Patients have a sense that their care team is “always available,” and that they will be able to reach someone who knows them and can help them quickly whenever necessary. Practices offer same-day appointments and accommodate walk-ins, extend evening and weekend hours, typically take their own after-hours calls, and can rapidly access their patients’ electronic medical records outside of conventional office hours. (Back to list)
The care team is conscientiously dedicated to ensuring patients get all necessary care, proactively identifying needed tests and treatments and ensuring patients get them. At the same time, they conserve resources by tailoring care to align with the needs and values of their patients. Three components illustrate a dedication to conserving resources without compromising the conscientious protection of patients’ health:
A. Fulfilling Quality of Care Guidelines: The care team ensures that patients receive all evidence-based preventive care and treatment. This often means making guideline-based reminders available to clinicians at the time of the patient’s visit, right on the electronic medical record, for example. Practices that do this most effectively place responsibility with one person—often the office manager—who holds the care teams accountable by regularly running reports to rapidly identify any outstanding care gaps and alerting the care team to take action. This conscientiousness is balanced with a more thoughtful use of tests, treatments and referrals. In the “grey areas” of medicine, these clinicians stop to take the time to ask whether additional care aligns with their patients’ personal preferences and quality of life goals.
B. Individualized Intensity of Care: Each patient receives care and support that is matched to his or her unique clinical needs. Patients with the greatest needs receive the most support. For example, patients categorized as “high-risk” are monitored and advised by a care manager, scheduled for longer office visits or receive frequent phone checks by office staff, or in some cases, clinician house calls.
C. Shared Decision-Making and Advanced Care Planning: When there are multiple diagnostic and treatment options and they substantially differ in their risk of complications and cost, the physician takes the time to walk a patient through likely scenarios and tradeoffs. This includes discussions about the pros and cons of aggressive treatment options near the end of life. (Back to list)
Complaints from patients are regarded to be as valuable as compliments, if not more so. High-value primary care sites take every opportunity to encourage patient feedback.
The office manager at Memphis Primary Care Associates speaks with three to five patients daily for immediate, informal feedback on their visit. Not only is the feedback provided in real-time, but it ensures that patients without the interest or resources to fill out an electronic survey are heard. Back to list
Three features illustrate how these high-value providers of primary care play a more active role in orchestrating other players in their local healthcare eco-system. That includes medical specialists, hospitalists and emergency physicians, as well as staff at nursing homes, physical rehabilitation centers, and pharmacies.
Primary care teams do as much as they can safely do rather than referring patients out. These primary care physicians practice within the full scope of their expertise, delivering minor procedures and other treatments that other primary care physicians often refer out—such as skin biopsies, insulin initiation and stabilization, joint injections or suturing—because they take more time than the average patient visit. If they can arrange specialist supervision, they take on additional low complexity services sometimes performed at a higher cost by specialists, such as treadmill testing for cardiac patients. (Back to list)
When services outside the scope of the primary care practice are necessary, these physicians rely on a carefully selected list of preferred local specialists who share their philosophy of conscientious conservation.
At Florida Medical Clinic, primary care physicians also act as hospitalists, and go to the emergency department as soon as one of their patients arrives. They use their medical group’s personal knowledge of the patient to decide whether the patient needs to be admitted to an inpatient bed or can be safely referred back to the practice for an urgent care visit.
Although these primary care physicians cannot always select the hospitalist or emergency department (ED) physician who cares for their patients, they maintain relationships with them regardless, stay connected with the care of their patient, and assure that treatment plans respect their patients’ personal preferences and health goals. They remain in close communication with other physicians and insist on being kept in the loop as their patient’s treatment plan evolves.
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The care team ensures that each element of the treatment plan agreed upon by the patient and their physician is fulfilled. This includes confirming that a patient went to her specialist appointment, proactively tracking medication adherence, and following up expeditiously when patients are unexpectedly admitted to a hospital.
Family Physicians Group in Kissimmee, Fla., obtains health insurance claims data for prescription refills from their health plan’s pharmacy to confirm that high-risk patients fill their prescriptions in a timely manner. Back to list
Four features illustrate how these high-value sites are organized to support the greater depth and breadth of primary care interactions.
Physicians are supported by a team of nurse practitioners, physician assistants, nurses, and/or medical assistants—all of whom are working at the “top of their licenses.”
Ridgewood Meds-Peds in Rochester, N.Y., calculated that fulfilling all of the administrative and clinical activities associated with an eight-hour day of patient visits requires 18 hours of staff time. Their staffing approaches assure that all activities that don’t need to be performed by a physician are assigned to other care team members.
This enables physicians to spend more time with the patients who need the most direct physician contact, and to take care of more patients. Upshifted staff roles are often facilitated by an empowered practice manager who runs an efficient office and frontline staff team—allowing the clinicians to focus only on activities that require clinical judgment and training. (Back to list)
Care teams work together side-by-side in an open “bullpen” environment that facilitates continuous communication among both clinical and non-clinical staff. This approach, in which physicians work in a room with others on the care team, goes hand in hand with upshifted staff roles. It facilitates learning through collaboration without regard to hierarchy. It also prompts physician-to-physician dialogue about complex cases and differences in practice style. In some larger practices, we saw this dialogue facilitate agreement on approaches to uncomplicated common illnesses. This in turn, allowed their teams to standardize workflow and solve patients’ problems more quickly. (Back to list)
Physicians are not paid solely on the basis of their productivity. Rather than basing physician income solely on service volume—in other words, ‘fee for service—pay typically also reflected performance on at least one of the following components: 1) quality of care, 2) patient experience, 3) resource utilization, and 4) contribution to practice-wide improvement activities. (Back to list)
By saving money on space, equipment and technology, these providers didn’t need to see more patients or order expensive tests to generate a competitive income. These physicians rent very modest offices. To save money and eliminate incentives to use expensive equipment, the practices only invest in lab, imaging and other equipment if it allows them to provide care more cost-effectively in-house. Some partner with other practices to jointly operate imaging equipment. This lowers their cost and charge per imaging study to patients and insurers by spreading the fixed cost of the equipment over more patients. (Back to list)