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Archive for July, 2016
f3abeb1495ea283f82d1ac19cec25873-huge-58PCP's 5th annual Gregg Stracks Leadership Summit is just a few weeks away. What can you expect? For one thing, an environment where students and practitioners in all disciplines are respected and embraced. Today on the blog, a nurse practitioner and summit moderator describes how she discovered PCP's interprofessional culture at the first Gregg Stracks Leadership Summit in 2012.

By Alana Rose, N.P.

I recently attended Primary Care Progress’s Gregg Stracks Leadership Summit. The summit brought together chapter leaders from around the country to get coaching in how to lead our chapters to accomplish our individual goals. 
 
I went to the summit knowing that PCP values teams – the team-based model of organizing to improve the primary care profession and the team-based model of primary care delivery.  In both cases, there would be a place for me, an RN and a nurse practitioner student.
 
But amidst the initial excitement and bustle of registering and sharing greetings with strangers, when I put on my name tag, I noted that it clearly identified me as part of an under-funded school of an under-respected profession: nursing. I recognized myself as part of a minority of non-medical students, and, despite what I knew about PCP, I wondered if I would be taken as seriously as my new weekend peers. Would medical students, residents, and doctors be as interested in networking or even just talking with a nurse?  I realized that I had internalized the historic tension between nurses and doctors and between nurses and nurses, and it occurred to me that this tension could be a possible barrier to PCP’s efforts to engage more nurses in its work. 
 
I am more of an anthropologist than a nurse or nursing student in my comments here. And I am neither the first to make this observation nor am in any way qualified to unpack the many layers of history that have colluded to keep these two groups at odds. Still, these tensions are worth bringing out in the open if the efforts of those of us involved in PCP are going to include a space for those who are not doctors or doctors in training, and in so doing, bring different perspectives and a history of (dis)empowerment to navigating the problems in health care.
 
Before I decided to go into health care, an oncologist friend cautioned me against nursing. “Do you want an M.D. or an N.P. after your name?” she asked. She warned me both as a woman from another generation and also as a clinician who greatly valued the power she saw as intrinsic to becoming an M.D. I believe many who choose medicine share my friend’s value, but ultimately I entered nursing because as a non-traditional student, I wanted to gain clinical skills and experience as quickly as possible.
 
I was both haunted by and propelled towards health care by experiences I had while working as an English-Swahili interpreter for a group of American doctors and nurses in Tanzania. There, I saw the harm that can come from efforts “to do good” through the stasis of hierarchy and at the exclusion of others. In one typical clinic, a nurse stood before a long line of Masaai tribal members seeking care outside of the handmade community structure that they had built years ago, hand prints baked into the clay walls. The doctor and resident sat within the cool spacious building and saw one patient at a time, while the nurse worked outside, assessing vital signs and watching as people, weary from many miles of travel under the hot sun, grew frustrated with such a slow and inefficient use of space and personnel. The doctors had essentially recreated the design of their offices back in the U.S. and, like they may have done back home, greatly underutilized the expertise of the nurse. In the end, the clinic ended abruptly, as the numbers of hot and tired patients kept growing and reached a crescendo when a doctor slammed a young man’s hand in the car door while trying to leave the site in haste.  Although the nurse commented throughout each and every clinic about other (perhaps better) ways to utilize space, provide care, or understand a given  problem, she rarely spoke up to express her views to the doctors. I can only assume she felt she would not be listened to or respected.  In part through this experience, I saw nursing as an opportunity to be of use to another human being in some of the most concrete ways possible. After all, the nurse was outside with the patients all day; few saw the doctor. We see in the U.S. health care system as well that nurses (and CNAs) are more often able to be at the bedside when it matters, addressing our most basic human needs. The work can be as humble as assessing a patient’s urinary or fecal output, or as profound as attending to someone in their final hours of life.
 
I knew little of the deep professional rift between nursing and medicine, and I knew even less about the complex way in which this legacy has impacted not only the way doctors and nurses work together, but also how nurses treat one another and undervalue themselves. Nurses are notorious for “eating their young,” and will not only often ignore their own needs but they also have an unfortunate legacy of hazing new nurses in ways that emphasize a culture of workaholism, co-dependency, and fear. In most clinical settings, doctors’ and nurses’ worlds are so deeply divided despite their interdependence. Even socially these divisions are maintained by many in choices as simple as with whom to sit at dinner.
 
You can imagine my relief at the summit when, during our first break-out group, I met a young med student who introduced himself by way of a story of meeting an RN at a homeless shelter and expressed his humility and respect for the clinical knowledge she had. This was one of many experiences during the weekend that opened me to the possibility that the hot buzzword of interprofessionalism is actually a living force and exists in genuine collaboration and creative exchange between diverse constituents.
 
The weekend helped me to step outside the isolation of my education program and of my future career path. The patterns of division and reactivity that have kept students and practitioners of medicine and nursing separate seemed absolved for a few days. Learning of new generations of programs that truly foster collaboration between health care trainees was radical and nourishing.
 
There is no need to reiterate the fact that our current primary care system in the United States needs a thorough overhaul. We all have stories and evidence of this need. I was heartened, however, to see that PCP chapter members I met at the summit seem to value the interprofessional matrix that primary care requires to survive this difficult time. It is my hope that all PCP members reflect that value. And I hope they do so without becoming lost in a quest for power that is equivalent to their peers in sub-specialties, but rather begin to assert an entirely new value system. As we begin our work to recreate health care delivery in the United States, it is not only good practice to bring all health care professionals to this drawing board, it is essential if we are to catalyze a new story of primary care.
 
Alana Rose wrote this piece in 2012 as a nurse practitioner student at University of Southern Maine, where she helped found a PCP chapter. Today she is a Family Nurse Practitioner.  She is committed to supporting innovations in the training and delivery of primary care and believes this can only be accomplished through rich communication and collaboration within interdisciplinary teams. She lives in Belfast, Maine.

Read archived blog posts from other members of the summit training team. 
Kat Barnes
Victoria Boggiano
Jonathan Jimenez
Michael Mattiucci
Stephanie Nothelle
David Choi
Kyle Turner

 
Posted by Sonya Collins on Jul 28, 2016 1:31 PM EDT
22069c27baec2f32b385876c2039e5de-huge-daPCP's 5th annual Gregg Stracks Leadership Summit is just one month away. Led by an interprofessional training team, the summit introduces chapter leaders to PCP’s innovative leadership framework and the variety of high-impact projects PCP chapters have used to revitalize primary care. Today on the blog, meet a member of the training team, David Choi. In this blog post from our archives, David shares his experience helping his PCP chapter open the DAWN clinic. 

By David Choi

As I write this, the DAWN Clinic will open for its first patients in 18 days, two hours and 28 minutes. The leadership team anxiously buzzes around each another at our meeting where we’re tying up loose ends and generating solutions. The tangible excitement in the room is felt by all as we finish up our respective projects. 
  
At the risk of sounding cliché, it really does seem like just yesterday that our Colorado PCP chapter held the first meeting to discuss the clinic. Students of the medical, nursing, pharmacy, physical therapy, and dental schools convene at our meetings to bring change to our surrounding community, educational institution, and the greater field of primary care.
 
At one of our early meetings about the clinic, we divided into different workgroups to take on the various tasks involved in opening a student-run free clinic. It was just an idea, that became a movement which garnered the support of the Dayton Opportunity Center and the Fields Foundation. And now we are days from opening the doors of the Dedicated to Aurora’s Wellness and Needs (DAWN) Clinic to the underserved.
 
Back then, we were a group of many students from many professions. I am amazed at how little I understood about my colleagues’ professions back then – before we became a high-functioning, interdisciplinary team.  
 
As the leader of the Pharmacy and Procurement workgroup, I was tasked with obtaining all the essential items for the clinic. How was I supposed to do this? I was a second-year pharmacy student. I didn’t know what a primary care clinic needed in order to function. I remember sitting with my co-leader Katie, trying to develop a list for the clinic, we sat there thinking “exam room table… otoscope… stethoscope… cotton balls… that’s it, right?” We knew we had a challenge and that we had to overcome it.
 
We were presented with something we were not comfortable with. But as we were taught in pharmacy school and through our work with PCP, we sought out resources and contacts to help us. We started off with the WHO guidelines for primary care clinic supplies and continuously adjusted it as we compared it to other clinics’ lists. For example, after A.F. Williams Family Medicine Center provided us with the inventory list of their current supplies, we sat down as a small group to update our own list. After one week, we had a complete list. But now we had to actually find donors to give us the items on the list. We approached clinics asking if they would be willing to donate any items. They in turn referred us to other clinics and organizations. Then we were introduced to ClinicNet and Doctor’s Care. They put us in contact with the vast network they had established to get us the items we needed. A clinic that was closing in Littleton, CO, donated roughly $15,000 worth of equipment to us. When we met with the doctor to pick up the donation, he stopped us before we left and told us he believes in our cause and our initiative. It is these experiences that demonstrate what we are capable of as students and as a team.
 
The problems of the underserved community around us are within our reach, and as health care professionals, we have a social responsibility to rise to the challenge and enact change. As students of diverse disciplines, we have the combined resources to bring together the knowledge, skills and, yes, equipment and supplies necessary to care for this population. This has truly been an interdisciplinary project. While moving closer to opening this clinic, I have learned more every day about what the different health professions are capable of. Together, we are bringing change to our campus and our community.

David Choi is a fourth-year pharmacy student at University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. David has been part of Colorado's PCP chapter since 2014. During his third year of pharmacy school, he and others worked to set up a student-run free clinic at University of Colorado called Dedicated to Aurora’s Wellness and Needs (DAWN) Clinic. David aspires to bring change to the curriculum at University of Colorado to promote primary care. He loves photography and plays piano when he has time.

Read archived blog posts from other members of the summit training team. 
Kat Barnes
Victoria Boggiano
Jonathan Jimenez
Michael Mattiucci
Stephanie Nothelle
Alana Rose
Kyle Turner



 
Posted by Sonya Collins on Jul 21, 2016 3:47 PM EDT
8ab6e4087f15be4cdc51c0e79e718ef1-huge-1ePCP's 5th annual Gregg Stracks Leadership Summit is coming up. Today on the blog, PCP's president tells the story of Gregg Stracks and why the summit is named for him. 

By Andrew Morris-Singer, M.D.

My junior year of Internal Medicine residency was a difficult, confusing time. A trainee committed to a career in outpatient primary care, I found myself spending a great deal of time on inpatient hospital wards with some of the sickest, most complicated patients I’ve ever encountered. While the medical conditions were fascinating, most were preventable exacerbations of chronic problems or late outcomes of diseases that could have been caught earlier with screening. It felt like we were perpetuating a failed health care system that did little to manage and protect patients’ health but rather waited until they got really sick, and then dumped everything we had in our medical armamentarium on them. It seemed divorced from good economic sense and completely at odds with both the skills that I wanted to learn to keep patients out of the hospital and the values that brought me into health care in the first place.

Despite the dysfunction in the system, my job was to care for those patients, manage the team of house staff and students, and strike the right balance between my clinical, educational and managerial responsibilities – a significant leadership challenge for anyone, let alone someone feeling as conflicted as I was. 

My disdain for the disconnect between the care we delivered and what patients actually needed came across to everyone I supervised. “It was impossible to see this coming,” I’d sarcastically mutter to my team as we’d re-admit a heart failure patient who’d fallen through the cracks due to non-existent communication between the previous inpatient team and the outpatient providers.
 
This is how Gregg Stracks found me when he arrived to offer leadership training to a handful of residents in our program. He found someone who was overwhelmed and jaded; someone for whom team leadership meant modeling unyielding perseverance and determination, with no allowance for emotion or vulnerability.
 
“The stuff we’re seeing is so upsetting, so backwards, I’m afraid if we let any emotions out, we’ll be unable to work,” I told him at our first meeting.
 
Get done. Get out. Keep the emotions in. That was my game plan for surviving my ward time and helping my fellow residents survive.
 
One day Gregg observed our interdisciplinary care rounds on the medicine wards. The members of our large care team were overwhelmed by a particularly difficult patient and his family. We were tired of jumping through hoops to get him the best care only to be rebuffed and manipulated by him and his family. We were also frustrated with each other, convinced that members of the team from other disciplines were making the situation worse. On rounds that day, a social worker said the situation made her question going the extra mile for any patient and their family. After a long silence, to everyone’s surprise, a nurse on the team, who was typically quite contrarian, agreed with her and said she too was having a difficult time and was also questioning her values. But, concerned about “staying on track,” I interrupted and encouraged the team to focus on concrete tasks so we could “get the work done and all go home.”
 
After the meeting, Gregg pulled me aside and in his usual kind, curious, yet direct style, he asked why I had shut down the most intimate interaction he had ever seen our team have. It was the closest we had come to connecting and building real relationships with one another. Connections around values and personal experiences, he said, are the glue that binds team members together to get their work done in a sustainable way.
 
Gregg showed me that by avoiding the emotional, I was missing the opportunity to truly lead the team. Focusing exclusively on the technical and not allowing the team to publicly voice their emotions and values, I couldn’t harness the greatest motivations that had brought every member of the team into health care in the first place: commitment to helping others; to making a difference in someone’s life; to easing unbearable symptoms when there was no hope for cure. Deep connections between team members would only form when we identified our shared motivations and values.
 
Gregg taught me the importance of tapping into the heart.  He assured me that it didn’t make our team less professional. In fact, it allowed us to expand our professional selves to bring all our values, strengths and passions to our work.
 
With Gregg’s guidance, teaching and unremitting support, my notion of leadership transformed. No longer was my job about getting the work done, the boxes checked. It was about helping each team member harness the full spectrum of their intellect, passion, commitment and values for the challenge at hand. Evoking the non-technical or non-analytical wouldn’t slow us down or take us off track. Rather, it would energize us, connect us, and keep us true to the values that seemed to frequently run counter to the system in which we worked.
 
Despite the profound impact Gregg had on my approach to clinical team leadership, the greatest gift he gave me was confidence that we could take these same team-building approaches into the world of primary care advocacy to do things that many of us never thought possible. We could use this leadership style to build new teams that could push for family medicine divisions at institutions where they didn’t exist, accelerate innovation in primary care delivery, or advocate for curricular reform.
 
Many people in primary care at the time knew that we needed a new approach to advancing the field. At Harvard, my own medical school, the primary care division had recently been defunded. At other academic medical institutions around the country, primary care and its practitioners faced constant devaluation and marginalization. We needed to bring our diverse community of primary care professionals together and depart from the traditional siloed approach that only increased animosity among primary care disciplines and professions. We needed to pull average primary care health professionals or trainees out of primary care despondency syndrome. We needed an antidote to the helplessness many of us felt. Most importantly, we needed an approach that harnessed our full potential power and raised a united voice.
 
Starting in Boston, we adopted a grassroots organizing approach that essentially builds mini-campaigns to promote careers in primary care, advance innovation in care delivery and accelerate reform in training. Three years later, over 26 chapters of this network have taken root. What unites us is a commitment to building powerful relationships between individuals and using those connections to spawn action.
 
Just like Gregg taught us, we now see that when we bring a group of people together to fix a difficult problem, we must spend as much time eliciting people’s emotional response to the problem as we do their logical response to have the best chance of creating and sustaining a new team that can solve the problem. The head steers us, but the heart is the engine that makes us go. Just like I discovered on the wards, our job as primary care leaders is to create spaces where like-minded individuals not only can brainstorm solutions to the problem, but where they can express and subsequently harness their emotions and values as well. 
 
Sharing ourselves with others and inviting others to do the same is at the heart of PCP’s effort to lead change in primary care. In my travels around the country and my communication with many of you, it warms my heart to see this leadership approach manifest in all of your great work. Your commitment to this practice has grown the network. Others join us not because their heads tell them to, but because their hearts compel them to.
 
As one faculty member recently confessed to me while we were watching a group of interprofessional students share their values and experiences at a PCP meeting, “It’s not only inspiring to watch this…it’s totally intoxicating.”
 
Gregg Stracks passed away in January of 2012, at the age of 40, from metastatic ocular melanoma, years after he had been told he had months to live. All of the work we did together – all of which occurred after he was suffering from metastatic disease – was the greatest gift I’ve ever received.
 
I believe two things helped Gregg survive so long. First, the deep love, devotion and companionship of his wife Sara and his family and friends. And second, his work with Primary Care Progress and others, helping people like me share our emotions and values and exercise our responsibility to enable others to do the same. Simply put, Gregg was energized by helping people connect with one another. It helped him survive and helped spawn a primary care movement.
 
Gregg’s passing was a great loss to everyone who knew him. He took a piece of our hearts with him, but he left a piece of his heart with us, too. He left us with an approach to leadership, connecting with others, understanding ourselves and building teams that can help each of us do our best work during whatever time we’re lucky enough to have in this life.
 
Please join me in reflecting on our collective luck at being a part of a network and movement connected to such an amazing person as Gregg Stracks, who gave so much of himself, at such a difficult time. Let’s commit to using his leadership summit to reconnect with the values that brought us into primary care. Through those values, we can connect with one another to build new visionary teams to fight for the health of our patients,  our families, our communities, and this nation.
 
Andrew Morris-Singer is a physician and former community organizer and trainer. As president of Primary Care Progress, Dr. Morris-Singer has been instrumental in igniting an interprofessional trainee-led grassroots movement to reform primary care delivery and training.  Dr. Morris-Singer writes and speaks regularly on the topics of primary care community advocacy, utilizing organizing strategies to advance primary care clinical innovation and the critical role of trainees in the revitalization of primary care. Dr. Morris-Singer is board-certified in internal medicine and is an affiliate instructor at Oregon Health and Science University. He lives in Portland, Oregon.

Read more about the Gregg Strack's Leadership Summit.
 
Posted by Sonya Collins on Jul 14, 2016 2:17 PM EDT
50d194de2607f04f2fe9a65d50bcb085-huge-unPrevention and multidisciplinary teams are the cornerstones of a transformed primary care system. Today on the blog, Dr. David Moen explains how TeamMD is putting these values to work to keep the elderly on their feet.

By David Moen, M.D.

Rose was 83, lived alone, and came to the ER by ambulance around 11pm.  She had fallen earlier that day and was unable to get up.  Over the next few hours, she slid to the phone and finally dialed 911.  When I met her, she complained of severe right hip pain and exhaustion but not much else.  I didn’t find much in her history or exam: mild cognitive impairment, mildly elevated blood pressure, and a tender right hip with no swelling or bruising anywhere.  I ordered some labs and x-rays. 

During her ER stay, she became a bit agitated.  She wanted to go back home.  I didn’t think that would work.  She couldn’t stand by herself.

I needed an admitting diagnosis to solve “my problem.”  Her hip x-ray was normal.  A broken hip would be an “easy admission” for me as an ER doctor.  Medicare wouldn’t pay for a ride to her apartment, no family responded to our calls, and no home care was available at this time of night.  Her blood work was normal.  “Fortunately” for me she had bacteria and some white blood cells in her urine (like most women her age).  Rose was admitted with intractable hip pain, possible UTI, and cognitive decline. It seemed to be the only and best option.

Rose never returned to her beloved apartment.  The night I admitted her, she became more agitated and confused.  She was experiencing delirium, just like 65 percent of all elders with any cognitive impairment admitted to a hospital.  That night she fell and struck her head.  A CT scan showed a subdural hematoma.  Then she aspirated, developed pneumonia, and after a 12-day hospital stay, she was sent to a nursing home.  Rose died 183 days later (an average-length nursing home stay). 

The hospital quality review committee determined that the night nurse “wasn’t watching Rose closely enough.”  The night nurse was reprimanded for what most of us would admit is a broader system failure.  She felt terrible and quit working nights a few months later.

Patients like Rose inspired me to imagine that there might be something better.  Can we find the Roses at risk for falls and illness exacerbations in our communities before the crisis?  Can we build a team that responds to their needs proactively and prevents them from the dangerous and sometimes deadly trips to the hospital?  If so, how do we do that efficiently and how do we pay for it?

In fact, 16 percent of Medicare recipients spending over 70 percent of all funds are at risk for unanticipated hospitalizations due to falls or worsening chronic conditions.  We can find them before the crisis, and when we build a team responsive to their needs 24/7/365, they live longer and happier lives, and cost us all over 25 percent less.  And we can pay for it by combining physician fee-for-service revenue, care management revenue, and quality incentives for quality and cost performance.

United Health Care’s Venture Capital Team recently funded TeamMD to be there for the Roses of the world.  Modeled after a successful Minnesota company named Genevive, TeamMD provides exceptional primary care and comprehensive care management for frail, and mostly poor, elders.  Given Genevive’s track record in Minnesota (exceptional patient and family satisfaction, high physician and staff satisfaction, and lower costs of care), TeamMD has a high likelihood of success.

TeamMD started in its first outside-Minnesota market (Des Moines, IA) on January 1. The Iowa program now serves over 1,600 patients living in nursing homes, assisted living facilities, and their own homes. Its growth has been fueled by committed nurses, social workers, doctors, nurse practitioners, and support staff passionate about serving this “underserved and over-serviced” patient population. Recruiting clinicians hasn’t been as difficult as anticipated. That’s because well-supported clinicians and support staff find great reward caring for this challenging population.

So what makes it work? Well-trained and supported clinical teams that are paid more than clinic doctors (due to aligned payment model) find the right patients in the community sooner rather than later, answer the phone when it rings, and provide multi-disciplinary care planning for every patient and family before, during, and after each crisis.  This is a model that could be implemented in many communities across America.  It proactively addresses the physical decline, cognitive failing, and social isolation that plague many as we age. It emphasizes prevention and the value of a multidisciplinary team.  Falls, injuries, and worsening chronic conditions are more proactively and holistically addressed.  That keeps elders in their homes and prevents hospitalizations and nursing home stays that cause harm.

Our leadership team is partnering with health system leaders across the country to improve the lives of these patients.  We will reach many markets, attract the best and brightest to execute our mission, and enhance training opportunities and job growth in the markets we serve.  And the Roses of the world will get better care and live happier and longer.  To learn more, see www.TeamMD.com.  If inspired, come for a visit to learn more!  Thanks, Rose!

David Moen, M.D., is a health care consultant and board chairman of TeamMD.

Read more about team-based care.



 
Posted by Sonya Collins on Jul 7, 2016 10:02 AM EDT
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