Integral to the very concept of the patient-centered medical home is the need for a very real, very concrete, one-on-one relationship between the patient and his or her primary care provider.
No matter who this is, the patient needs to know who their internist, or gynecologist, or pediatrician, or nurse practitioner, or other primary care provider is. Nothing can replace this, and everything else about the patient-centered medical home is designed to augment this relationship and help it flourish.
Nothing can substitute for this relationship, this long-term, mutually respectful relationship, that when successfully built and nurtured helps patients move towards a state of better health.
This relationship is built on the very foundations of the patient-centered medical home: quality, continuity, access, and transitions.
Now, one might think, of course, everyone knows who their doctor is. That kindly face you see at every office visit, the gray haired old doctor who has seen you through many illnesses large and small, the pediatrician who watched you pass from infant to toddler to teenager to adulthood.
Yet in many health systems, especially resident-based practices, this is not the case. Some are set up on a first come, first served basis. You need to be seen today? Here is who you will see. An acute visit? Your doctor’s schedule is full, but we have a walk-in provider who can see you. Want to schedule an annual? Next available is 6 months from now.
Not very conducive to relationship building.
At our resident-based practice we recently changed to a new scheduling system that is completely separate from our EHR, and we have discovered that it does not have the ability to identify the primary care provider (PCP) in its templates. Registrars making appointments hope that patients know who the PCP is, or they can guess from the most recent visits in the record.
Begging for discontinuity.
Access to your provider, being able to see who you want to see when you want to see them, leads to improved patient satisfaction and better quality.
Studies have repeatedly shown that a PCP will order less testing for almost any given complaint than an interim provider who does not know the patient. Those headaches? No need to scan again. That abdominal pain? No need for blood tests.
Sometimes the payoff from the long-term relationship of PCP and patient is rewarding in ways both tangible and unfathomable.
And those critical transitions, moving from inpatient back to outpatient, having your own PCP there to pick up the reins of your care, can make all the difference in the world.
As described in a previous column, we have been dealing with the forced discontinuity of a resident practice by building teams to care for patients, with the PCP at the center and the other residents in their “pod” fleshing out the core. Our residents come to practice in 2-week ambulatory blocks, and then are away for 6 weeks. We have tasked the residents to create continuity by handing off active patients to the next member of the pod coming on service, and helping the patients understand that this pod member is the “equivalent” of their PCP for all intents and purposes.
We have created special color “pod pamphlets” that have pictures of the whole team, the resident PCP, the other pod residents, responsible supervising attending, staff supervisor, and practice NP. Useful information such as available appointment dates, patient portal website, and phone/fax numbers are there for patients to help them feel like they really have a team behind them, with the PCP at the helm.
We are studying the “continuity index” (what percent of visits are with PCP or pod mates) to see if enforcing this can really improve quality and patient and provider satisfaction, and maybe even improve outcomes.
We have been building up our transitions program, adding formal structure and dedicated personnel, to get patients right after discharge back to the care of the PCP (or pod), and hopefully even prevent some of those dreaded less than 30 day readmissions.
Enhanced ability to reach your PCP via our EHR’s secure patient portal will also help this relationship. As everyone knows, getting a message to your provider and getting some healthcare back can be a daunting process. Phone tag is our lives. But even the reassurance and recommendations given over the Internet can help heal many wounds.
Open access and advanced scheduling may in the near future allow even more continuity, helping patients get all the care they feel they need.
Knowing who your PCP is, and feeling like they are looking out for you and are there when you need them, will allow the patient-centered model of care to thrive and evolve, with us standing right by our patients’ sides.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
