Can we solve the adult primary care shortage without more physicians?
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Can we solve the adult primary care shortage without more physicians?

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Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium

Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium

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  • Our building blocks to high performing primary care were developed as a roadmap to guide practices during transformation. Transforming to a primary care medical home requires more than checking boxes and capturing screen shots. <br /> I will spend the rest of the presentation discussing how the blocks were developed, the overall sequencing, practical implementation of the components of each block and showcase exemplars from high-performing sites and from other clinics that we are familiar with or coach. <br />
  • Our building blocks to high performing primary care were developed as a roadmap to guide practices during transformation. Transforming to a primary care medical home requires more than checking boxes and capturing screen shots. <br /> I will spend the rest of the presentation discussing how the blocks were developed, the overall sequencing, practical implementation of the components of each block and showcase exemplars from high-performing sites and from other clinics that we are familiar with or coach. <br />

Can we solve the adult primary care shortage without more physicians? Can we solve the adult primary care shortage without more physicians? Presentation Transcript

  • Can we solve the adult primary care shortageCan we solve the adult primary care shortage without more physicians?without more physicians? Tom BodenheimerTom Bodenheimer Center for Excellence in Primary CareCenter for Excellence in Primary Care UCSF Dep’t of Family and Community MedicineUCSF Dep’t of Family and Community Medicine Weitzman Symposium 2014Weitzman Symposium 2014
  • Colwill et al., Health Affairs, 2008:w232Colwill et al., Health Affairs, 2008:w232 Petterson et al, Ann Fam Med 2012;10:503Petterson et al, Ann Fam Med 2012;10:503 0 5 10 15 20 25 30 35 40 45 50 2000 2005 2010 2015 2020 Percent change relative to 2001 Adult care: projected generalist physicianAdult care: projected generalist physician supply vs. demandsupply vs. demand Demand:adult popDemand:adult pop’n’n growth/aginggrowth/aging Supply: familySupply: family med, generalmed, general internal medinternal med Shortage of 40,000 by 2020 Shortage of 52,000 by 2025
  • NP/PAs to the rescue?NP/PAs to the rescue? • New graduates each yearNew graduates each year – Nurse practitioners:Nurse practitioners: 80008000 – Physician assistants:Physician assistants: 45004500 • % going into primary care% going into primary care – NPs:NPs: 65%65% – PAs:PAs: 32%32% • Adding new GIM, FamMed, NPs, and PAsAdding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary careentering primary care each year, the primary care clinician to population ratio will fall byclinician to population ratio will fall by 9%9% fromfrom 2005 to 2020.2005 to 2020. Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al,Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.Health Affairs 2009;28:64. View slide
  • Panel sizes too large to managePanel sizes too large to manage • Average primary care panel in US isAverage primary care panel in US is 23002300 • PCP with panel of 2500 average patients willPCP with panel of 2500 average patients will spendspend 7.4 hours per day7.4 hours per day doing recommendeddoing recommended preventive carepreventive care [Yarnall et al. Am J Public Health 2003;93:635][Yarnall et al. Am J Public Health 2003;93:635] • PCP with panel of 2500 average patients willPCP with panel of 2500 average patients will spendspend 10.6 hours per day10.6 hours per day doing recommendeddoing recommended chronic carechronic care [Ostbye et al. Annals of Fam Med 2005;3:209][Ostbye et al. Annals of Fam Med 2005;3:209] View slide
  • Results of large panelsResults of large panels • Poor access for patientsPoor access for patients • Inconsistent qualityInconsistent quality • Lack of time to build relationships with patientsLack of time to build relationships with patients • Clinician burnoutClinician burnout – Survey of 422 general internists, family physiciansSurvey of 422 general internists, family physicians • 27%: definitely burning out27%: definitely burning out • 30%: likely to leave the practice within 2 years30%: likely to leave the practice within 2 years – Physician burnout is associated with poor patientPhysician burnout is associated with poor patient experience and reduced patient adherence toexperience and reduced patient adherence to treatment planstreatment plans Linzer et al. Annals of Internal Medicine 2009;151:28-36; Dyrbye, JAMA 2011;305:2009; Murray etDyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.
  • The dilemmaThe dilemma • Panel size too large for average PCP to managePanel size too large for average PCP to manage • We can’t reduce panel size due to worseningWe can’t reduce panel size due to worsening shortage of adult primary care cliniciansshortage of adult primary care clinicians • Shortage = larger panels, poorer access forShortage = larger panels, poorer access for patients, poorer quality, more PCP burnout, higherpatients, poorer quality, more PCP burnout, higher health care costshealth care costs • More PCP burnout means fewer medical studentsMore PCP burnout means fewer medical students will be attracted to primary carewill be attracted to primary care Unless we think differentlyUnless we think differently
  • Re-defining the adult primary care shortageRe-defining the adult primary care shortage • Most people define it as a physician shortageMost people define it as a physician shortage • Or a clinician shortage (MDs, NPs, PAs)Or a clinician shortage (MDs, NPs, PAs) • These formulations are aThese formulations are a bridge to nowherebridge to nowhere • If clinician shortage is the problem, then the only solutionIf clinician shortage is the problem, then the only solution is more cliniciansis more clinicians • More clinicians would help, but there willMore clinicians would help, but there will nevernever be enoughbe enough • We must re-define the shortage as a demand-capacity gapWe must re-define the shortage as a demand-capacity gap • We address the gap by increasing capacity and/or reducingWe address the gap by increasing capacity and/or reducing demanddemand • We can do this without more cliniciansWe can do this without more clinicians
  • 0 5 10 15 20 25 30 35 40 45 50 2000 2005 2010 2015 2020 Percent change relative to 2001 Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand Demand for careDemand for care == Capacity toCapacity to provide careprovide care Thinking differentlyThinking differently It’s not only about doctorsIt’s not only about doctors Share the careShare the care
  • Clinica Family Health Services Group Health Olympia Multnomah County Health Dept South Central Foundation Univ of Utah- Redstone Newport News Family Practice Cleveland Clinic- Stonebridge Quincy, Office of the Future West Los Angeles- VA La Clinica de la Raza Clinic Ole Sebastopol Community Health Martin’s Point- Evergreen Woods Harvard Vanguard Medford Brigham and Women’s and MGH Ambulatory Practice of the Future North Shore Physicians Group Medical Associates Clinic Mercy Clinics ThedaCare Fairview Rosemont Clinic Mayo Red Center Allina 23 High-Performing Practices23 High-Performing Practices
  • 10 Building Blocks of High-Performing Primary Care Annals of Family Medicine 2014;12:166-71 Team-based careTeam-based care
  • Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care • CliniciansClinicians • Non-clinician team membersNon-clinician team members – Non-professionalNon-professional • MAs as panel managersMAs as panel managers • MAs as health coachesMAs as health coaches • MAs as scribesMAs as scribes – ProfessionalProfessional • RNsRNs • PharmacistsPharmacists • BehavioristsBehaviorists • PatientsPatients – Peer health coachesPeer health coaches – Self careSelf care • TechnologyTechnology Bodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6
  • Share the care: who does it now?Share the care: who does it now? Tasks PCP RN LPN Medical assistant Pharmacist Orders mammograms for healthy women between 50 and 75 years old Refills high blood pressure medications for patients with well-controlled hypertension Performs diabetes foot exams Reviews lab tests to separate normals from abnormals Cares for patients with uncomplicated urinary tract infections Finds patients who are overdue for LDL and orders lipid panel Prescribes statins for patients with elevated LDL Does medication reconciliation Screens patients for depression using PHQ 2 and PHQ 9 Follows up by phone with patients treated for depression Totals
  • Share the care: preserve the relationshipShare the care: preserve the relationship • Share the Care means that the personal clinicianShare the Care means that the personal clinician does not provide all the caredoes not provide all the care • Patients should not be asked to transfer trust from a clinician to a large team • Historically patients trust a small team (teamlet) • The relationship changes from patient-clinician toThe relationship changes from patient-clinician to patient-teamletpatient-teamlet • Members of the larger team are involved if neededMembers of the larger team are involved if needed • Blue Shield of California Foundation survey: patientsBlue Shield of California Foundation survey: patients are willing to receive care from a team even if itare willing to receive care from a team even if it means seeing their physician less (June 2012)means seeing their physician less (June 2012)
  • Team-based care: stable teamlets Patient panel 1 team, 3 teamlets Clinician + MA teamlet Patient panel Clinician + MA teamlet Patient panel Clinician + MA teamlet RN, behavioral health professional, social worker, pharmacist, complex care manager
  • High-performing teamletsHigh-performing teamlets
  • High performing teamletHigh performing teamlet
  • Sharing the care with non-clinicianSharing the care with non-clinician team membersteam members • Panel managementPanel management – MAs use preventive and chronic disease registries,MAs use preventive and chronic disease registries, and EMR health maintenance screens, to identifyand EMR health maintenance screens, to identify patients with care caps and close the care gapspatients with care caps and close the care gaps – Standing ordersStanding orders are needed to empower the MAsare needed to empower the MAs – Best done within the teamletBest done within the teamlet – Quality of preventive services improvesQuality of preventive services improves [Chen and[Chen and Bodenheimer, Arch Intern Med 2011;171:1558]Bodenheimer, Arch Intern Med 2011;171:1558]
  • Clinician confidence that medical assistantsClinician confidence that medical assistants will do a good job on panel managementwill do a good job on panel management 2012 Survey of 231 PCPs2012 Survey of 231 PCPs Source: System Transformation Evaluation Survey (STEP). 2012. Available at http://familymedicine.medschool.ucsf.edu/cepc/
  • Preventive services: new wayPreventive services: new way • MA (panel manager) checks registry every monthMA (panel manager) checks registry every month • If due for mammo, MA sends mammo order to patientIf due for mammo, MA sends mammo order to patient • Result comes to MA, if normal, MA notifies patientResult comes to MA, if normal, MA notifies patient • If abnormal MA notifies clinician and app’t madeIf abnormal MA notifies clinician and app’t made • For most patients, clinician is not involvedFor most patients, clinician is not involved • For women 40-50 who want or need mammogram,For women 40-50 who want or need mammogram, clinician is involved for discussionclinician is involved for discussion • Similar for colon cancer screeningSimilar for colon cancer screening • Requires standing ordersRequires standing orders
  • Sharing the care with non-clinicianSharing the care with non-clinician team membersteam members • Health coachingHealth coaching – MAs trained as health coaches can assist patients with chronicMAs trained as health coaches can assist patients with chronic conditions to become informed active participants in their careconditions to become informed active participants in their care [Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93;[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; Willard et al, in press]Gensichen et al, Ann Intern Med 2009;151:369; Willard et al, in press] • Example: diabetesExample: diabetes – Closing the loop to check for understanding (50% don’tClosing the loop to check for understanding (50% don’t remember what happened in the clinician visit)remember what happened in the clinician visit) – Know your ABC numbers (A1c, BP, Cholesterol)Know your ABC numbers (A1c, BP, Cholesterol) – Know your ABC goalsKnow your ABC goals – Know how to get from your number to your goalKnow how to get from your number to your goal – Behavior change goal-setting and action plansBehavior change goal-setting and action plans – Know your medications, and med adherence counselingKnow your medications, and med adherence counseling • Difficult to do on teamlet unless 2 MAs per clinicianDifficult to do on teamlet unless 2 MAs per clinician
  • Health coaching in the teamlet modelHealth coaching in the teamlet model
  • Chronic care: hypertension: new wayChronic care: hypertension: new way • MA checks registry every monthMA checks registry every month • Patients with abnormal BP contacted for pharmacist, RN,Patients with abnormal BP contacted for pharmacist, RN, or health coach visitor health coach visit • Health coach: education, med adherence, lifestyle changeHealth coach: education, med adherence, lifestyle change • If BP elevated and patient med adherent, RN/pharmacistIf BP elevated and patient med adherent, RN/pharmacist intensifies meds by standing ordersintensifies meds by standing orders • If questions, quick clinician consultIf questions, quick clinician consult • Health coach f/u by phone or e-mailHealth coach f/u by phone or e-mail • Clinician barely involvedClinician barely involved • Blood pressure control improved with this innovationBlood pressure control improved with this innovation [Margolius et al, Annals of Family Medicine 2012;10:199][Margolius et al, Annals of Family Medicine 2012;10:199]
  • Share the care:Share the care: MA acts as scribe while MD does physical examMA acts as scribe while MD does physical exam
  • EMR pushes more work to physician, leading toEMR pushes more work to physician, leading to vast amounts of time spent documentingvast amounts of time spent documenting If changes are notIf changes are not made to reduce thesemade to reduce these time penalties ontime penalties on primary careprimary care physicians there will bephysicians there will be no primary careno primary care physicians left tophysicians left to penalize.penalize. Clement J McDonaldClement J McDonald MD, Arch Intern Med 2012;172:285-287MD, Arch Intern Med 2012;172:285-287 (Clem McDonald created one of the(Clem McDonald created one of the first EMRs in the 1970s)first EMRs in the 1970s)
  • Vast amounts of time spent documentingVast amounts of time spent documenting • Scribing • Assistant order entry • Re-engineering the prescription renewal work out of the practice • I come in to my doctor for anI come in to my doctor for an examination, but it seems allexamination, but it seems all he wants to do is examinehe wants to do is examine the computer.the computer. Patient 3/2/12Patient 3/2/12 • I used to be a doctor.  Now II used to be a doctor.  Now I am a typist.am a typist. Internist Anchorage ALInternist Anchorage AL • I really like my doctor of overI really like my doctor of over 10 years, but rarely get to10 years, but rarely get to talk with her face to face; astalk with her face to face; as I’m talking, she is typing.I’m talking, she is typing. Annoys the hell out of me.Annoys the hell out of me. Patient, 12/30/10Patient, 12/30/10
  • Hey doc, I’m here too
  • Scribes to reduce documentation timeScribes to reduce documentation time • University of Utah “Care by Design” • Right person/right job • MAs receive additional training • MA takes history using EMR templates • MD reviews history does physical exam and MA enters findings into EMR • MD calls out lab, imaging, prescriptions and MA enters them as pended orders that MD quickly Oks • Profits up, patient satisfaction up, provider satisfaction up, quality measures up Blash et al, UCSF Center for the Health Professions, April 2011
  • The best way to reduce burnoutThe best way to reduce burnout
  • Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care • CliniciansClinicians • Non-clinician team membersNon-clinician team members – Non-professionalNon-professional • MAs as panel managersMAs as panel managers • MAs as health coachesMAs as health coaches • MAs as scribesMAs as scribes – ProfessionalProfessional • RNsRNs • PharmacistsPharmacists • Physical therapistsPhysical therapists • BehavioristsBehaviorists • PatientsPatients – Peer health coachesPeer health coaches – Self careSelf care • TechnologyTechnology
  • Team-based care: stable teamletsTeam-based care: stable teamlets PatientPatient panelpanel Clinician/MAClinician/MA teamletteamlet PatientPatient panelpanel Clinician/MAClinician/MA teamletteamlet PatientPatient panelpanel Clinician/MAClinician/MA teamletteamlet Health coach, behavioral health professional,Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager,social worker, RN, pharmacist, panel manager, complex care managercomplex care manager
  • Share the care with professional teamShare the care with professional team members using standing ordersmembers using standing orders • RNs treat uncomplicated UTIs, URIs, STIs, and low back pain withoutRNs treat uncomplicated UTIs, URIs, STIs, and low back pain without clinicians: equal quality and better patient satisfactionclinicians: equal quality and better patient satisfaction • Physical therapists manage low back pain with better functional reliefPhysical therapists manage low back pain with better functional relief and patient satisfaction compared with physiciansand patient satisfaction compared with physicians • RNs or pharmacists can care for a sub-panel of patients with diabetes,RNs or pharmacists can care for a sub-panel of patients with diabetes, hypertension, hyperlipidemia with minimal clinician involvementhypertension, hyperlipidemia with minimal clinician involvement • Behaviorists in primary care improve depression outcomesBehaviorists in primary care improve depression outcomes • RN complex care managers can provide much of the care for time-RN complex care managers can provide much of the care for time- consuming, complex, high-utilizing patientsconsuming, complex, high-utilizing patients • These changes can add 10-20% capacity without more clinician timeThese changes can add 10-20% capacity without more clinician time Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199;Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199; http:http: //impact-uw//impact-uw.org.org; Bodenheimer and Berry-Millett, RWJF Synthesis Project, DecemberBodenheimer and Berry-Millett, RWJF Synthesis Project, December 20092009;; Bodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6
  • Share the care with patients:Share the care with patients: peer health coachespeer health coaches • Patients trained as peer health coaches can add capacityPatients trained as peer health coaches can add capacity • VA diabetic patients paired with peers had greater glycemicVA diabetic patients paired with peers had greater glycemic improvement than patients with nurse care managersimprovement than patients with nurse care managers [Heisler et al, Ann Intern Med 2010;153:507][Heisler et al, Ann Intern Med 2010;153:507] • Latino diabetic patients with peer-led classes: betterLatino diabetic patients with peer-led classes: better glycemic control than usual careglycemic control than usual care [Philis-Tsimikas et al, Diab Care[Philis-Tsimikas et al, Diab Care 2011;34:1926]2011;34:1926] • Diabetes patients with a peer coach had greater HbA1cDiabetes patients with a peer coach had greater HbA1c reductions than usual care patientsreductions than usual care patients [Long et al, Ann Intern Med[Long et al, Ann Intern Med 2012;156:416]2012;156:416] • Low-income diabetic patients with low-income peerLow-income diabetic patients with low-income peer coaches achieved better glycemic control than usual carecoaches achieved better glycemic control than usual care patientspatients [Thom et al, Ann Fam Med 2013;11:137-144][Thom et al, Ann Fam Med 2013;11:137-144]
  • Training peer health coachesTraining peer health coaches
  • 0 5 10 15 20 25 30 35 40 45 50 2000 2005 2010 2015 2020 Percent change relative to 2001 Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand Demand for careDemand for care == Capacity toCapacity to provide careprovide care Thinking differentlyThinking differently Sharing the careSharing the care adds capacityadds capacity Patient self-carePatient self-care reduces demandreduces demand Share the careShare the care Self careSelf care
  • Reducing demand through self careReducing demand through self care • Home pregnancy kits, home HIV testingHome pregnancy kits, home HIV testing • Internet sites (good and not good)Internet sites (good and not good) • More OTC medicationsMore OTC medications • Patients with home blood pressure monitors whoPatients with home blood pressure monitors who self-titrate their medications can achieve betterself-titrate their medications can achieve better blood pressure control than that achieved by MDsblood pressure control than that achieved by MDs • Patients on anti-coagulation who home-monitor andPatients on anti-coagulation who home-monitor and self-titrate warfarin doses can achieve better INRself-titrate warfarin doses can achieve better INR control than MDs.control than MDs. McManus et al, Lancet 2010;376:163; Heneghan et al, LancetMcManus et al, Lancet 2010;376:163; Heneghan et al, Lancet 2012;379:322.2012;379:322.
  • Add capacity, reduce demand through technologyAdd capacity, reduce demand through technology • Much panel management can be done by computersMuch panel management can be done by computers rather than MAs. Computers identify care gaps, remindrather than MAs. Computers identify care gaps, remind patients. MAs needed only when patients don’t respond.patients. MAs needed only when patients don’t respond. • Computers can be programmed to authorize med refillsComputers can be programmed to authorize med refills without expenditure of human effortwithout expenditure of human effort (Healthfinch.com)(Healthfinch.com) • Patient self-care for uncomplicated UTI is safe andPatient self-care for uncomplicated UTI is safe and effective. Patients enter UTI symptoms into aeffective. Patients enter UTI symptoms into a kiosk/vending machine.kiosk/vending machine. If no red flags, 3 days ofIf no red flags, 3 days of antibiotics are dispensed from vending machine. Noantibiotics are dispensed from vending machine. No involvement of health care personnel.involvement of health care personnel. • Cell phone otoscopes allow parents to dx peds earCell phone otoscopes allow parents to dx peds ear infections or send to clinician via patient portalinfections or send to clinician via patient portal
  • Take-home pointsTake-home points • The “primary care physician shortage” must beThe “primary care physician shortage” must be re-conceptualized as a demand-capacity gapre-conceptualized as a demand-capacity gap • Capacity can be increased by sharing largeCapacity can be increased by sharing large amounts of care with non-cliniciansamounts of care with non-clinicians • Patients not only receive, but can provide carePatients not only receive, but can provide care as peer coachesas peer coaches • Demand can be reduced through growth of selfDemand can be reduced through growth of self carecare • Technology can facilitate this transformationTechnology can facilitate this transformation • In the future, primary care will be dramaticallyIn the future, primary care will be dramatically differentdifferent
  • The Building Blocks ofThe Building Blocks of High-PerformingHigh-Performing Primary CarePrimary Care Think differentlyThink differently