Here's how CPC+ benefits patients

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

For the third segment in my CPC+ (Comprehensive Primary Care Plus) blog, I have interviewed an RN who is now working solely as a CPC+ nurse, and we discussed some of the benefits to the patients from the CPC+ program and some of the difficulties with it. Remember that CPC+ is a national model for primary care that encourages quality care along with more intensive care for the sickest patients in the hopes of saving money and transforming health care.

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L.R.  What is different about being a CPC+ nurse versus a traditional triage nurse?

D.S.  CPC+ has a very different model. When you are doing everyday office nursing, the encounters tend to be more reactive, and with CPC+, you are being more proactive. Also, there is more opportunity to encourage and teach patients to be more proactive with their own health. In some respects, they are very similar roles. Many days you put out the fires first in both situations, but with CPC+, you then go on to check in with the patients to be sure they made it to their specialist appointment and had their labs done. It becomes important with CPC+ to help support self-care and autonomy.

L.R.  What advantages do you see in the CPC+ program?

D.S.  Encouraging patients to take better care of themselves is a big plus. Also, keeping the communication between PCPs, specialists and family caregivers is very advantageous.

L.R.  How often do you check in with patients?

D.S.  General check-in for most patients is two to four weeks depending on the severity of the diagnoses and the living situations. Occasionally, the patient will have something episodic that puts them at higher risk, and I could be checking in more frequently until things have resolved or are at least more stable.

Next: Patient numbers and the value of CPC+

L.R. How many patients are you currently managing?

D.S.  Our office currently has 170 patients that are considered high risk, with more on the way as providers recognize more need. We are looking to hire more CPC+ clinical help.

L.R. Do you seem to talk with the same difficult patients over and over or is there a wide variety of issues and patients? And what do find are the main diagnoses you help to manage?

D.S. With 170 patients enrolled, there is a wide range of patients that I talk with, but there are certain patients that are having exacerbations of a condition and I will speak with these patients more frequently. When one of these patients is in crisis, I will check in with him/her more often to help get them back to baseline or perhaps even improve. The main diagnoses are diabetes, COPD, chronic pain, heart disease, cancer and depression.

FURTHER READING: This is how CPC+ is changing physician offices for the better

L.R. Do you think the money the government is investing in this program is worth it?

D.S. Any program that is set in motion to ultimately keep our patients healthier and to encourage autonomy certainly in theory should be worth its weight in gold. We are providing an enhanced opportunity for patients and caregivers to communicate with their practitioner.

L.R. Do you think you are cutting down on ED visits and hospital readmissions?

D.S. This program is striving to give patients more access to care, care continuity, comprehensive care management and transitional care management. So, hopefully with these goals in mind, we will be seeing a decrease in ED visits and hospital readmits. Sometimes it is hard to teach an old dog new tricks, and if patients are having a crisis at home, they may seek out the ED as a first choice. We are working on changing those habits and teaching patients to call the office first if possible.

Next: The effects of social issues

L.R. How often are social issues coming up and what are these issues?

D.S. Social issues come up daily. These can include transportation needs and in-home needs. We have referred patients to local food pantries and directed patients to legal aid. We now have a behavioral health counselor embedded in our office one half day a week to help our patients deal with depression and anxiety. Personally, I feel that patients need more ‘soft touches’. The more we ‘touch’ them and check in on them, the more confident and in control of their own issues they feel. When a healthcare team can set goals and promote patient activation of those goals, it can increase a patient’s own health literacy. Social issues play a huge role in the overall health of a patient and need to be addressed.

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L.R. From the interview, it certainly seems that working more closely with patients who have more need is very gratifying for the clinical staff involved. It also sounds like the CPC+ model may be able to make a difference for our sickest patients with hopefully less ED visits and less hospital admissions. Patients will need some re-education on the best way to handle their chronic illnesses and acute flares. As this occurs, it should make a vast difference in quality of care and improve the healthcare situation of our patients.  A win-win for all involved.