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Archive for September, 2016
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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