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5007ac119026da42397d8344edfa1d8f-huge-ffIt's Medical Assistants Recognition Week. Today on the blog, a former PCP chapter member shares how he learned first-hand the importance of MA's to the primary care team. 

By Adam Nelson

“We’ll each do a few and that way it will go faster for the baby,” said Amanda, the medical assistant (MA) who was teaching me how to vaccinate a two-month old.   “Always save the empty bottles, because you enter the lot numbers into the computer later on.” Then she handed me two syringes.  Entering the room with an assortment of needles in hand, I was a bit uneasy about sticking those needles into this sweet, tiny person. I winced slightly watching Amanda give the baby the first shot in her leg, and then I followed suit. Gently holding her other leg and avoiding the temptation to hesitate, I delivered two injections into the baby’s thigh. This was followed by a bright blue Dora the Explorer band-aid, which probably did more to make me feel better than the baby. Aside from the crying, everything went fine and our patient was now doing her part for herd immunity. 

This was a typical afternoon in my community clinic during the first two years of medical school. My class was the first to be afforded this early introduction to clinical medicine. Starting in our first year, each of us spent two afternoons per month with an assigned faculty preceptor in a primary care clinic. At first, my task was to learn and ultimately play the role of the MAs, the idea being to understand the workflow of the clinic from the ground up. I learned how to room patients, start patient notes and interviews, record vitals, draw blood, and administer shots and rapid strep tests. I was glad to have the time to learn, practice and become proficient at these skills. And in learning to function as an MA, I began to realize just how essential non-physician staff members are to a smoothly running clinic. My lecturers constantly spoke of medicine as a team-oriented enterprise, but I was struck nonetheless to experience this firsthand.
As the months passed and I entered my second year, my role evolved and I started working more directly with my attending physician. My job was now closer to that of a beginning third-year medical student in a more traditional curriculum. After rooming patients, I gathered their history and performed a focused physical exam. In addition to developing clinical skills, I was now able to observe the role of the MAs from the perspective of the physician. From here, I could more fully appreciate that physicians serve as leaders in the team approach to medicine. It was apparent that effectively directing the efforts of other team members required a good understanding of the scope of their work. And not just the scope of the MAs’ work -- I saw here that physicians are expected to lead all the professionals that contribute to patient care: nurses, pharmacists, social workers, mid-level practitioners and consulting physicians. Although it is daunting to know that patient care today requires orchestration of so many different resources, it is a relief to know that physicians have so much clinical support.
Now as a third-year on wards, I am grateful to have had this introduction to clinical medicine. For one, it served as a relatively low-stakes arena where I was able to develop basic skills before launching headlong into clerkships. More importantly, I was able to experience the concept of a medical care team from multiple perspectives. For me, the result was a better understanding of and respect for the team approach to medicine and those who work within it. As a third-year, I have already been able to apply this experience when working with nursing staff and support personnel on the wards. The delivery of health care is rapidly changing in order to accommodate increasingly complex patients as well as more restrictive financial demands. Early introduction to clinical medicine and, specifically, letting students become familiar with the roles of other health care professionals, is one innovative way medical education can adapt to ensure physicians are able to meet these increasing needs. 
When this piece was published in 2012, Adam Nelson was a third-year medical student at the University of Utah. His class was the first to participate in a revised curriculum that integrates primary care exposure into the first two years of medical school. 
Posted by Sonya Collins on Oct 20, 2016 12:26 PM EDT
72145da9e1b223c986c45c5b47158be8-huge-ciIt's National Physician Assistant Week. Here in a post from our archives, the Physician Assistant Program director at Case Western Reserve University calls for P.A.s to step up and help create the change we need in primary care.

By Cynthia Booth Lord, M.H.S., P.A.-C

Last month I was in a store and I saw a young child fall to the ground after appearing to have fainted.  I approached the crowd that quickly gathered and introduced myself to the child’s parents and said I was a P.A. and I could help.   Immediately the crowd moved back as I proceeded to evaluate and help the child until EMS arrived.  I gave a report, the parents thanked me profusely, and I wished the little girl and her parents well and went on my way.  As I drove home that day I thought about the fact that no one asked me “What is a P.A.?” or “Are you qualified to help?”   Instead, they said, “A P.A., that’s great, would you mind helping us?” 

As I get ready for the week-long celebration of both P.A. Week and National Primary Care Week, I am reminded of the incident with the little girl because it shows just how far the P.A. profession has come in a very short time.  But the path has not always been easy.  I reflect back on a few years ago when I was serving as president of our national association, the American Academy of Physician Assistants (AAPA).  We were in San Diego at our national conference, and I walked from the convention center to the House of Delegates with Mrs. Estes, the wife of Dr. E. Harvey Estes, one of the founding fathers of the P.A. profession.  In her soft spoken North Carolina accent, Mrs. Estes shared stories that demonstrated just how hard Dr. Estes and Dr. Eugene Stead (Duke) had to work to create our profession.  She said that every night Dr. Estes would get calls at home from his physician colleagues, to argue all the things they thought a P.A. could not and should not do.  She talked about those who would call and say, “Harvey, P.A.s cannot do physicals.  They cannot order tests.  They certainly cannot write prescriptions.” And every night Dr. Estes would calmly say, “Yes they can; P.A.s can do that.” 
Forty-eight years ago, the P.A. profession was an experiment.  Four Navy medical corpsmen were accepted into the nation’s first physician assistant program at Duke University.  The belief was that P.A.s would provide cost-effective access to primary care and health care, particularly in areas where there were physician shortages. With over 100,000 certified P.A.s today, the profession is a well-established, critical component of our health care system.  It remains a model that is flexible and adaptable as demonstrated by our ability to step in and fill gaps in our health care system as they arise.
Drs. Stead, Estes, Silver, Sadler, Smith had the courage to create a change in our health care system.  Their challenges were real and they each made personal sacrifices to ensure the success of our profession. Dr. Estes’ colleagues believed he had a “brilliant career” ahead of him as a cardiologist and cardiovascular physiologist in electrocardiography. Instead, he saw a different need and chose to help create a new type of medical provider.
Like those physicians and P.A.s in the early days of our profession, we must have the courage to create change. We must revitalize primary care training and education in our country and P.A.s need to step up to that challenge.  The generalist education, commitment to team-based practice and the relatively short but intense training period of the P.A. curricular model could help bring the revitalization that primary care needs.   
The last time I had the privilege of meeting with Dr. Estes, he shared his thoughts about the P.A. profession in the early days, today and in the future.  He spoke of the balance he believes we have created between primary care practice and specialty practice without compromising the original mission of the P.A. 
Like Dr. Estes, we must choose to create a change.  We must have the courage to stand up and say, “We believe in health care that prevents illness before it begins, treats the whole patient, cares for communities, stewards our resources responsibly and is accessible to all.”  We are P.A.s and we believe in primary care.

Cynthia Booth Lord is the program director of the physician assistant program at Case Western Reserve University. 
Posted by Sonya Collins on Oct 11, 2016 2:45 PM EDT
04f5368590761fa224a0fe31ef646392-huge-11It's National Primary Care Week! This year's theme is improving health care access for all. PCP is especially proud of one of its contributions to this mission - the Interprofessional Student Hotspotting Learning Collaborative. As hotspotters, health professional students learn to work together on interprofessional teams. They develop crucial leadership skills while improving health care access for the patients who need it most. Today on the blog, a former member of our hotspotting cohort shares her story.

By Eliza Hutchinson, M.D.

“There was one time when I wasn’t here for seven months in a row,” “Pam” told me.
I sat with Pam in her third floor hospital room – the floor on which she always stays when admitted to the inpatient medicine service – as nurses, doctors, and janitors poked their heads in the door to say friendly hellos and “Nice to see you again, Pam!” A dining facility staff member entered with a tray, letting Pam know, “I brought you the usual, Pam. I missed you!” Pam smiled and joked with the parade of staff members as I pondered this oddly happy reunion. 

I told Pam that the hospital seemed like Cheers for her, as it is a place where everybody knows her name as the show’s theme song says. She laughed and agreed. “I can’t go down the hall to the CAT scan machine without someone stopping to say hello. It’s like home here.”
Later, looking through Pam’s chart, I found her medical problem list, rivaled in length by her list of medical providers, and topped by her number of recent inpatient admissions. I counted a dozen conditions at first glance. Her providers included primary care, urology, pulmonary, otolaryngology, social work, physical therapy, nutrition, nephrology, dermatology, rheumatology, endocrinology, in-home caregiver, Medicaid case manager. Number of inpatient admissions in four years: 42. I was impressed but disheartened and daunted by the number of providers involved in Pam’s care. How could someone attended by so many brilliant minds with world-class skills remain so sick? What could we, a team of six students, possibly contribute to her life?
When I first imagined Hotspotting, I pictured working with stereotypical high-utilizing patients: individuals with complicated socioeconomic and psychosocial circumstances with no continuity of health care. I envisioned that we could help patients establish relationships with primary care providers, obtain bus passes for transportation to appointments, and organize their medications. However Pam didn’t seem to need any of these interventions. She had friends, family, financial resources, biweekly appointments with her primary care provider, and a brilliantly organized system to take her medications at the exact times prescribed. What more could anyone do, especially a group of students with good intentions but few real skills?
During the next several weeks after Pam’s discharge from the hospital, members of our team attended outpatient medical appointments with her and visited her when she was admitted to the inpatient medicine service again. We visited Pam at home and talked with her about her goals. We learned that she wished for greater mobility than she had in her electric scooter but struggled to walk more than several steps without sitting down to rest. This led her to avoid leaving the house to socialize in the neighborhood as she once enjoyed. She wanted to eat better and lose weight, but she relied on her in-home caregiver to cook, and the caregiver tended to cook cheap, unhealthy food. We saw that the kitchen was full of packaged foods and suffered a notable shortage of fresh fruits and vegetables. As we sat in Pam’s living room and explored her hopes, we also discovered that she was caring for her dying mother, often at the expense of her own health and well-being.
These details of Pam’s life would have been difficult to uncover during a 15-minute primary care appointment in an office far from her home. As students with time as our resource, we had the opportunity to understand the determinants of her health in a patient-centered context. Our multiple hour-long visits to her at home, combined with accompanying her to health care appointments, allowed us to better understand her goals and the challenges to achieving them. Accordingly, we are working with her to obtain a rolling walker with a seat, so she can leave the house with an assistive device that not only helps her walk but also allows her to sit for rest at any moment. We are exploring how to help her obtain healthier food through Meals On Wheels. And we can support her when she transitions through periods of grief related to her mom’s illnesses.
While I realize that we will not cure Pam of her chronic illnesses, I like to think that we can make a small impact on the trajectory of her life.  For instance, by helping her obtain a walker, we can encourage exercise and socialization, which may decrease her risk of hospitalization for infections from pressure ulcers. The cost of one hospitalization offsets the cost of a walker many times over. By helping her make healthier food choices, not only can we promote weight loss, but also help her to develop a sense of self-efficacy around her health. This increased confidence may enable her to make other difficult lifestyle changes.
Perhaps most importantly, by listening to Pam’s life’s narrative, we can validate the difficult experiences she has survived. We can also show her that her perspective is valuable in teaching us about a patient’s experience in the health care system and how to live a meaningful life in the face of serious illness. In this way, I believe that the power of storytelling cannot be underestimated. As hotspotters, I see our role as bearing witness to our patients’ struggles and supporting them as they work toward achieving their goals.

Eliza Hutchinson, M.D., is a family medicine resident at Swedish Medical Center. She wrote this piece as a fourth-year medical student at the University of Washington, where she was a member of their hotspotting team. 

Read more about hotspotting. 
Posted by Sonya Collins on Oct 6, 2016 11:44 AM EDT
a5582733b7d0ab1bc38a21f1d4039e2c-huge-imIt's National Primary Care Week! The theme is improving health care access for all. One way we believe that the health care system can do that is through interprofessional team-based care. Many health care providers love the concept, but what to do patients think? That's what we wanted to find out.

By Sonya Collins

Ridie Ghezzi was dealing with depression. Her doctor tried her on one medication, then another, then changed her dose, but it just wasn’t working for her. So she called Amanda Rice, the behavioral health specialist at Dartmouth Health Connect in Hanover, NH, where Ghezzi is a patient.
Rice immediately contacted Ghezzi’s primary care doctor – also at Dartmouth Health Connect – who called Ghezzi that day. The phone conversation was long and unhurried. During the call, the doctor decided to change Ghezzi’s prescription, and she made an appointment to meet with Ghezzi, her health coach, and the behavioral health specialist as a team the next month.

“I felt like the wagons had surrounded me in protection,” Ghezzi recalled.a2e8f0f6d32aa0b1c45cbf1a47c77f6a-huge-24

A same-day call back from a doctor? A long phone conversation? An appointment with three health professionals in the room at the same time? If this doesn’t sound like a typical interaction with the health care system, it’s because Dartmouth Health Connect is not a typical clinic. Its team-based model of care strikes a stark contrast to the solo doctor-does-all, seven-minute-visit model that most patients know (and few love).
By design, team-based practices, also called patient-centered medical homes, have the potential to redistribute provider workload, change the way health care providers get paid, and – in the best cases – put patients at the center of it all. Providers have many reasons to love the model of care, but what do patients think?
Research shows that patients want four things in a medical practice: whole-person care; coordination and communication among providers and between providers and patients; patient support and empowerment; and ready access.
If a health care model by any name delivers those benefits, patients are likely to take to it. “Patients love the concept, but if it’s not operationalized, if the practice isn’t visibly operating as a team, they won’t embrace it,” said Christine Bechtel, co-chair of the Center for Patients, Families and Consumers at the Patient-Centered Primary Care Collaborative. Bechtel co-authored the aforementioned research published in 2010 in Health Affairs.
What is team-based care?
The idea behind team-based care is that doctors cannot – and should not – do it all. They can’t see all the patients, solve all the problems, and complete all the associated administrative tasks in a day’s work. Even if they could do it all, they’re not always the best one for the job. Doctors diagnose, but pharmacists unravel complex medication regimens to discover which one is causing the unpleasant side effects. Dietitians help patients come up with a meal plan to achieve a healthy weight or manage their diabetes. Behavioral health specialists address the mental and emotional issues that may prevent us from achieving optimum health. Sure, doctors can refer patients to these and other specialists, but patients don’t always follow through. And when they do, the referring doctor may never know what happened during the visit.
Team-based care can bring multiple health care providers together under one roof, or it can include a care coordinator who quarterbacks care that happens in multiple settings. Team members can free up their teammates to do what they do best, whether it’s diagnose, manage medications, or optimize a diet.
“It’s not about a doctor just writing a prescription and telling you what to do,” said Amy Gibson, RN, who is chief operating officer of the Patient Centered Primary Care Collaborative. “It’s about bringing [providers] together as partners who can provide expertise. At any given point in time, it may be the behavioral health specialist or some other team member besides the physician who needs to be leading that team.”
Placing patients with the most appropriate health care provider, rather than the doctor every time, can also increase access to all providers for all patients. That’s why some team-based models may offer same-day appointments, email and telephone access to providers, and longer appointments. Team-based models may also allow for innovative payment structures. For example, payers might reimburse practices a flat monthly fee per patient rather than a fee for each service provided.

When it doesn’t work
Simply declaring a practice to be “team-based” is not enough to convince patients. Bechtel selected her current primary care provider because it was a team-based clinic. She has been a patient there for several years now. But every time she goes, she says she feels like a new patient that no one knows. She fills out paperwork for the receptionist, who asks her why she is there. She then sees the medical assistant (MA), who takes her vitals and asks her why she’s there. The MA then leaves her with a doctor, physician assistant (PA) or nurse practitioner, who again asks her why she is there.

6fdda907c4100770eef3b10984c50415-huge-0e“Where is the team part of this? I’ve just been asked why I’m here three times,” Bechtel said. “It’s so obvious to patients when they’re not operating as a team.”
For patients, a team-based model like this one just seems to place more barriers between their doctors and themselves.
“Oftentimes, what patients observe, unfortunately, is that they can’t get to their doctor because it’s ‘team-based,’” Bechtel said. “They ask, ‘Well, what does that mean?’ And the practice tells you it means that all providers can access the medical record and read each other’s notes. But that’s not a team.” Shared access to an electronic medical record may streamline the workflow for providers, but it’s not necessarily a visible improvement in the patient’s experience.
Even the best intentioned team-based clinics may not get full buy-in from patients if patients don’t know what team-based care is. Patients need to be fully oriented as to what the new model offers, what issues it addresses and how patients can make the most of it.
“If no one ever explains to patients what a team-based approach is, that you might sometimes see a different person, but that person is always going to know what’s happening with you and has full access to your doctor and your records,” Bechtel said. “If no one ever says that, the patient experience isn’t going to be good.”

When it works
Team-based care that works puts the patient at the center and addresses the patient’s needs and concerns ahead of those of the provider or payer. “We haven’t done such a good job of knowing and engaging our customer in health care, and we’re trying to make that happen through the patient-centered medical home,” said Gibson.
Whether patients like Ghezzi can cite precisely those four things that research says patients want, the way she describes her experience reflects these values. Her physician teamed up with the behavioral health specialist to address her complaints as a whole person. The providers communicated with each other prior to contacting her and then engaged her in a conversation with them during a group appointment. The quick call-back demonstrated their support for her and her ready access to them.
“Everyone is working together, recognizing that none of these things are separate from each other. Emotional and physical are interconnected,” Ghezzi said. “And you feel, by the kind of care they give, that it’s all being worked on as a whole.”
Is a rose a rose?

Many medical practices can call their model team-based, but that doesn’t predict what the patient’s experience will be. At the same time, whether or not patients even know the name of the model, they will know whether their health care providers are working together as a team with the patient at the center.
“If you build it will they come?” Bechtel asks in the title of her 2010 Health Affairs article on team-based care. The answer, she says, is “if you build it with them, they will already be there.”

Sonya Collins is an independent journalist who covers health care and scientific and medical research. She is the editor of Progress Notes. 

Read more about team-based care.
Posted by Sonya Collins on Oct 4, 2016 9:29 AM EDT
c0360b13e6964753f926952a94499b36-huge-snIt's National Primary Care Week! This year's theme is improving health care access for all. PCP is especially proud of one of its contributions to this mission - the Interprofessional Student Hotspotting Learning Collaborative. As hotspotters, health professional students learn to work together on interprofessional teams. They develop crucial leadership skills while improving health care access for the patients who need it most. Through this program, PCP is helping to develop the next generation of primary care leaders. 

By Stephanie Nothelle, M.D.

For the last three years, the student hotspotting program has allowed teams of health professional trainees from all across the country to take control of the health care system and help the patients left in the shadows. A team of students gave a kidney failure patient – dependent on hemodialysis for her survival – a second chance at survival. After the patient had been kicked out of all the units in her community, the team negotiated readmission to a local unit. This intervention cut her hospital admissions from over 200 a year to just a handful. Another team cut a patient’s emergency department visits for a patient with sickle cell disease in half when they introduced her to a primary care physician whom she can call instead of 911 when she doesn’t feel well. 

The hotspotting program, built on the work of the Camden Coalition of Healthcare Providers in collaboration with the Association of American Medical Colleges and Primary Care Progress, launched three years ago. Its mission is to teach students to deliver the interprofessional, team-based care that the sickest patients in the healthcare system need. As an advisor for the hotspotting team at my home institution, Johns Hopkins, I have seen students learn in a matter of weeks what it took me years to learn as a physician: how our health care system works…or doesn’t. Moreover, they learn this with a colleague from another profession who they otherwise would not have met until they entered their first job, at which point it would have been more challenging, and less likely, to learn about respective roles and skills. Every list of health professional competencies includes “systems-based learning” and “interprofessional teamwork,” but for the first time, I actually saw trainees reach this competency in a meaningful way. What’s more, while students might not recognize it at first, hotspotting helps them build crucial leadership skills. Development of this skill set is at the heart of Primary Care Progress’ mission.

The students who advocated for the patient with kidney failure, for example, had to connect with the leadership at the hemodialysis unit and build trust to convince them that this patient was worth another chance. They had to communicate a shared goal, which was to keep patients with kidney failure healthy and safe, and use this as currency to advocate for their patient. Since the hotspotting team had already been trained in building rapport and trust with patients and working together to find a common goal, they applied this to their interaction with leadership of the hemodialysis unit. They mastered the foundation of relational leadership, a model that emphasizes the relationships among and between team members just as much as the goal of the team’s work - it just hadn’t been labeled as such. 

When the students get a taste for leadership through hotspotting, eventually they want to lead. With very little guidance from me, the students in our local group have decided to work in pairs, always with someone from another profession, to care for a patient. Quite frankly, at first this notion made me a bit nervous. Would the traditional medical hierarchy trickle into our project? Would the nursing student-medical student pair essentially be the medical student taking charge and the nursing student “assisting?” Time and again, I have seen that my fears are entirely misguided. The medical students quickly see that nursing students bring essential skills that enhance patient care and from which the medical students themselves can learn. After a few bumps, the students’ work together is fluid. They naturally alternate roles, at times taking the lead and at other times following, depending on one another for success. 

One of these pairs worked with a patient who struggled with drug addiction and had a severe illness. There was a treatment for her illness, but the doctors at the local hospital weren’t sure it was appropriate given her ongoing drug use. The students advocated tirelessly and eventually found a physician who would be willing to give the patient the treatment she needed. But when they went to tell her the news, they learned that it was too late, she had already passed away. My heart broke not only for the patient and her family but also for the students, who I knew worked diligently to get the patient the treatment she deserved. In practice, I have seen situations like this turn people sour. Why, they ask, should I put all this work in just for it to end in heartache? But rather than turn sour, the students were mindful about the event, took the time they needed to process and turned to each other for support before moving forward. 

I think about these particular students and the work of student hotspotters around the country when I feel myself struggling in my everyday work. While I am an advisor in the program, the students teach me so much. Seeing their resilience in the face of a broken system is the boost of inspiration I need to steer clear of burnout. The leadership they show gives me confidence that they will usher the health care system into the next decade – a health care system that will have been made better by them.

Stephanie Nothelle is a Clinical and Research Fellow in Geriatrics at Johns Hopkins School of Medicine and an advisor to the school's hotspotting team. In the future, she plans to take care of older adults in the primary care setting and inspire learners to do the same.

Read more about hotspotting.
Posted by Sonya Collins on Oct 3, 2016 10:41 AM EDT
7303c1a13401b03d4d0130ca8bd47d78-huge-kiHotspotting is an innovative model of care through which health professionals across disciplines work as a team to identify health care super-utilizers - people who are admitted to the hospital multiple times a year, frequently for avoidable complications of chronic conditions, and who often have social barriers to adhering to their care plan. Hotspotters proactively bring additional attention, follow-up, resources and care to these patients in their homes and communities to help keep them out of the hospital. Today on the blog, a recent hotspotting fellow shares her story. 

By Kimberly McGuinness

I walked out of my office just in time to watch DM pass out, falling backwards off of the scale, narrowly missing my MA. He had come to his primary care visit drunk and hypoglycemic again. I made changes to his medications and insulin, referred him to specialists and had him see our nurse and behaviorist, whom he could only see once because he would not be able to afford her copay. At each subsequent visit, he was able to repeat all of our prescribed changes back to my nurse and me before he left the office to return to his life and world. He would then return for primary care follow-up after even more ER visits and hospital admissions and without having made any progress. We continued this trend for weeks and months until one day his death certificate arrived on my desk. I failed this patient. We failed this patient. Our system failed this patient.
At the time, I was practicing at a Philadelphia-based federally qualified health center (FQHC) providing primary care for the sickest of the sick. I am an Adult Nurse Practitioner and, when I started to work at the FQHC, I was fresh out of graduate school with a decade’s worth of RN experience. As time went on, I was expected to see more and more of these complex patients, many of whom didn’t speak English, and often waited too long to seek care. As I pushed back on rising productivity expectations, administrators told me that if we went bankrupt and closed our doors, then no one else was going to help these patients. So I became a hamster on the wheel. I might have been keeping our clinic open, but I was not making a difference in the well-being of these patients. I would see one patient, make adjustments to meds, and they would return (maybe) without any discernible improvements to their health. This work was not fulfilling to me. When I walked in the door on Friday evenings, I’d say hello to my husband and then burst into tears – the release of tension from a frustrating week at work. And Monday I would go get back on the hamster wheel.
Then I learned about the Hotspotting Fellowship run by Dr. Jeff Brenner’s Camden Coalition of Healthcare Providers (The Coalition) and the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. Dr. Brenner developed a community-based care coordination model that provides quality care for high utilizers of emergency rooms and hospitals through a team-based approach – with the intent of keeping them out of emergency rooms and hospitals. Without a doubt, I knew this was the way that we need to practice medicine.
I got the fellowship, which is now coming to a close. Had I met DM during this program, I would have attempted to get to know who he really was and where he came from. I would have asked, “What happened to you?” and not “What is wrong with you?” I would have surrounded DM with a team to address the social and psychological issues that might be hindering his medical care and to work toward empowering him to take responsibility for his own care. He would be placed at the center of this care, and we would assist by breaking down barriers and providing him with solid relationships to help build his trust in the health system.
Over the last year, I have learned how to pool data and manage a super-utilizer intervention. I have been welcomed into C-suite meetings and negotiations with insurance companies in order to learn how to develop a successful hotspotting program for their beneficiaries. I have attended state legislative sessions to enact policies designed to break down the silos that intensify the need for a team-based approach. I have had the opportunity to travel to conferences around the country to present the data that we have been working on and to learn from and absorb the knowledge of others who are pushing the boundaries of our current practices.
But most importantly, I have spent my days working in interprofessional teams, providing high-touch, high-intensity care for these high-priority patients in their homes (or wherever they call home). Now when a patient like DM walks into my office, I take a step back from the pressing issue, like uncontrolled diabetes, to look at him as a whole. Together with the patient, we try to get to the root of the issue – no refrigerator to keep insulin because the patient is homeless, for example – because that is likely the cause of the uncontrolled diabetes. Having the opportunity to visit the patient on his turf and to deploy a pharmacist or social worker to assist with needs that arise – this feels like real medicine.
The faculty and team at Crozer and the employees of the Camden Coalition have provided me with unbelievable opportunities. They have opened my eyes to the infinite possibilities that are available to aid patients in healing and growing. And for the first time in my practice, I have started to meet the patients where they are, not where I am or where my studies tell me they should be. For the first time in my career, I am practicing commonsense medicine and I am watching patients flourish. 
Kimberly McGuinness is an adult nurse practitioner. Currently, she is in a year-long Super-Utilizer and Hotspotting Fellowship run by the Camden Coalition of Healthcare Providers and the Crozer-Keystone Family Medicine Residency Program. She hopes to continue to work with the underserved, breaking down silos and redesigning primary care. 

Read more about hotspotting and PCP's Interprofessional Student Hotspotting Collaborative.

Posted by Sonya Collins on Sep 29, 2016 9:12 AM EDT
ad7d7769f7ae6b4e66a9be5d3bd4d596-huge-joIt's World Pharmacists Day. Today on the blog, a pharmacy student talks about why he wants to be a pharmacist clinician and a key player on the health care team. 

By Joe Oropeza

Eleven years ago my dream of becoming a soldier in the U.S. Army – to serve my country, my community and my family – was shattered. While training exceptionally hard on an early spring day in 2006, I endured two mini-strokes (TIAs) that nearly rendered half of my body completely useless. Doctors told me that the strokes were caused by a mass in my heart that would need to be removed through open heart surgery.  Now what could I do with my life? What I could physically do and how I could continue to serve my country, my family, my community?
A team of amazing health care providers were involved in my recovery, both generalists and specialists alike. Nurses tended to be the first and last people I saw. They always took the time to greet me with warmth and care, no matter how busy they were. My primary care physician, who originally sent me to the hospital, coordinated between all my specialists and facilitated my recovery. The physical therapists that helped me regain much of my strength and coordination were so kind and encouraging during my rehabilitation. However, the first visit to my PCP after being discharged was the most memorable during this timeframe as it set the stage for my future. Once the nurse finished taking my vitals she left the room with a smile saying, “the doctor will be in shortly.” Several minutes passed when I was greeted by two people in white coats. I assumed they were both physicians, but I quickly learned otherwise.
My PCP introduced his female colleague as a pharmacy resident. My initial reaction was ‘Why was there a pharmacist in the room?’ Were they going to dispense my medications here? Then the physician explained that the pharmacist was there to educate me about the slew of medications I was going to be on during recovery. How difficult could it be, I wondered. I just need to take the pills with some water, right? After my visit, my PCP left, I presumed to take care of his many other patients, leaving me and the pharmacist behind in the exam room.
Before talking about any specifics of medications, the pharmacist recognized my challenging situation and asked - “How are you feeling?” She followed that with, “This whole experience has to be scary for you, with all the procedures you’ve had and all these medications you have to take.” After about 10 to 15 minutes, the pharmacist had taught me all about what times of day I should take certain medications, how some medications work better with food in my stomach, what each medication did and how I could expect to feel on them. She even caught a duplication in my medications and was able to contact my cardiologist and cardiac surgeon, as both had ordered the same type of medication to be dispensed later that afternoon. She was able to serve as my advocate between the different specialists on my care team and make appropriate changes. This helped promote my well-being and facilitated my recovery.
That day, during my conversation with the pharmacist, I discovered my answer to how I could serve others, and a passion was ignited in me to become a pharmacist clinician. I was fired up to be a part of a team of health care professionals continually seeking to help patients attain their goals in a personalized way, while maximizing positive clinical outcomes. I entered my training with this vision in mind and soon realized that the typical health care world often doesn’t function this way. The classic, lone-wolf model, where we all work independently, is alive and well and continues to fall short of optimizing care while minimizing potential errors. Despite this, I have been able to work on some amazing teams, where we’ve collaborated to care for patients, just as my PCP and that pharmacist did in their encounter with me that day.
We need that type of collaboration to be the norm.  The journey to achieving that will require diverse, inter-professional teams in primary care, in which each member is willing to step up to not only be a liaison between each person involved in a patient’s care, but also an advocate to change the system. It has been over a decade since I decided to pursue my career as a pharmacist. My commitment to that vision, where we all work in teams, empowering patients and each other, remains strong. I am encouraged and hopeful by the change I have seen around me in my training, as we collectively move toward making that vision a reality.

Joe Oropeza is a third-year pharmacy student at Skaggs School of Pharmacy and Pharmaceutical Sciences. He completed his BS in biology at University of Colorado at Denver, where his passion to serve underserved populations was born. Joe is excited to work in and promote an interdisciplinary approach to patient-centered care and provide services to the underserved populations of Aurora Colorado.

Check out other posts by pharmacists.

Posted by Sonya Collins on Sep 22, 2016 1:36 PM EDT
More than 100 interprofessional students and faculty attended PCP’s 5th Annual Gregg Stracks Leadership Summit at the end of August. The two-day, hands-on training introduced attendees to PCP’s innovative relational leadership framework and the variety of impactful projects PCP chapters can use to revitalize primary care. Below are some takeaways: more...
Posted by Nate Leskovic on Sep 14, 2016 12:12 PM EDT
5d7572de75060ec69d546f064bfb5bc8-huge-ccIt's World Physical Therapy Day! Today on the blog, we share a post from our archives by then-physical therapy student Krista Eskay, who shows us the essential role physical therapists play in primary care - especially when seeing patients multiple times a week. As she explains, frequent patient visits enable strong relationship-building and an almost unrivaled opportunity to improve access to care.  
By Krista Eskay

“Who here is in medical school or a physician?” A multitude of hands fly up. “Who here is in nursing?” “How about pharmacy?” Cheers erupt and hands raise in the air. They worked through the ranks: physicians, nurses, pharmacists, physician assistants, public health professionals. And then they paused…

“Anyone else?” Two physical therapy students raise their hands, one being myself. Immediately I think, “We have two people here at the 2015 Gregg Stracks Leadership Summit, yes!”
What does physical therapy have to do with primary care? It’s not an uncommon question as we roll out a new Primary Care Progress chapter at Shenandoah University, where our student body consists of physician assistant, physical therapy, occupational therapy, pharmacy and nursing students. The answer: a whole lot! In a world where 60 million people lack access to primary care, we all need to do our part to manage patient needs. In particular, as physical therapists move into the realm of direct access, where a patient can be seen directly by a physical therapist for a period of time without a physician’s prescription, it becomes more and more essential that we are able to screen patients appropriately, keep open dialogue with primary care providers to report our findings and refer when appropriate. As a first point of access to the health care system for a growing number of patients, it is increasingly crucial for us to embrace primary care ideals and our role in patient management. At the core, we need to foster collaborative relationships with our patients and other health care professionals and improve patient access to care.
For anyone who has ever been to physical therapy, you know the appointments are typically not short. This is the nature of PT, where one-on-one provision of care for 30-60 minutes, multiple times a week, over multiple weeks or months is common. This provides physical therapists with the unique opportunity to foster rapport and develop strong relationships with our patients. It provides time for patients to think of questions and it  facilitates discussion. It provides us with excellent opportunity to assist in chronic disease management, from monitoring vitals or other aspects of health over a consistent period of time to encouraging healthy and active lifestyles, offering tips and tools for prevention of disease and injury, answering health questions that the patient may not have thought of at other medical visits, and monitoring mental health changes - just to name a few! PT provides consistency, and the time to grow with the patient on their journey to wellness.
Because we have the privilege of spending such large amounts of time with our patients, it becomes our responsibility not only to monitor conditions for change but also to relay pertinent health information to the patient’s primary care provider and refer them to see their provider when warranted. What a great opportunity we have to contribute to primary care!
At the end of the day, it’s exciting to realize our potential as physical therapists and expand upon our role in primary care - from patient management to communication with patients and fellow practitioners - so that we may provide the optimal level of care to every person who steps through our clinic door.
Krista Eskay is a doctor of physical therapy based in Washington, D.C. As a physical therapy student at Shenadoah University, Krista was a leader of the school's PCP chapter.
Posted by Sonya Collins on Sep 8, 2016 11:26 AM EDT
eb598939914141499e1b6ec6455d1b99-huge-wif09ed67c95d936fb1cb58fae7870a553-huge-biThe emphasis on quantity over quality seen in our health care system has deep roots in our culture. See how a citizens group in Minnesota is trying to change it. 

By William Doherty, Ph.D., and Bill Adams

Primary care providers are keenly aware of the dangers and consequences of the “more is better” culture of our health care system. But too often when they push for quality over quantity of care, they are criticized for championing primary care over other specialties.  Government doesn’t fare much better getting the message out. Any campaign to cut unnecessary costs is met with public outcry about “health-care rationing” and “death panels.” When the health care companies and insurers try to curtail overuse, they are accused of profit mongering. When hospitals and medical specialty associations criticize excessive care, it’s often about what other hospitals and specialists are doing. That’s why a group of citizens took it upon themselves to launch Baby Boomers for Balanced Health Care.  

The organization was formed out of a conviction that unless everyday community members get involved in the conversation about medical overuse and cost savings, nothing meaningful will change. We are a small group of citizen Baby Boomers (including one primary care physician) who believe that health care spending is out of control and will bankrupt our country unless we all take responsibility for changing how we do health care.  Our goal is to create a public conversation about a neglected dimension of the problem:  the cultural belief that more health care is better health care, a belief that contributes to overdosing on health care: too many tests, procedures, and devices that can cause harm along with bankrupting individuals and communities.  We are calling for a new mindset that values balanced health care—“Goldilocks” health care—not too much, not too little, but just right.  

The project was initiated by Bill Doherty and Jim Hart, a primary care physician, using the Citizen Health Care model Doherty developed.  We approached citizen organizations in Minnesota to recruit engaged Baby Boomers to come together to reflect deeply on the more-is-better cultural dimension of the health care crisis in the U.S. Without new cultural norms, we argued, health care reforms, such as payment for outcomes instead of services,  will yield backlash. Citizens groups can lead the way where government and health care professionals cannot.

So why Baby Boomers? When we asked members of our group about their generation’s unique role in this issue, they said, “We came of age in abundance, witnessed medical miracles like the polio vaccine and heart transplants, and came to believe that more is always better in many areas of life, including health care. We were wrong. Now that we are elders, we want to lead a cultural conversation about restoring balance in health care: smarter health care, not more health care.”

So far we’ve developed community conversation guides (for small groups and larger community forums) and sponsored conversations around the Twin Cities and in Fergus Falls, Minnesota.  Three-month follow-up evaluations indicate that the average participant has talked with seven other people about medical overuse and the more-is-better culture.

We’ve also partnered with Consumers Reports and Choosing Wisely to make these conversation guides (including video demonstrations) available nationally. Doherty and Adams have given webinars on Choosing Wisely and citizen engagement, as well as presentations at Lown Institute and Institute for Clinical Systems Improvement conferences.

We’ve developed and begun working with Minnesota-based HealthPartners to implement a “Clinician Guide for Conversations about Medical Overuse.”  This guide, spearheaded by Baby Boomer member and family physician Cate McKegney, will become part of continuing medical education and specialty re-certification training.  In a year, we hope the training materials will be available nationally.  HealthPartners will also begin sponsoring community forums using our conversation guide.

Finally, we are looking into ways to distribute our “Guide for Families and Loved Ones” for talking about overuse.

It’s still an open question whether Baby Boomers for Balanced Health Care will play any role in reducing out-of-control health-care spending in the U.S.  But this project illustrates a community and cultural change method of working together with other citizens to tackle a problem that cannot ultimately be solved unless we-the-people, not just we-the-professionals, get involved. We hope it will inspire your conversations with patients, friends and loved ones. And we hope our citizens’ movement will inspire your continued grassroots work to transform the health care system.
William Doherty, Ph.D., is Director of the Citizen Professional Center and Adjunct Professor in the Department of Family Medicine and Community Health at the University of Minnesota.  He has developed Citizen Health Care as a way to engage community members as co-producers of health care innovations.

Bill Adams is engaged in health care public policy issues. As an engaged citizen and patient voice, he focuses on local and national initiatives to transform health care by co-creating a health care system that works for both patients and providers.

Posted by Sonya Collins on Sep 1, 2016 1:42 PM EDT
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