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obe­sity can sign up for the free, peer-led course and learn how to bet­ter man­age their own health, says Alan Glaseroff, chief med­i­cal of­fi­cer of Hum­boldt-Del Norte IPA, Eureka, and a mem­ber of the al­liance.

“We started out try­ing to find ways to use mo­ti­va­tional in­ter­view­ing and ac­tion plans in our own prac­tices, but then we came to the con­clu­sion that the best person to de­liver this message is a peer and not a physi­cian,” Glaseroff says. “I think the fo­cus now should be look­ing at ways that we can build up com­mu­nity re­sources that physi­cians can re­fer people to in or­der to help them suc­ceed.”

Betsy Sta­ple­ton, a for­mer nurse prac­ti­tioner who now serves as a vol­un­teer peer leader in the Path­ways pro­gram, says or­ga­niz­ers are try­ing to ap­peal to lo­cal providers by billing them­selves as the “easy but­ton to press” when pa­tients need ed­u­ca­tion. The key el­e­ment, she says, is en­sur­ing pa­tients are tak­ing re­spon­si­bil­ity for their care and the best way to do that is to show them some­one who has the same ill­ness and is suc­cess­fully man­ag­ing their symp­toms.

To date, the Path­ways to Health pro­gram has more than 300 grad­u­ates and has been trans­for­ma­tive for the ru­ral com­mu­nity, Glaseroff says. But he also ac­knowl­edges that com­mu­nity-based self-man­age­ment pro­grams run into the same pay­ment wall as those ini­tia­tives that take place in physi­cian of­fices.

“We have some grants and a lot of vol­un­teers, and that is not a sus­tain­able model,” Glaseroff says.

Peer groups are great, says Bo­den­heimer of UCSF, but they run the risk of at­tract­ing the pa­tients who are most mo­ti­vated to make a change. Com­mu­nity groups fill an im­por­tant role, he says, but the first line of health man­age­ment sup­port should take place in the pri­ma­rycare set­ting.

Med stu­dents show in­ter­est

Even though fewer and fewer med­i­cal stu­dents are choos­ing to go into fam­ily prac­tice, those who do are ex­press­ing in­creas­ing in­ter­est in pa­tient-cen­tered care, says Mau­reen Gecht-Sil­ver, di­rec­tor of pa­tient ed­u­ca­tion and com­mu­nity medicine in the de­part­ment of fam­ily medicine at the Univer­sity of Illi­nois at Chicago Col­lege of Medicine.

Gecht-Sil­ver leads a three-ses­sion, self­man­age­ment learn­ing pro­gram, manda­tory for all sec­ond-year fam­ily medicine res­i­dents that stresses ac­tion plan­ning, mo­ti­va­tional in­ter­view­ing tech­niques and col­lab­o­ra­tion with pa­tients. Res­i­dents work di­rectly with pa­tients to iden­tify their chief con­cerns and help with prob­lem-solv­ing strate­gies, she says.

“Our de­part­ment of fam­ily medicine is very in­ter­ested in be­com­ing a pa­tient­cen­tered med­i­cal home, and we see lots of pos­i­tive changes com­ing,” Gecht-Sil­ver says. “People are get­ting more fa­mil­iar with the ter­mi­nol­ogy, and I have med­i­cal stu­dents that are sign­ing up for the ses­sions by choice.”

Self-man­age­ment is also a key com­po­nent of the Joint Com­mis­sion’s Dis­ease-Spe­cific Care Cer­ti­fi­ca­tion pro­gram, launched in 2002, which aims to im­prove care for pa­tients with chronic dis­eases. How­ever, 95% of the or­ga­ni­za­tions that have pur­sued this cer­ti­fi­ca­tion are hos­pi­tals, says Charles Mowll, the com­mis­sion’s ex­ec­u­tive vice pres­i­dent of busi­ness de­vel­op­ment, gov­ern­ment and ex­ter­nal re­la­tions. Fu­ture in­cen­tives, pi­lots and even­tual pay­ment changes could al­low more physi­cians of­fices to seek cer­ti­fi­ca­tion, he adds.

At Green­house In­ternists, the staff is keep­ing its fin­gers crossed and hop­ing that fund­ing for self-man­age­ment ed­u­ca­tion pro­grams won’t run out when the pilot ex­pires, Baron says.

“This used to be a con­ver­sa­tion only had by pri­mary-care physi­cians, but now pur­chasers and pay­ers seem to be re­al­iz­ing that the way we have han­dled pri­mary care up un­til this point has been bad for pa­tients and bad for the value that the sys­tem can de­liver,” Baron says. “That re­al­iza­tion is the most hope­ful thing that I see on the hori­zon.”

Gecht-Sil­ver: Med­i­cal stu­dents in­ter­ested in pa­tient-cen­tered care.

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