Solving the adult primary care crisis: it's time to think - AAMC.org

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Solving the adult primary care crisis: it’s time to think differently Thomas Bodenheimer MD, MPH

Center for Excellence in Primary Care (CEPC) UCSF Department of Family and Community Medicine

Presenter Disclosure

No personal financial relationships with commercial interests are relevant to this presentation.

Adult primary care crisis • Plummeting numbers of new practitioners entering primary care • Declining access to primary care • Practitioner burn-out • Unsatisfactory quality • The primary care medical home is falling off the cliff

Residency Match, 2010 - 2012 % of graduating US medical students choosing specialties

2010 NRMP Main Residency Match data

2012: Adult primary care = 9.6%

Why are US med students avoiding adult primary care • Money

• Worklife • Medical school culture

Stressful worklife • Survey of 422 general internists and family physicians 2001-2005 – 48%: work pace is chaotic – 78%: little control over the work – 27%: definitely burning out – 30%: likely to leave practice within 2 years Linzer et al. Annals of Internal Medicine 2009;151:28-36

• An estimated 30-40% of US physicians experience burnout • Physician burnout is associated with poor patient experience and reduced patient adherence to treatment plans Dyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.

Joy in practice???

Joy

Burnout Ambitious goal

Adult Care: Projected Generalist Supply vs Pop Growth+Aging Percent change relative to 2001

50 45 40 35 30

Shortage of 40,000 adult primary care physicians by Demand:adult population 2020 growth/aging

25 20 15 10 5 0 2000

2005

2010

2015

Colwill et al., Health Affairs, 2008:w232-241

Supply: family medicine, general internal 2020 medicine

NP/PAs to the rescue? • New graduates each year – Nurse practitioners: 8000 – Physician assistants: 4500 • % going into primary care – NPs: 65% – PAs: 32% • Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care clinician to population ratio will fall by 9% from 2005 to 2020.

Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.

Is there a shortage of specialists? • No • 46.3% of specialty visits are for routine follow-up and preventive care for patients already known to the specialist • Most of these visits could be better handled in primary care • Primary care provides better preventive care, better adherence to treatment, lower costs Valderas et al, Ann Fam Med 2009;7:104; Bindman and Grumbach, JGIM 1996;11:269; Welch et al, NEJM 1993;328:621.

Panel sizes too large to manage • Average primary care panel in US is 2300 • PCP with panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care [Yarnall et al. Am J Public Health 2003;93:635]

• PCP with panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care [Ostbye et al. Annals of Fam Med 2005;3:209]

The dilemma

Re-defining the crisis • The crisis is currently defined as an adult primary care physician shortage • In fact, it is a demand-capacity mismatch • Demand for adult primary care services is greater than the capacity to provide those services • Yet adult primary care capacity can be greatly expanded without thousands more MDs, NPs, and PAs

Adult primary care: capacity vs. demand 50

Percent change relative t

45

It’s not only about doctors

40

Share the care

35

Demand for care

=

30

Capacity to provide care

25 20 15 10 5 0 2000

2005

2010

2015

2020

Thinking differently

Practices can add capacity without adding MDs, NPs, PAs • • • •

How? By sharing the care among the entire team High-performing clinics have done it These clinics have same-day or same-week access without reducing panel size

23 High-Performing Practices

Martin’s PointEvergreen Woods

Group Health Olympia Fairview Rosemont Clinic Multnomah County Health Dept

Harvard Vanguard Medford

ThedaCare

Allina

Brigham and Women’s and MGH Ambulatory Practice of the Future

Mayo Red Center

Medical Associates Clinic Clinic Ole

North Shore Physicians Group

Cleveland ClinicStonebridge

Clinica Family Health Services Sebastopol Community Health La Clinica la Raza

Mercy Clinics Univ of UtahRedstone de

Quincy, Office of the Future

Newport News Family Practice

West Los AngelesVA

South Central Foundation

CEPC High-Performers study ABIM Joy in Practice study

10 Building Blocks Patient-centeredness is not a separate building block

10 Template of the future

Increasing capacity is not a separate building block Joy in practice is not a separate building block All building blocks should support these goals 1 Engaged leadership

9

8 Prompt access to care

5 Patient-team partnership

Coordination of care

6 Population management

2

3

Data-driven improvement

Empanelment

7 Continuity of care

4 Team-based care

10 Building Blocks 10

Team-based care

Template of the future

Population management

Prompt access to care

5 Patient-team partnership

1 Engaged leadership

9

8

6 Population management

2

3

Data-driven improvement

Empanelment

Coordination of care

7 Continuity of care

4 Team-based care

Building Block #4: Team-based Care • Culture shift: Share the Care • Stable teamlets • Co-location • Standing orders/protocols • Defined workflows and roles – workflow mapping • Training, skills checks, and cross training • Ground rules • Communication – huddles, team meetings, and constant interaction

Team-based care: stable teamlets Patient panel

Patient panel

Clinician + MA teamlet

Clinician + MA teamlet

Patient panel

Clinician + MA teamlet

RN, behavioral health professional, social worker, pharmacist, complex care manager

1 team, 3 teamlets

Clinician satisfaction with teams San Francisco Dep’t of Public Health primary care clinics n=135 Teamlet (work with same MA) (n=27) Not satisfied 15% Neutral 15% Satisfied 70%

Team (work with group of MAs) (n=90) Not satisfied 35%

Satisfied 37%

No teams (work with different MAs) (n=18) Satisfied 11%

Neutral 28% Neutral 28%

Not satisfied 61%

Stable teamlets reduce burnout

Share the Care: what does it mean? • Non-clinicians assuming responsibility for care that does not require a MD/NP/PA level of training • Key aims of sharing the care: • Improve access in a primary care clinician-shortage environment • Reduce clinician burnout

Share the Care: preserving the relationship • Share the Care means that the personal clinician (MD, NP, PA) does not provide all the care • To preserve patients’ relationship with the personal clinician, sharing the care should take place in the teamlet • The relationship changes from patientclinician to patient-teamlet

Building Block #6: Population-management: stratifying the panel

Panel Management: Ensuring that ALL of the patients in our panel get recommended preventive and chronic care

Sharing the care using panel management • Panel management – Medical assistants use preventive care and chronic disease registries to identify patients overdue for routine services and arrange for those services to be performed – Physician-written standing orders are needed to empower the medical assistants – Quality of preventive services improves [Chen and Bodenheimer, Arch Intern Med 2011;171:1558]

– An estimated 50% of all preventive care activities could be shared with medical assistants [Altschuler et al, Annals of Family Medicine 2012, in press]

Preventive services: old way • Mammogram for 55-year-old healthy woman • Old way: – Clinician gets reminder that mammo is due – At next visit, clinician (maybe) orders mammo – Clinician gets result, (sometimes) notifies patient

Preventive services: new way MA (panel manager) checks registry every month If due for mammo, MA sends mammo order to patient Result comes to MA, if normal, MA notifies patient If abnormal MA notifies clinician and app’t made For most patients, clinician is not involved For women 40-50 who want or need mammogram, clinician is involved for discussion • Similar for colon cancer screening • Requires standing orders • 50% of preventive care can be re-allocated away from the clinician • • • • • •

[Altschuler et al, Annals of Family Medicine 2012;10:396]

Stratifying the panel Health Coaching: Helping patients with chronic conditions to improve their selfmanagement. MA health coaches, RNs, health educators, peer coaches

Sharing the care using health coaching • Health coaching – Medical assistants trained as health coaches can assist patients with chronic conditions to learn about their disease, engage in healthier behaviors, and increase their medication adherence [Margolius et al, Annals of Family Medicine

2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369]

– An estimated 25-30% of all chronic care activities could be shared with medical assistants [Altschuler et al, Annals of Family Medicine 2012;10:396]

Health coaching in the teamlet model

Chronic care: hypertension: old way • • • • •

Clinician sees today’s blood pressure Clinician refills meds or changes meds (maybe) Clinician makes f/u appointment No one addresses med adherence Often blood pressures are not adequately controlled

Chronic care: hypertension: new way • Patients with abnormal BP contacted for pharmacist, RN, or health coach visit • Health coach does education, med adherence, lifestyle change • Patient taught home BP monitoring • If BP elevated and patient med adherent, RN/pharmacist intensifies meds by standing orders • If questions, quick clinician consult • Health coach f/u by phone or e-mail • Clinician barely involved • Blood pressure control improves with this innovation [Margolius et al, Annals of Family Medicine 2012;10:199]

More sharing the care opportunities • RNs can treat uncomplicated UTIs, URIs, STIs, and low back pain without clinician involvement with equal quality and better patient satisfaction • Physical therapists can manage low-back pain with better functional relief and patient satisfaction compared with primary care physicians • RNs or pharmacists could care for a sub-panel of patients with diabetes, hypertension and/or hyperlipidemia with minimal clinician involvement • RN complex care managers can provide much of the care for time-consuming, complex, high-utilizing patients Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199, Bodenheimer and Berry-Millett, RWJF Synthesis Project, December 2009

Take-home points • Re-define the adult primary care crisis • It is not only a doctor shortage • It is a demand-capacity mismatch • A substantial portion of the demand can be met by non-clinicians who share the care • This requires high-functioning teams with standing orders to empower all team members • It won’t happen without payment reform

Adult primary care: capacity vs. demand It is possible to solve the adult primary care crisis without 40,000 more doctors

Share the care Demand for care

= Capacity to provide care

We must think differently

Share the Care

10

10 Building Blocks of High- Performing Primary Care

Prompt access to care

5 Patient-team partnership

Engaged leadership

9

8

Willard and Bodenheimer California HealthCare Foundation, April 2012 www.chcf.org

1

Template of the future

2 Data-driven improvement

Coordination of care

6 Population management

3 Empanelment

7 Continuity of care

4 Team-based care

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Solving the adult primary care crisis: it's time to think - AAMC.org

Solving the adult primary care crisis: it’s time to think differently Thomas Bodenheimer MD, MPH Center for Excellence in Primary Care (CEPC) UCSF De...

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