Solving the adult primary care crisis: it s time to think differently

Transcription

1 Solving the adult primary care crisis: it s time to think differently Thomas Bodenheimer MD, MPH Center for Excellence in Primary Care (CEPC) UCSF Department of Family and Community Medicine

2 Presenter Disclosure No personal financial relationships with commercial interests are relevant to this presentation.

3 Adult primary care crisis Plummeting numbers of new practitioners entering primary care Declining access to primary care Practitioner burn-out Unsatisfactory quality The primary care medical home is falling off the cliff

4 Residency Match, % of graduating US medical students choosing specialties 2010 NRMP Main Residency Match data 2012: Adult primary care = 9.6%

5 Why are US med students avoiding adult primary care Money Worklife Medical school culture

6 Stressful worklife Survey of 422 general internists and family physicians %: work pace is chaotic 78%: little control over the work 27%: definitely burning out 30%: likely to leave practice within 2 years Linzer et al. Annals of Internal Medicine 2009;151:28-36 An estimated 30-40% of US physicians experience burnout Physician burnout is associated with poor patient experience and reduced patient adherence to treatment plans Dyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.

7 Joy in practice??? Burnout Joy Ambitious goal

8 Percent change relative to Adult Care: Projected Generalist Supply vs Pop Growth+Aging Shortage of 40,000 adult primary care physicians by Demand:adult population growth/aging Supply: family medicine, general internal medicine Colwill et al., Health Affairs, 2008:w

9 NP/PAs to the rescue? New graduates each year Nurse practitioners: 8000 Physician assistants: 4500 % going into primary care NPs: 65% PAs: 32% Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care clinician to population ratio will fall by 9% from 2005 to Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.

10 Is there a shortage of specialists? No 46.3% of specialty visits are for routine follow-up and preventive care for patients already known to the specialist Most of these visits could be better handled in primary care Primary care provides better preventive care, better adherence to treatment, lower costs Valderas et al, Ann Fam Med 2009;7:104; Bindman and Grumbach, JGIM 1996;11:269; Welch et al, NEJM 1993;328:621.

11 Panel sizes too large to manage Average primary care panel in US is 2300 PCP with panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care [Yarnall et al. Am J Public Health 2003;93:635] PCP with panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care [Ostbye et al. Annals of Fam Med 2005;3:209]

12 The dilemma

13 Re-defining the crisis The crisis is currently defined as an adult primary care physician shortage In fact, it is a demand-capacity mismatch Demand for adult primary care services is greater than the capacity to provide those services Yet adult primary care capacity can be greatly expanded without thousands more MDs, NPs, and PAs

14 Adult primary care: capacity vs. demand It s not only about doctors Percent change relative t Share the care Demand for care = Capacity to provide care Thinking differently

15 Practices can add capacity without adding MDs, NPs, PAs How? By sharing the care among the entire team High-performing clinics have done it These clinics have same-day or same-week access without reducing panel size

16 Group Health Olympia 23 High-Performing Practices Martin s Point- Evergreen Woods Multnomah County Health Dept Allina Fairview Rosemont Clinic Mayo Red Center ThedaCare Harvard Vanguard Medford Brigham and Women s and MGH Ambulatory Practice of the Future Clinic Ole Sebastopol Community Health La Clinica la Raza de Univ of Utah- Redstone Clinica Family Health Services Medical Associates Clinic Mercy Clinics Quincy, Office of the Future Cleveland Clinic- Stonebridge North Shore Physicians Group Newport News Family Practice West Los Angeles- VA South Central Foundation CEPC High-Performers study ABIM Joy in Practice study

17 10 Building Blocks Patient-centeredness is not a separate building block Increasing capacity is not a separate building block Joy in practice is not a separate building block All building blocks should support these goals 5 Patient-team partnership Prompt access to care 6 7 Population management Template of the future Coordination of care Continuity of care Engaged leadership Data-driven improvement Empanelment Team-based care

18 10 Building Blocks Team-based care 10 Template of the future Population management 8 9 Prompt access to care Coordination of care Patient-team partnership Population management Continuity of care Engaged leadership Data-driven improvement Empanelment Team-based care

19 Building Block #4: Team-based Care Culture shift: Share the Care Stable teamlets Co-location Standing orders/protocols Defined workflows and roles workflow mapping Training, skills checks, and cross training Ground rules Communication huddles, team meetings, and constant interaction

20 Team-based care: stable teamlets Patient panel Patient panel Patient panel Clinician + MA teamlet Clinician + MA teamlet Clinician + MA teamlet RN, behavioral health professional, social worker, pharmacist, complex care manager 1 team, 3 teamlets

21 Clinician satisfaction with teams San Francisco Dep t of Public Health primary care clinics n=135 Teamlet (work with same MA) (n=27) Team (work with group of MAs) (n=90) No teams (work with different MAs) (n=18) Satisfied 70% Not satisfied 15% Neutral 15% Satisfied 37% Neutral 28% Not satisfied 35% Neutral 28% Satisfied 11% Not satisfied 61% Stable teamlets reduce burnout

22 Share the Care: what does it mean? Non-clinicians assuming responsibility for care that does not require a MD/NP/PA level of training Key aims of sharing the care: Improve access in a primary care clinician-shortage environment Reduce clinician burnout

23 Share the Care: preserving the relationship Share the Care means that the personal clinician (MD, NP, PA) does not provide all the care To preserve patients relationship with the personal clinician, sharing the care should take place in the teamlet The relationship changes from patientclinician to patient-teamlet

24 Building Block #6: Population-management: stratifying the panel Panel Management: Ensuring that ALL of the patients in our panel get recommended preventive and chronic care

25 Sharing the care using panel management Panel management Medical assistants use preventive care and chronic disease registries to identify patients overdue for routine services and arrange for those services to be performed Physician-written standing orders are needed to empower the medical assistants Quality of preventive services improves [Chen and Bodenheimer, Arch Intern Med 2011;171:1558] An estimated 50% of all preventive care activities could be shared with medical assistants [Altschuler et al, Annals of Family Medicine 2012, in press]

26 Preventive services: old way Mammogram for 55-year-old healthy woman Old way: Clinician gets reminder that mammo is due At next visit, clinician (maybe) orders mammo Clinician gets result, (sometimes) notifies patient

27 Preventive services: new way MA (panel manager) checks registry every month If due for mammo, MA sends mammo order to patient Result comes to MA, if normal, MA notifies patient If abnormal MA notifies clinician and app t made For most patients, clinician is not involved For women who want or need mammogram, clinician is involved for discussion Similar for colon cancer screening Requires standing orders 50% of preventive care can be re-allocated away from the clinician [Altschuler et al, Annals of Family Medicine 2012;10:396]

28 Stratifying the panel Health Coaching: Helping patients with chronic conditions to improve their selfmanagement. MA health coaches, RNs, health educators, peer coaches

29 Sharing the care using health coaching Health coaching Medical assistants trained as health coaches can assist patients with chronic conditions to learn about their disease, engage in healthier behaviors, and increase their medication adherence [Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369] An estimated 25-30% of all chronic care activities could be shared with medical assistants [Altschuler et al, Annals of Family Medicine 2012;10:396]

30 Health coaching in the teamlet model

31 Chronic care: hypertension: old way Clinician sees today s blood pressure Clinician refills meds or changes meds (maybe) Clinician makes f/u appointment No one addresses med adherence Often blood pressures are not adequately controlled

32 Chronic care: hypertension: new way Patients with abnormal BP contacted for pharmacist, RN, or health coach visit Health coach does education, med adherence, lifestyle change Patient taught home BP monitoring If BP elevated and patient med adherent, RN/pharmacist intensifies meds by standing orders If questions, quick clinician consult Health coach f/u by phone or Clinician barely involved Blood pressure control improves with this innovation [Margolius et al, Annals of Family Medicine 2012;10:199]

33 More sharing the care opportunities RNs can treat uncomplicated UTIs, URIs, STIs, and low back pain without clinician involvement with equal quality and better patient satisfaction Physical therapists can manage low-back pain with better functional relief and patient satisfaction compared with primary care physicians RNs or pharmacists could care for a sub-panel of patients with diabetes, hypertension and/or hyperlipidemia with minimal clinician involvement RN complex care managers can provide much of the care for time-consuming, complex, high-utilizing patients Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199, Bodenheimer and Berry-Millett, RWJF Synthesis Project, December 2009

34 Take-home points Re-define the adult primary care crisis It is not only a doctor shortage It is a demand-capacity mismatch A substantial portion of the demand can be met by non-clinicians who share the care This requires high-functioning teams with standing orders to empower all team members It won t happen without payment reform

35 Adult primary care: capacity vs. demand It is possible to solve the adult primary care crisis without 40,000 more doctors Share the care Demand for care = Capacity to provide care We must think differently

36 Share the Care 10 Building Blocks of High- Performing Primary Care 10 Template of the future Willard and Bodenheimer California HealthCare Foundation, April Prompt access to care Coordination of care 6 7 Patient-team partnership Population management Continuity of care Engaged leadership Data-driven improvement Empanelment Team-based care