Self-help for the chron­i­cally ill

Pa­tient self-man­age­ment touted as tool to im­prove chronic ill­ness out­comes

Modern Healthcare - - Front Page -

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.”

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.