Improve the triple aim by adding a fourth: Provider satisfaction

My husband and I had a family practice in Arcata, California, for 28 years, during which time we learned the importance of addressing the patient’s context outside of the medical visit in order to maximize health and self-efficacy.

We went to great lengths to keep patients out of the ER and hospital.  I saw one patient with massive pedal edema twice weekly for months to wrap her legs, since she lived alone and was unable to wrap them herself.  Throughout this time, she had no ER or hospital admits for ulceration or infection.

However, she insisted on sleeping in her recliner despite my pleading that her hospital bed was much better for relieving her dependent edema.  Home health had “fired” the patient because she would not comply.  Eventually I made a home visit to see why she would not use the hospital bed and found that she was trying to get in it when it was raised up and the head and feet were elevated, rather than flattening the bed out so she could swing her legs up.  We were finally able to figure out how she could get in and out of bed, and elevate her feet more effectively.

My husband and I are now looking forward to providing this type of comprehensive, individualized care with the support of an entire team in a new patient-centered medical home.

Because of our experience in health policy through our administrative jobs – I served as county health officer and he as medical director of the local IPA – and years of delivering patient-centered, team-based care in our small practice, we were recruited and supported by Stanford to set up an innovation clinic for employees with complex chronic conditions.

Our leap out of a happy rural lifestyle into an academic setting was nudged along by the fact that our two grown children and first grandchild live in San Francisco. We are fully capitated by Stanford – no billing, which takes 20% of some doctors’ time! – to care for employees and their dependents with chronic complex conditions who are not ‘doing well,’ and are among the top 20% of high spenders in the health plan.  In medical parlance, we are running an ambulatory ICU, but our Patient Advisors did not like that concept and named our clinic Stanford Coordinated Care. Our targeted patients have either lost hope or are simply overwhelmed by disjointed specialty care.

We have assembled a team with a physical therapist who specializes in pain management; a behavioral health specialist, an RN, a clinical pharmacist and three care coordinators.  Care coordinators will serve as medical assistants, but more importantly, they will have their own panel of patients for whom they will coordinate care, coach, assist with medication issues, and do whatever it takes between visits to promote self-management.  The ratio of care coordinator to MD is 3:1.  Patients who do not want to leave their primary care clinician for our services can opt for Chronic Care Support by our nurse or licensed clinical social worker. The entire clinic staff has had training including motivational interviewing, quality improvement, assessing patients’ level of activation and the four domains contributing to their health: medical neighborhood; medical status and health trajectory; social support; self management and mental health.  We will measure our success as the triple aim: improved patient experience, improved clinical outcome and reduced costs. As part of a skilled team, I do not feel overwhelmed caring for very complicated patients.  We get the satisfaction of doing the job right without feeling overwhelmed.

It has been exciting to have the resources to put ideas grown out of a long career into practice.  Our service-intensive model is justified for patients whose care is most costly as savings offset the expense.  The model could have a role in risk-bearing managed care settings or as part of an employer’s health plan. Each patient is different, but hospitalizations and ED visits are consistent contributors to high cost.  While the model of care we are developing may not be directly applicable to a general primary care practice, there are lessons to be learned about patient-centered care and team-based care. We feel like this is just the tip of the iceberg of innovations in primary care – innovations that can not only improve the triple aim, but contribute to the fourth aim: provider satisfaction.

Ann Lindsay is a family physician who blogs at Primary Care Progress.

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