Self-help for the chronically ill
Patient self-management touted as tool to improve chronic illness outcomes
In many ways, Greenhouse Internists is very similar to the thousands of other primary-care and internal medicine practices scattered across the country. Like many other offices, the five-physician practice based in Philadelphia serves a diverse base of about 9,000 patients, the majority of whom have at least one chronic illness such as diabetes, high cholesterol or high blood pressure.
And like most other practices, Greenhouse physicians are pressed for time. Richard Baron, the practice’s president and CEO and one of its internists, made headlines in April when he published an article in the New England Journal of Medicine about primarycare offices’ crippling load of follow-up calls, e-mails, laboratory report reviews and other non-compensated activities.
What separates Baron’s practice from so many others, however, are the strategies its physicians are now able to employ to try to help patients manage their chronic diseases. Greenhouse is part of a three-year, patientcentered, medical home pilot program organized by Pennsylvania Gov. Ed Rendell’s Chronic Care Commission. The initiative includes six payers and 31 other practices in the southeastern part of the state. During the course of the pilot, Greenhouse expects to see an increase of about 15% in gross revenue from supplemental payments provided for things such as patient self-management support, performance reporting and referral tracking, Baron says.
The overarching goal of the program is to give physicians adequate resources to improve communication with patients and help them to set goals and realistic, actionable plans for making lifestyle changes and managing the symptoms of their diseases.
“Self-management is critical,” Baron says. “The patient spends one-tenth of 1% of their time in the doctor’s office and the rest of the time on their own. Coming up with good ways to engage them and encourage them to take control and make changes is very important.” In order to incorporate self-management strategies into their practice, Greenhouse has used funds from the pilot to hire a health educator, who then trained medical assistants in motivational interviewing techniques to use in helping patients set personal goals. They also customized their electronic health-record system with an action-plan form that offers sample goals, such as better medication compliance and dietary choices, based on the patients’ conditions.
After medical assistants take patients’ vital signs, they ask whether they are interested in making changes to better take control of their illness or illnesses, Baron explains. If the patients are open to change, the assistants solicit more specific behaviors that the patients think they will be successful at adopting, such as walking around the block once each day or eating less sugary foods. The form in the practice’s EHR provides conversation prompts for the medical assistant, and patients leave with a printed document that details their goal and the strategy they will use to get there. Assistants can follow up with patients later.
Implementing the changes has taken significant time and money, Baron says, and, under the existing payment structure, he says he doubts Greenhouse’s approach would be feasible in other practices.
“Changes to the payment system are essential, and I am optimistic that these enhanced models of primary care will eventually be paid for,” Baron says. “Primary care can be of very high value, but only if it is structured and paid for differently.”
The cost of chronic illness
The stakes are high, says Thomas Bodenheimer, adjunct professor of family and community medicine at the University of California at San Francisco. According to figures he cited in a 2009 article in Health Affairs about the growing burden of chronic illness, more than 130 million Americans are living with at least one chronic disease, and more than 60 million have multiple chronic diseases. According to the Centers for Disease Control and Prevention, chronic disease care accounts for more
Daniel Peterson, an internist at Greenhouse in Philadelphia, consults with Doris Pitts, a certified medical assistant. Medical assistants help patients set health status goals.
Baron: “Changes to the payment system are essential.”