A patient of mine — we’ll call her Ruby — is a 79-year-old woman from the same part of rural Tennessee as my mother. Her recent successful experiences with treatment illustrate some of the themes that my colleagues and I encountered when we undertook an 18-month practice-design-thinking process. Let’s start with Ruby’s example and then dig into Primary Care 2.0.
Ruby’s story: tech and team
Ruby had been a slow adopter of technology, but when the pandemic hit, she got online. She got a blood-pressure cuff and was sending me all her measurements. Through video visits, we titrated her blood pressure medications. Over time, the cardiology nurse who was monitoring Ruby’s measurements noticed a spike in blood pressure, and when she reached out, she learned that Ruby was running a fever. It wasn’t COVID-19 but rather pneumonia. We were able to send Ruby for an X-ray and get her seen and treated without her ever entering the hospital.
Prominent themes in primary care redesign
As we continue through this transformational period in primary care, Ruby’s care experience illuminates several principles that have informed my team’s thinking about practice redesign:
Asynchronous patient data—too much of a good thing. Ruby’s willingness to tech up and send me measurements was a blessing and a curse — with so many patients, the quantity of patient data streaming through became overwhelming. I felt like I was in the classic chocolate factory sketch from “I Love Lucy. “So did many other practices, here in the Bay Area and elsewhere: One primary care practice network in New England saw patient medical advice messages per day double during the pandemic. The team-based approach of Primary Care 2.0 helps mitigate this burden.
Team-based care. The physician shortage is already here, even as demands on physicians’ time expand. Fortunately, help is on the way. Over the next ten years, we’ll see two advanced practice clinicians (APCs) for every physician entering the primary care workforce. As we’ll see below, their support will be key to Primary Care 2.0.
Efficiencies. Many older patients with pneumonia land in the hospital, with its attendant risks and costs. The way our team helped Ruby access non-hospital treatment is something we hope to pattern with Primary Care 2.0. Others have succeeded in this area: At a recent primary care conference, Arumani Manisundaram of Netrin Health described a primary care network in Maryland where remote patient monitoring was associated with a 71 percent reduction in 30-day readmission and 64 percent reduction in visits to the emergency department (ED).
Primary Care 2.0: each team member at the top of their license
When my colleagues and I visited high-performing primary care clinics across the country, we sought insights to inform a new model for providing the most efficient and high-quality care. Here’s how we’re practicing in Primary Care 2.0:
Patients at the center of the team. We put patients at the center of Primary Care 2.0, a team-based care model that simultaneously engages patient care complexity and physician burnout. Three care teams per clinic each include one MD/APC pair, plus four medical assistant Care Coordinators. Each care team is supported by nutritionists, behavioral health specialists, physical therapists, and other onsite extended care specialists.
Role definition. To perform in this model, role definition and authorization protocols are key. For example, we’ve determined what a pharmacist can do to manage chronic diseases like hypertension or diabetes, so I rarely see a hypertensive patient to manage medications. In primary care, we have a long-term trusting relationship with our patients. We have to transfer that trust. If we feel it, it will come through to the patient when we say, “I might not see you next time. It will be a member of my team, and I know they’re going to take care of you. They always communicate to me.”
Tech-enabled consultation. Since the start of the pandemic, we’ve seen increased uptake of eConsult, a way to message a colleague to ask how they would manage or at least indicate the workup for the patient. Any specialist across our system is able to respond, and 40 percent of patients presenting complaints are resolved this way. From the perspective of the patient, this gives the primary care provider superpowers. Providing specialty-level care through the primary care platform also brings efficiencies and cost-effectiveness.
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Care relationships and diversity in teams
Ruby now works with her pharmacist to continue medication management, so she and I can focus on other things and build our relationship.
Speaking of relationships: If we’re going to be successful in the health equity realm, we need to think about diversity in teams. A review of studies related to diversity in health care showed positive associations between diversity, quality, and financial performance. And patients generally fared better when cared for by more diverse teams. As we lean into team-based care models, it makes sense to ask ourselves: Who on the team could perhaps connect culturally or have some chemistry with the patient so that they can feel like they have a trusting relationship with their care team? This question will become increasingly important to the transformations of care coming over the next decade.
This article is discussed on The Podcast by KevinMD in the episode Primary Care 2.0: new thinking and practice redesign.
Megan Mahoney is a family physician and member, board of governors, The Doctors Company and TDC Group of Companies.
Founded and led by physicians, The Doctors Company is relentlessly committed to advancing, protecting, and rewarding the practice of good medicine. The Doctors Company helps hospitals and practices of all sizes manage the complexities of today’s healthcare environment—with expert guidance, resources, and coverage—and is the only medical malpractice insurer with an advocacy program covering all 50 states and the federal level. The Doctors Company is part of TDC Group, the nation’s largest physician-owned provider of insurance and risk management solutions. TDC Group serves the full continuum of care.
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