman says, 75% of typical primary care visits are for multiple chronic illnesses. HHS projects that by the year 2020 81 million Americans will have multiple chronic health conditions.
These numbers, along with other changes to the healthcare system, make the practice of medicine far more challenging today for PCPs, particularly those operating independently or in small groups.
On the upside, physicians today have more tools and knowledge available to effectively treat chronic illness, says Thomas Bodenheimer, MD, MPH, adjunct professor of family and community medicine at the University of California, San Francisco School of Medicine. At the same time, however, they have less time to treat each chronic health condition. Bodenheimer says that even though the length of the primary care visit has increased slightly to roughly 18 minutes, there are an average of 7.1 issues that have to be dealt with during the patient’s time with his or her physician. “Those are the issues that the patient brings up, or things that the physician feels need to be dealt with. That means it’s about 2-1/2 to 3 minutes per issue, which is almost impossible to deal with,” he says.
Still, experts say small practices can put in systems and resources in place to better manage the chronic health conditions of a patient population, while also helping their practices.
“I think the first, most important thing to communicate is that there are resources that can help the private chronic care physician,” says Jay Shubrook, DO, associate director of clinical care at the Diabetes Institute at Ohio University in Athens, Ohio, and spokesperson for the American Osteopathic Association.
Some practices around the country are putting team-based care into action, in part by training practice staff to help them develop a set of skills that allows the physician to delegate to them much of the low-complexity work, such as making sure patients receive preventive services including immunizations and colon cancer screenings, Parchman says.
“Now, there are times in which I need to have a conversation with a patient around things like, should you get a PSA for prostate cancer; that’s a difficult shared decision to make,” he says.
Parchman says that another commonality among practices taking full advantage of the team-based approach is that staff have clearly defined roles but with a lot of task flexibility. For example, he says, “My role here is I’m the RN, I do the triage, I do the care coordination, and case management of complex patients, and I’m here for emergencies. But I can do almost any task in the clinic if need be, and I have my radar scope on all the time, monitoring everybody in the clinic to see who is falling behind, how can I pitch in and help them catch up.”
Working with specialists
Another trend Parchman sees is small- to medium-sized practices reaching out to specialists and developing written agreements about referrals and referral management. The goal is to make sure that as the PCP you maintain full knowledge of the care your patient receives elsewhere. These agreements should require, as a condition of continued referral that specialists agree to forward a written report following a visit, and to address no more than the specific problem the patient was referred for.
The message to the specialist, Parchman says, is “Your responsibility is to not take over the management of my patient, but to send my patient back to me. Your responsibility is not to make multiple secondary referrals to other specialists that I don’t know about, without coming back to me as the PCP.”
A significant part of adherence and lifestyle modification for improved management of chronic conditions involves educating patients. “Studies have shown that if people know their numbers and know their goals, they do better than people who don’t, and most people don’t know,” Bodenheimer says.
Incorporating motivational interview techniques, putting action plans in place, and working with patients on medication adherence, while time consuming, have been proven to improve care. This is an area where training staff, such as medical assistants, to prepare the patient for the physician visit, conduct motivational interviewing, check and preload medications that require refills, and then link patients to community resources or make other referrals can go a long way toward improving care while freeing up a physician’s time.
In addition, Bodenheimer says, patients can be trained as health coaches. “We did a randomized control trial of training patients with diabetes to be health coaches for other patients, and the patients who had coaches did better than the patients with usual care,” he says.
An important component of health coaching is that staff work with patients to set small and achievable goals. “Any time they make improvements, you can give credit for that. I think those small pieces, not just chiding your patient, recognizing the small achievements, helping them to reach their goals, take a lot less time than you think, and they have a huge impact on adherence,” Bodenheimer says.
The group visit is not a new concept, experts say, and it can be effective. But there are barriers to putting group visits into effect. “The problem is that the administrative work required to actually make group visits happen is considerable, so it’s tough to do in a small practice,” Bodenheimer says.
As an alternative, he suggests small practices consider something called a mini-group visit. “Instead of seeing one patient with diabetes for 15 minutes, you see two patients with diabetes for half an hour, or three patients with diabetes for 45 minutes, all at the same time,” he says.
This model offers the advantages of the group visit with the physician spending more time with patients, and with patients able to interact with each other. This is very effective in encouraging patients to better manage their illness. “Those are very easy to set up,” Bodenheimer says. “You just ask the patient if it’s okay if they come in together with another patient who has the same problem. The patient says okay, you do it, and if they like it, you keep doing it.”
Each patient can be billed, giving this model the potential of increasing productivity, according to Bodenheimer. Instead of the 15-minute visit, “You could see two patients in 20 minutes, which would probably be doable. That would save you 10 minutes of time that you could use for other patients, or for recovering, or doing your paperwork.”
Developing new programs
In his own practice, Shubrook set up a diabetes “boot camp” that involves patients attending several educational sessions. Instead of relying on insurance reimbursement, his practice approached employers interested in helping workers better manage their health. “It required a little bit of work, but less than you might think, to go to these employers,” Shubrook says. “They actually pay our center the whole fee for the participant, with the hope that they’re going to get downstream reduction in costs.”
Use local hospitals
If incorporating a new program into a practice is difficult, experts say there are numerous community resources available. Most hospitals, for example, have educators who can offer health coaching for a variety of chronic illnesses, as well as other resources. Bodenheimer also points to the National Diabetes Prevention Program, a public-private partnership of community organizations, private insurers, employers, healthcare organizations, and government agencies. The National Diabetes Prevention Program is available in 42 states, mainly provided by the YMCA.
In some parts of the country, houses of worship and other nonprofit healthcare organizations may offer services that practices can use to to help patients gain the knowledge, resources, and support they need to better manage their health.
Electronic health records and registries
“The electronic health record (EHR) is indispensable,” Shubrook says. “You can’t do good managing without it.” One way in which it’s useful in the primary care setting, he adds, is by highlighting the quality of care being provided and using the information to make needed adjustments.
“Universally, physicians, including myself, overestimate the quality of care we provide,” Shubrook says. “And that’s not saying that we’re trying to be deceptive. It’s just that we think we’re doing more than we’re really doing.”
An EHR allows physicians to see what they’re doing more objectively, and to make adjustments to address issues that arise, including specialists not informing PCPs about the tests they are referring patients for, such as diabetic eye exams.
In addition, registries of patients with diabetes, asthma, or other chronic illnesses are critical to managing patient care. “Having an electronic disease registry is very helpful for looking at your whole population and really trying to work on everyone in your panel of patients being in reasonable control and getting the periodic tests that they should have on time,” Bodenheimer says.
Parchman points to several ways in which practices around the country are using registries to better manage chronic illness in their patient population. First, he explains, they often assign one person-such as an RN or a medical assistant-to be the registry lead. This person spends a few hours a week reviewing the registry and determining which patients are behind on tests or other needed services. Then they contact the patient.
“The second thing we see them doing is figuring out ways to use health information technology (IT) that improves their workflow and their work processes during the day,” Parchman says. For example, it’s a good idea to ask the practice IT support person to join morning huddles. The idea is that by hearing the workflow challenges staff is facing, he or she may be able to recommend an IT-based solution.
Finally, many practices are successfully using their IT systems to incorporate care coordination for patients that are at high risk for emergency department visits, hospitalization, falls at home, and adverse reactions to medications “What they’re doing is risk stratifying their patient population-identifying those high-risk, complex patients,” Parchman says. He adds that having resources in the practice, or working with regional health plans to identify a resource that can do proactive monitoring of patients improves quality of care.
The demand for primary care will grow given our aging population, the implementation of the Affordable Care Act, and the increases in chronic illnesses such as diabetes and other conditions related to obesity, experts say. And though this adds to the pressure, it also presents opportunities, according to Shubrook.
“I do think it’s important to highlight, particularly to PCPs, that there’s a real hope that things are about to get a lot better,” Shubrook says. “Because chronic disease management is killing the healthcare system, and because at least there are attempts to sort of change the incentives around it.”
Source: Centers for Disease Control and Prevention