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In This Issue:
From left, team members gather for a morning huddle to go over the day’s patients; pharmacist Sonia Freitas, care coordinator Caroline Melia and medical director Stuart Pollack, MD.
For patients, the new patient-centered medical home at Brigham and Women’s Advanced Primary Care Associates is a place to experience an innovative approach to team-based care. For the staff who work there, it’s an opportunity to practice to the full extent of their licenses and to be part of a new model of health care that is improving quality while also reducing costs to the health care system overall.
“I tell people that the patient-centered medical home is excellent primary care delivered by a highly integrated team – it is the kind of care we want for ourselves and our families,” said medical director Stuart Pollack, MD.
The practice opened Aug. 1 in a LEED-certified building on South Huntington Avenue in Jamaica Plain. Each patient receives care from a team that includes a primary care physician, physician assistant, two medical assistants, a licensed practical nurse and a social worker. For complex patients who require more services, the team will also consist of nurse care coordination, pharmacy and nutrition services, as well as a community resource specialist. These resources can improve preventive care as well as post-hospitalization support, decreasing unnecessary Emergency Department visits and hospital admissions.
“Patients leave here with all of their questions answered because they can see a doctor as well as a dietitian, social worker or pharmacist if they need to,” said Steve Rodriguez, medical assistant. “This type of practice is revolutionary here, and I really wanted to be part of it.”
The practice is dedicated to testing advanced models of primary care delivery, one of which is called the “warm handoff.” That’s when a
patient has an appointment with a physician and expresses concerns about diet, medications or behavioral health needs, for example. A dietitian, social worker or pharmacist meet with the patient right away for a few minutes to address these concerns and determine whether a follow up appointment is needed.
“These warm handoffs are possible because our dietitian, social workers and pharmacist have just half of their schedules filled with appointments and are otherwise able meet with patients with very little notice,” said practice manager Linda Jo Stern, MPH.
One way to improve access, patient satisfaction and overall efficiency is to explore alternatives to the traditional face-to-face medical appointment. The practice incorporates e-visits, phone follow up and shared medical appointments, in which patients with a shared diagnosis utilize a group format to maximize education, share best practices and offer group support and encouragement.
“This type of appointment is an option – it’s certainly not in place of a one-on-one appointment if a patient prefers that,” said Pollack. “But a lot of people do better in a group – they are with other patients who have the same questions or whose questions and answers can benefit them too.”
A constant focus on improvement is one of the hallmarks of Brigham and Women’s Advanced Primary Care Associates. Behind the scenes, population manager Ryan McGovern collects data and new information pertinent to advancing patient engagement and the overall patient experience. “Quality of care and access to care are two of the major areas we’re focused on,” he said.
Social Work, Nutrition and Pharmacy in the Primary Care Setting
Every patient is screened for domestic violence and depression, and those who are at risk are immediately connected with one of the two social workers at the practice. “If you have a patient with diabetes and depression, for example, the depression can really impact the patient’s ability to take care of him or herself,” said Lara Sullivan, MSW, LICSW. “Research suggests that more than 50 percent of the population has some sort of behavioral health issue, and we’re here to focus on that so patients can get the best care.”
In addition to Social Work, patients also have immediate access to dietitian Mara Sansevero, RD, CDE, and pharmacist Sonia Freitas, PharmD.
Freitas is the first full-time pharmacist to work in a primary care setting at the Brigham. “We’ve all seen a great need for pharmacists to be in the ambulatory setting when it comes to patient education,” she said. “I work with patients who have problems adhering to their medications, as well as those trying to manage a long list of medications for multiple conditions.”
Freitas and Sansevero are collaborating on a program for patients with diabetes that incorporates both medication management and lifestyle. “For me as a dietitian, I have a lot of opportunities to show patients the benefits of healthy eating,” Sansevero said. “Not a lot of dietitians work in the same place for 40 hours a week.”
Patients also have the support of community resource specialist Jordana Montolio, who helps remove barriers to care by connecting them to transportation, child care, support groups and low-cost physical activity options. “I make sure patients get what they need so none fall through the cracks,” she said.
The practice is accepting new patients. For more information, visit www.brighamandwomens.org/southhuntington
Did You Know?
There are currently primary care medical home pilots in 44 states, involving more than 4,500 practices and close to 5 million patients. Early data from these pilots have found increases in patient and provider satisfaction, improved quality, fewer unnecessary trips to the ED and reduced readmissions.
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