While it is well established that primary care is at the critical core of all the evolving patient-centric, value-based healthcare delivery system plans of the future, it seems to me that our current primary care physicians and practices are not optimally organized to operate with top efficiency as we refocus our systems differently to fully achieve the quadruple aim for healthcare (improved patient experience of care, reduced total cost of care, improved quality of care, and improved healthcare provider well-being). This is becoming increasingly apparent as old systems are disrupted by new ideas for care delivery founded on meeting our patients/customers where they are rather than trying to fit those new patterns of care into and simultaneously preserve our traditional models of care. The system is in flux and both doctors and patients are currently feeling distressed and disenfranchised.
In my recent posts I have lauded a new book, Reframing Healthcare: A Roadmap for Creating Disruptive Change by Zeev Neuwirth, MD. who describes the evolving healthcare world and how to make the necessary changes to improve our healthcare system in all the necessary ways. Dr. Neuwirth is a traditionally trained primary care internal medicine specialist who understands both the current training and practice of our primary care physicians and the evolving trends in the healthcare revolution very well. He fully understands the core role that primary care doctors, nurse practitioners, and physician assistants and their support teams currently play and the pressures that the changing healthcare scene is putting on them that often can make them less than fully effective and certainly very frustrated. So he has analyzed and broken down his concept of primary care medicine into specific areas of focus based on different needs presented by the patients each segment sees. He suggests that primary care delivery can be more efficient and more effective if we reorganize our primary care system into sub-systems focused on addressing each of those areas of need.
Thinking about what our different customers need from the healthcare system, Dr. Neuwirth suggests redesigning primary care delivery into 6 main areas of focus:
“On-Demand, Urgent Care” – for fast, convenient, inexpensive service to address simple problems,
2. “Complex-Chronic Care” – to keep people with multiple, complex medical issues as functional and comfortable as possible and to optimize and streamline their care by thoughtful use of medical resources,
3. “Condition-Specific Care” – to use the latest technology to customize and optimize continuous care for a specific predominant condition,
4. “Continuity Care” – long-term, relationship-centered care as a health-coach and system guide for the long haul,
5. “Wellness Care” – to optimize energy, vitality, connectivity, and resilience.
6. And Dr. Neuwirth also envisions a technology-driven “Coordinating Platform” to electronically integrate and analyze the efforts of all these divisions of the new primary care system and enhance communication between all the divisions and customers too.
Dr. Neuwirth had depicted his proposed system as such:
From:Reframing Healthcare, Dr. Zeev Neuwirth
As a long-time family physician, traditionally trained to address about 90% of my patients’ needs right in my own office, my first reaction to this breakdown of tasks, as with many recent disruptive ideas, was knee-jerk opposition. My nature and teaching was to try to be all things to all people on all levels just as much as possible, and then guide my patients to the proper specialist for the rest. But, after pausing to consider the demands of current practice, I have to admit that there are so many nuances and new ideas springing up on each of the levels of primary care described by Dr. Neuwirth, that it is increasingly hard, probably impossible, and certainly overly taxing, for an individual practitioner to try to consistently perform at the highest level in each area for everyone. That realization is backed up by superior outcome-based data from new ventures in today’s healthcare that focus solely on delivering each of the segments of primary care (well documented in Dr. Neuwirth’s book).
So I have been thinking a lot about the process for how one might redesign a traditional healthcare system for primary care providers to address this type of breakdown of types of care. To start, I came up with a slightly different design than Dr. Neuwirth’s.
I would use his construct but combine his last three categories (Continuity Care, Wellness Care, and Coordinating Platform) into one that we might call “Ongoing Care Management”. Based on my background in Family Medicine, which is all about long-term relationships with patients and families, getting to know their medical and emotional needs, and helping them to prevent illness and achieve their best health possible, I think that model still works. Ideally all customers of the practice would have an “Ongoing Care Management PCP” but they may utilize that PCP differently, depending on whether Urgent Care, Chronic Care, or Condition-Specific Care applied more appropriately. The Ongoing Care PCP could definitely be helped by a subsystem of the same practice to focus on Condition Specific chronic problems (like diabetes and heart failure) to achieve optimal management by using all the latest medicines, lifestyle efforts, and technology. Likewise, having help from a subset of the practice to co-manage those with multiple, Chronic Complex medical issues and coordinate all the services required to optimize their comfort and function would distribute the workload in a much more effective manner and likely result in better outcomes for patients. Off-loading some of the simple, quick medical issues to Urgent Care might also help to distribute the work burden more realistically.
Note that I keep saying that these services should all be through the same practice if possible, as the coordination of the different elements of the new primary care practice will be critical for efficiency and enhanced effectiveness. In addition, each segment will be responsible for measuring and improving its own performance. But the bottom line of responsibility for patient outcomes would have to rest in one main area, which I think should still be the Ongoing Care Management PCP.
I would also add another element to the coordinated primary care bucket that I’ll call “Hospital Care Management” to provide a continuum of acute inpatient hospital, acute outpatient hospital, sub-acute rehabilitation, and skilled nursing facility care. These require specific skills and certainly need to be better coordinated with our outpatient primary care practices than currently happens. But the skills required and the necessary close relationship to outpatient care make this segment a natural province for primary care practice.
My proposed system might look like this:
The next challenge will be how to make the actual transition from one-size-fits-all to the proposed focused segments in a primary care setting. It seems that the most logical approach will be to first determine areas of interest and expertise for each provider. This will require careful planning, strong, decisive leadership and adequate funding to motivate willing participation, reorganize staffing, adjust the EHR to optimize communication between segments, etc. Then the practice will have to create the necessary unique, dedicated environment and support structure to help each specific area succeed. A practice could proceed to make global changes all at once, but would probably be better advised to create the new divisions within primary care one at a time to make sure that each works well and is well integrated with the rest before adding more.
Thinking specifically by PCP segment, On-Demand, Urgent Care is the most straightforward, as these sites already exist and the guidelines are established. Staffing could be mostly by nurse practitioners and physician assistants with strict protocols and appropriate physician oversight. The emphasis on easy access will make extended hours, simple patient interfaces, and telehealth some of the key principles and provide appropriate patient-satisfying, cost-efficient care. Appropriate geographic distribution is also a key component of accessibility. Real-time communication and coordination with all the other primary care segments will be crucial.
My Ongoing Care Management practice will also look a lot like current primary care medical home practices with patient-centered, team-based care, emphasis on accessibility, prevention, population-health and wellness and will have more traditional hours but add-ons like telehealth and email patient portals for multiple customer uses. The technology for coordinating care, like medication reconciliation, will mainly reside here, but also be prominent for the other segments to use concurrently. Embedded adjunctive mental health services will largely relate to this segment, but also significantly to the complex chronic care segment. Most current PCP’s will adjust comfortably to this focus, especially those used to team-based care.
Complex Chronic Care practice will be a new subdivision within the primary care practice marked by multidisciplinary teams including case managers, palliative care specialists, community outreach and other extended services. The physicians, as team leaders, will be able to spend the necessary time to truly identify and address patients’ medical and psychosocial needs. Most issues around the social determinants of health reside in this segment. Advanced directives are also a critical component. It will take a motivated, caring, thorough, and analytic personality who likes to work in a team to excel in this division.
Condition-Specific Care will be an area for education, innovation, and applying all the latest management technology for specific conditions to provide optimal management in real-time. Other techniques like group visits are also important here. The technophiles and those who like to drill down into details of a single subject are best suited to this task.
Hospital Care Management practices will not differ greatly from those existing today but there will be new emphasis on efficiency (for cost control), coordination, and communication between all levels of care, especially back to the Ongoing Care Management segment of the practice. This should be facilitated greatly by being part of the same primary care practice with shared goals, incentives, and processes. An integrated record system will by critically important. Those interested in the acute care and rehabilitation of the sickest patients will flourish here.
The segmentation of primary care practice has huge implications for how we train our new cadre of primary care physicians. Our existing family medicine, internal medicine, and pediatric programs need to address not only obtaining a sound fundamental medical knowledge base, communication, empathy, and care management skills, but also now will need to offer training in the specific skills required for each new division of primary care practice, including the latest communication and monitoring technologies. Then they should also offer the opportunity for residents to choose an area of concentration and spend dedicated time to hone their skills in that particular segment of practice. This will require a significant reorganization of those programs, especially their outpatient clinic models, which will need to reflect the new order.
Since the redesign and implementation of primary care practices is new and there are different variations of how each system may choose to re-organize, different medical records to accomplish this, different support systems and apps to choose from to augment and improve care, it seems that there will be real advantages for healthcare systems to create or incorporate their own primary care residency programs. This should greatly ease the transition from training to practice due to familiarity with the system and also be an important source for steady renewal of a system’s primary care workforce. Over time a consensus on best systems and best practices may develop, but right now we are still in a period of innovation, experimentation and rapid cycle improvement to find those best practices. Technology for primary care practice support is still in its infancy.
Clearly there is a very significant cost attached to designing and making these changes to our primary care system. Much of the resistance to these necessary changes will be driven by our current, traditional, fee-for-service reimbursement system that is not designed to address these new patterns of care. That makes it financially difficult for healthcare systems to adopt the necessary changes for which there is often no mechanism to provide revenue. So there needs to be a leap of faith commitment to start funding these changes and a concurrent shift to value-based payment (with adequate allowances for sustaining the system through the necessary learning curve). I believe that it should not be too long before the elimination of waste expenditures, reduction in hospitalizations and expensive specialty care, and overall greater efficiency should fully make up for the initial extra costs and more. And, above all, the increased quality of care and patient satisfaction itself will make this major shift a worthwhile endeavor.
I know that this is a brief review of a very complex subject. But we have to start these discussions and start to make changes NOW in order to make healthcare become what it needs to be before we frustrate our customers and our providers any more than they already are and bankrupt our system. It is high time to examine everything we are doing currently in healthcare delivery systems and begin to make the necessary changes to improve them. Despite its recognized central importance, primary care delivery is no exception. The process will take time, but improvements can and must be made for the benefit of both customers and providers and our economy.