Primary care is in crisis today. Fewer than two percent of medical students decide to pursue careers in primary care, right at the time when the need for primary care has never been greater. It’s estimated we’ll have 65,000 too few primary care physicians by about 2030.
Burnout is a problem. A study of PCPs suggests that only about 30 percent of people who are currently primary care doctors, would choose to do it again, if they had the choice. About 30 percent would say I’m not going to be a doctor at all.
Another study suggests that if a primary care physician did all of the acute, chronic and preventive care for his or her panel of patients, it would take them 23 hours a day.
The patient centered medical home is a model that uses a team of caregivers to provide care to patients in a coordinated fashion. It often involves a physician at the head of a team and then other team members that may include nurse practitioners or physician assistants. It can also include nutritionists, pharmacists, social workers, community health workers, community resource specialists and other behavioral health professionals. The team is formed to take care of one population of patients. And they interface with each other in real time to coordinate that care.
Highly functional medical home teams huddle every day about the patients who are coming in so they know who’s coming in, what their needs might be, and can anticipate those needs before the patient ever gets to the office. If there is a patient who has a particular problem with transportation, the community health worker or community resource specialist may need to set up transportation in advance to the clinic or have arranged transportation to get the next test that’s been ordered by the team. That’s a little different than just a multi-specialty clinic with lots of people working in it.
There is a lot of patient dissatisfaction with the current care model. Patients feel they don’t have enough access to their primary care physician or other physicians. They don’t feel that the practice knows who they are and can’t anticipate their needs. Because the design of the medical home is proactive, patients feel that when they come to the clinic or even if they receive care outside of the clinic, they’re getting their needs met in a proactive way.
The fastest growing segment of the Medicare population, those over 65, are people with four or five co-morbid simultaneous conditions. That’s a lot of people with a lot of illnesses to coordinate. This model is very effective at sorting out what those conditions are and how they can use all the members of the team to take care of those chronic conditions longitudinally, going forward. And on a cautionary note, the number of people over 65 in this country is going to double between now and 2030. We’re going to go from 35 million people to 70 million people over 65.
The patient centered medical home is much more effective at all forms of prevention. Primary prevention: if you can get someone to lose weight and exercise maybe they’ll never develop diabetes. Secondary prevention: let’s catch the diabetes early and treat it aggressively so that it doesn’t progress to kidney failure, amputations, or heart attacks. This model represents a possibility for all the benefits of the different stages of prevention. Better patient outcomes, lower cost, better patient satisfaction, and better care coordination.
Because of the benefits that have been shown in early studies, the notion is how can we extend the benefits of the medical home, which implies a primary care population and a primary care workforce, to the next level? If the medical home is so good, can we build a medical neighborhood? What a medical neighborhood means is: can we formalize the way that primary caregivers interact with their specialist colleagues?
Studies have shown that up to 50 percent of patients when questioned have had some issue with their primary caregiver and their specialty caregiver not communicating. Either they went to the specialist and there wasn’t sufficient data available from the primary care doctor, or they went back to their primary care doctor and the specialist hadn’t communicated with them, labs or tests weren’t available, or they couldn’t even get the results. That fragmentation leads to bad outcomes for patients.
A medical neighborhood example is: I’m the primary caregiver, and I’ve just diagnosed my patient with breast cancer. I want to be able to communicate with my oncologist colleague in a way that makes sense. When do I need to send my patient? When can I keep the patient in my practice and do the things that are necessary? If the patient is cared for by the oncologist, what is his or her responsibility, and how do we communicate so that redundant care isn’t given? How do we prevent unnecessary testing. This is the fundamental concept of the medical neighborhood.
When you have a team taking care of an identified panel of patients, the panel sizes of an individual physician can grow because they have colleagues to share their panel. Medical home models have already begun to evolve. Panel sizes grow because physicians are sharing their panel functionally with all the other members of the team. If it’s a young, healthy person who has a cold, maybe the physician doesn’t have to see that patient. Maybe the patient can see a nurse practitioner or a physician assistant. Or people with stable hypertension, maybe they’ll see the physician at one visit and three months later they’ll see one of their colleagues. If someone has a nutritional problem, they might not need to see the physician in that visit, Instead, they’ll come in and see the nutritionist. If they’re having emotional issues, the social worker can address the patient’s problems to get them rooted in the right direction to meet that need. Hence, the number of patients that the entire team can take care of grows and access for patients improves accordingly.
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