There is growing evidence that integrating behavioral health and primary care improves health outcomes, increases patient satisfaction with the experience of care, and ultimately reduces health care costs. Working with our community partners, Jefferson Center has pursued bilateral integration, i.e. bringing mental health services into the medical setting while also making physical health services available on-site at the mental health center offices. Bilateral integration takes into account patient preferences and helps mitigate transportation, stigma, cost and other barriers to care while improving overall health outcomes.

While the call for integration predates the Affordable Care Act, the health care reform law did call for the creation of models that allow patients to be managed by interdisciplinary teams and supports innovations that help shift payment from quantity to quality of care.

Yet integration continues to face numerous barriers, including different payment methodologies, a health care system that has been built over time to silo the body from the mind, and cultural differences between provider types.  For example, while behavioral health providers traditionally focus 45-60 minutes sessions on building a relationship, discussing emotions, and gathering qualitative information, primary care providers are accustomed to 15 minutes sessions focused on the physical/somatic, and use quantitative data to assess health. Integrated care often requires the extensive collaboration of multiple agencies, so there are organizational differences that may prove challenging as well.

I was introduced to Coach University when approached by HealthTeamWorks to help develop an extension the training program focused on integrated care. I wanted to participate in the week long program to better understand what was in the curriculum currently, and to see what I could bring back of value to Jefferson Center and other community mental health centers across Colorado and the nation.

My experience with Coach University has crystallized for me the importance of supporting behavioral health and primary care providers through the transformative process of creating a truly patient centered health care home. A quality improvement coach can help push the practice to clearly articulate its vision for how far along the integration continuum it wants to go, how it will measure the impact of integrated care, and how to create efficiencies that improve patient care and best utilize provider time.

One “ah-hah” moment for me during my week at Coach University was when we were  “Redesigning Practice Care Delivery,” in an activity that encourages us to think about the various roles in clinics and how they work together, and it occurred to me that when you are working with not only multiple team members, but team members from multiple agencies, you may think you have a good understanding of everyone’s role until you actually sit down and talk through what each person does now, and could do differently, to best utilize their skills.

I look forward to a continued partnership with Health Team Works to apply the knowledge and skills I gained at Coach U to Jefferson Center’s work in integrated care settings, and to assist community mental health centers across the nation in enhancing their own integration work.

Mindy Klowden, MNM, is a Coach University January 2013 graduate and guest blogger. She serves as director of the Office of Healthcare Transformation at Jefferson Center for Mental Health in Denver, Colorado.

Would you allow patients to read your encounter notes? That’s what 105 primary care physicians did recently in a year-long project involving 13,564 of their patients. Beth Israel Deaconess Medical Center (BIDMC) in Boston, Geisinger Health System (GHS) in Pennsylvania and Harborview Medical Center (HMC) in Seattle participated in this “quasi-experimental” study published in Annals of Internal Medicine. Patients received online access to their doctors’ notes and could review them at their own discretion.

At the project’s end, almost 99 percent of patients in the study wanted continued access to their visit notes, and no physicians elected to end the opportunity.
The authors noted that before the experiment, “both participating and nonparticipating doctors worried about the effect of open notes on their practices.” They expressed anxiety about offending or worrying patients. However, most physicians surveyed after the intervention indicated that their misgivings did not materialize.

Participating doctors observed that open notes:

• Strengthened their relationships with some patients, including more trust, openness and shared decision-making;

• Activated or empowered some patients toward their healthcare;
  

• May have improved patient satisfaction and patient safety; and

• Allowed them to reinforce the office visit and patient education.

The majority of responding physicians did not find the open-note process difficult, nor did they see changes in their practice. Some stated that crafting their documentation more carefully was a good thing.

Patients welcomed the opportunity to read their doctors’ notes. In a discussion that follows the article, the authors said, “In striking contrast to the doctors’ predictions, few patients reported being worried, confused, or offended by notes they read. We suspect that fear or uncertainty of what is in the doctor's ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select not to read them. Nevertheless, we anticipate that some may be disturbed in the short term by reading their notes, and doctors will need to work with patients to prevent such harms, ideally by talking frankly with them or agreeing proactively that some things are, at times, best left unread.”

The paper’s authors concluded that “Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.”

Perhaps open notes would benefit you and your patients. The opportunity might serve as one more patient-centered strategy to facilitate communication and involve patients in their care.

The patient-centered medical home (PCMH) strives to achieve the goals of the Triple Aim defined by the Institute for Healthcare Improvement¹: Enhance the patient’s experience of care, improve the health of populations and reduce the per-capita cost of healthcare.

Does that second dimension — improve the health of populations — intersect or conflict with the role of public health? Public health entities, such as city and county health departments, are charged with promoting and protecting the health of their communities.

Divergent agendas: Health of individuals vs. health of population 

“Primary care practices and public health tend to have different orientations and goals, ” says Martha Johns, MD, MPH, a family medicine physician with a background in public health. Johns is HealthTeamWorks’ medical director for guidelines and evaluation. “Primary care focuses on the benefit to individual patients; public health focuses on doing the greatest good for the greatest number of people. These goals do not necessarily overlap.”

For example, primary care physicians often see patients suffering from sinusitis who ask for antibiotics. Although some sinus infections are caused by bacteria that succumb to these drugs, many are caused by viruses that antibiotics don’t affect. To meet the goals of an individual patient, the physician might give her the medication on the small chance that the infection might be bacterial. However, from a public health standpoint, prescribing antibiotics unnecessarily helps promote drug resistance in infectious organisms — a public health threat.

Divergent agendas for primary care and public health may involve cost, Johns notes. “Say the primary care doctor, acting as the patient’s advocate, wants to order an MRI* to help diagnose a patient’s condition. Evidence-based medicine and healthcare economics both may stand against that choice.” All providers need to decide whether their healthcare spending is appropriate, depending on a number of factors.

More possibilities for collaboration than competition

Despite such issues, the ways primary care and public health can work together far outnumber the ways they might conflict. “We [primary care practitioners] can and should use public health resources to fill gaps in our services. We can refer patients to community programs for things like weight loss, diabetes education, and smoking cessation support” Johns says. “We can also partner with them in supporting immunization efforts, disease identification and control, and education and behavior change for healthier lifestyles.”

Johns recalls a movement in the United States nearly 30 years ago to establish community-oriented primary care. Practices formed community health boards to describe health needs, and the practices would respond. Public health entities were often involved. “[This approach] was very egalitarian, very humble,” she says. “It was person- and community-centered care, and filled gaps between medical practices and public health. We are now seeing some efforts to resurrect this type of approach, with collaboration between among primary care practices, public health and community organizations, which should bring great benefits for the health of individuals and communities.

* Magnetic resonance image

Source
1. Institute for Healthcare Improvement. The IHI Triple Aim. www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx

We watched last week as the national healthcare reform movement teetered on life support. Now that the Supreme Court has upheld the Affordable Care Act, we will need to decide as a nation whether we have the courage to make serious changes to our healthcare system or let “politics as usual” put it off once again.  This is not a Democrat issue ; it is not a Republican issue. It is a human issue!  

The current system is unsustainable. Ultimately, healthcare is local. We all need to work together to change how it is delivered and paid for to improve quality, reduce costs and improve the experience for patients and their healthcare teams — restoring the joy of practicing medicine. This will take comprehensive transformation at all levels. Patients, providers and staff, hospitals, health plans and employers must be willing to think creatively and make the needed changes.

We at HealthTeamWorks believe that THIS IS OUR TIME to make meaningful changes in our practices and communities to improve quality, safety, efficiency, communication and coordination of care to reach Triple Aim goals. By continuing to work from the ground up, while systems also change from the top down, we can meet in the middle to create the kind of health and healthcare system we want for ourselves, our families and generations to come.

Marjie Harbrecht, MD
CEO, HealthTeamWorks

The patient-centered medical home (PCMH) provides significant benefits to patients in their doctors’ offices, but it does not function in isolation. The PCMH, like any ambulatory medical facility, is part of the medical community: hospitals, medical specialists, public health entities, rehabilitation facilities, alternative-medicine practitioners, nursing homes and more.

The comprehensive, patient-centered approach emphasizes joint patient-physician decisions regarding care; proactive services to manage the health of populations of patients, such as those with diabetes or hypertension; and self-care. These elements, supported by technology and care teams, combine to reduce the frequency of emergency room visits, hospitalizations and other costly healthcare services.^1,2 Good news for patients and health insurance companies, no doubt.

But what about hospitals? Reducing emergency room visits and readmissions: Isn’t that taking care away from hospitals? How can this be a good thing?

Keeping people healthy is goal of all healthcare providers

“Hospitals and health systems pursuing accountable care need high-performing primary care practices as a foundation, and PCMHs can help hospitals and practices align incentives while delivering coordinated and comprehensive care,” said Kenneth Bertka, MD, in a 2011 article in Becker’s Hospital Review.³ Bertka maintains that keeping patients healthy is the ultimate goal. Healthcare providers — both individuals and institutions — ideally want fewer customers, not more. A U.S. citizenry that did all it could to avoid obesity, smoking, saturated fat, inactivity, substance abuse and other health hazards would send the national well-being index soaring even as it decimated the census of every hospital in the country. And that would be wonderful.

“The PCMH should work in concert with the medical neighborhood,” says Marjie Harbrecht, MD, CEO of HealthTeamWorks. “By engaging patients in their care, by keeping them as healthy as possible — even those who have chronic conditions — the PCMH helps bring down the cost of healthcare for the nation as a whole. The PCMH helps patients get appropriate care. People with diabetes know how to avoid glycemic crises; people with asthma know the triggers that set off breathing difficulties; people with high blood pressure take their medication regularly — and fewer patients need acute care. Those who go to ERs and get admitted to the hospital truly need such services.”

PCMH "natural extension" of hospitals' IT, care coordination efforts

The American Hospital Association sees “hospitals … begin[ning] a migration to embrace the PCMH model in coming years as a natural extension of clinical IT investments and increasing care coordination.” It notes that “hospitals can participate in the PCMH model in a supportive, complementary role to primary care practices” by convening physicians; offering capital, technology infrastructure, staff and management expertise; and serve as an administrator of bundled payment.⁴

Every healthcare initiative, from the development of antibiotics to cardiac stents, is intended to reduce human suffering and death. The PCMH is no different. The healthcare system adjusts to new treatment approaches and care innovations. Hospitals will always serve a vital purpose in the U.S. healthcare system. By keeping people as healthy as possible, the PCMH holds down unnecessary expenditures, raises the quality of life and encourages appropriate use of medical services.

Sources

1. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011 May-Jun;24(3):229-39.
2. Milstein A, Gilbertson E. American Medical Home Runs: Four real-life examples of primary care practices that show a better way to substantial savings. Health Aff (Millwood). 2009;28(5):1317-26.7.
3. Bertka K. Hospitals and patient centered medical homes: A practical pairing. Becker’s Hospital Review, Aug. 1, 2011. www.beckershospitalreview.com/hospital-physician-relationships/hospitals-and-patient-centered-medical-homes-a-practical-pairing.html, accessed Feb. 24, 2012.
4. American Hospital Association. 2010 Committee on Research. AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH). Chicago: American Hospital Association, 2010. www.aha.org/research/cor/content/patient-centered-medical-home.pdf

Recent articles in national and Colorado media put patient-centered care, compensation to primary care physicians and HealthTeamWorks in the spotlight. The coverage highlights insurers’ adoption of new payment strategies for primary care — approaches that acknowledge the value of front-line care and its role in preventing high medical costs down the line.  

The Wall Street Journal described the intent of WellPoint Inc., a major national healthcare insurer, to pay primary care doctors 10 percent more — with the possibility of up to 50 percent from bonus payments. The article notes that primary care currently makes up a tiny 2.8 percent of the nation’s healthcare spending, yet holds enormous potential to curtail high costs through prevention, screenings and patient education. Wellpoint leaders hope that by investing in the patient-centered medical home (PCMH) model of care — which applies care coordination, improved access, patient self-management strategies, standardized care protocols and tracks patients’ outcome data — the company’s projected medical costs could drop by up to 20 percent by 2015, the article states.

John Bender, MD, and his practice, Miramont Family Medicine in Fort Collins, Colo., are featured as participants in the Patient-Centered Medical Home (PCMH) Pilot convened by HealthTeamWorks.

Although Meredith Rosenthal, PhD, the Harvard researcher evaluating the pilot, notes that the PCMH model has not yet demonstrated cost savings, “Wellpoint said its savings are based largely on its own data from medical-home pilot projects,” the article says.

Anthem to pay Colorado primary-care providers for patient-centered care

In Colorado, Anthem Wellpoint, the state’s largest private insurer, announced it will pay bonuses to its 2,500 contracted primary-care doctors because of the success of the HealthTeamWorks-convened PCMH pilot. An article in The Denver Post on Feb. 2 stated that “Anthem found that paying primary-care doctors more to coordinate patient care cut hospital admissions by 18 percent and emergency room use by 15 percent.”

According to Elizabeth Kraft, MD, Anthem’s chief medical officer, paying primary care providers more to deliver PCMH-model care “creates a return on investment of 2.5 times to more than four times.”

Those financial results from the pilot convinced Anthem to take its payment model for patient-centered primary care nationwide, the article states. Other leading healthcare carriers, such as Humana and UnitedHealthcare, are expected to follow suit.

Northern Colorado newspaper features local practices in PCMH Pilot

The Northern Colorado Business Report featured the PCMH Pilot, focusing on results from Miramont Family Medicine and Internal Medicine Clinic of Fort Collins. In return for a monthly per-patient fee, pilot practices offer patients round-the-clock access to providers and same-day appointments, and involve patients in treatment decisions. The practices take a population management approach to patients with chronic conditions such as diabetes, ensuring that all get regular blood-sugar checks, eye and foot exams and know the dangers of high blood pressure and smoking. By reaching certain measures for patient care, practices receive bonuses from the participating health plans.

By extending the value-based primary-care payment model to providers nationwide, healthcare payers are establishing the PCMH as the paradigm. This is an important step toward a transformed healthcare system that provides personal, efficient, measurably effective care.
 

The employees of HealthTeamWorks were proud to nominate our CEO, Marjie Harbrecht, MD, for the 9News Leader of the Year Award. Although she was not ultimately selected, Marjie was among the eight finalists.

Marjie responded to her staff by saying: “I cannot tell you how honored I was to even be considered for this and want to thank Eric Palmer, one of our quality improvement coaches, who introduced the idea, Allyson [Gottsman, HealthTeamWorks Executive Vice President] and the rest of the staff who ran with it, and Cissy Kraft, MD [HealthTeamWorks board chair]; Alfred Gilchrist [CEO of the Colorado Medical Society]; Scott Hammond, MD [Westminster Medical Clinic] and Tracy Hofeditz, MD [Belmar Family Medicine] who were kind enough to write letters of support. All of this meant more to me than the award itself.

“I truly believe the accomplishments achieved to date have been a TEAM effort – I could not do this without all of you,." Marjie continued. "You are at the forefront of changing healthcare and I’m proud to be working with all of you to help lead this effort!”

We regret that 9News did not select Marjie as the leader of the year, but regardless, she is our Leader of the Year.

The HealthTeamWorks staff

HealthTeamWorks, which extols wellness and self-care as part of its mission to improve the healthcare system, puts its muscles where its mouth is. The Lakewood, Colo.-based nonprofit’s approach to health and wellness for its own staff might serve as a model for other firms.

Each month, staff members compete to see who can log the most workouts, who can take the most steps, who can exemplify a heart-healthy lifestyle. “I organized the program to motivate myself,” says Sara Schwankl, who started the HealthTeamWorks wellness program a year ago, expanding on the idea of a colleague. “Most adults don’t get anywhere near enough exercise to meet national activity goals. By keeping each other supported and motivated, it’s easier to achieve activity targets. This program keeps us all accountable.”

Teams of four, with names like the FitWits and the Queens of Cardio, get credit for each member’s daily workouts of at least 30 min. Lifting weights, running, a brisk walk, skating, cycling, yoga — almost any activity counts if it increases the heart rate. 

Participation is voluntary, and nearly half of the 40-member staff has joined the initiative. Employees compete fiercely to end each month with the most workouts. Staff members — who range in age from 22 to 66 — exchange good-natured taunts and eye the tally board to see who’s leading. Members of the winning team get their choice of $10 gift cards.

A separate contest pits individuals against one another: Who can take the most steps in a month? Schwankl issued staff pedometers so everyone can record each day’s distance in a log.

Logically, HealthTeamWorks’ wellness efforts are in step with one of the clinical guidelines it develops for Colorado primary care physicians. The adult obesity guideline helps clinicians assess and treat overweight patients according to the best and most current medical evidence.

The company’s program also aligns with a number of national wellness initiatives, such as First Lady’s Michelle Obama’s Let’s Move program, designed to combat childhood obesity, and the Presidential Active Lifestyle Award, which promotes wellness for people of all ages. 

“This fitness program is great fun for the staff, and emphasizes our companywide belief in wellness and prevention,” says Marjie Harbrecht, MD, HealthTeamWorks’ CEO. “The coaching that we provide to medical practices includes a focus on healthy lifestyle, weight management and cardiac fitness. Thanks to pressure from my teammates, now I get to the gym more often!”

What does your organization do to encourage a healthy staff? We’d love to hear about it.

The epidemic of obesity in the United States has claimed one-third of adults — 33.8 percent. Obesity is defined as a body mass index (BMI) of 30 or higher. (Those with a BMI of 25-29.9 are considered overweight.) As the Centers for Disease Control and Prevention notes, “During the past 20 years, there has been a dramatic increase in obesity in the United States and rates remain high. In 2010, no state had a prevalence of obesity less than 20 percent. Thirty-six states had a prevalence of 25 percent or more; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas and West Virginia) had a prevalence of 30 percent or more.”¹

The CDC’s Healthy People 2020 program aims for a 10 percent reduction in adult obesity over the next nine years.² The agency, along with the healthcare industry, wants to stem the surge of obesity-related conditions that include heart disease, stroke, type 2 diabetes and certain types of cancer. Not only do these conditions cause premature death, they also generate enormous medical costs. In 2008, obesity-associated healthcare costs were estimated at $147 billion; the medical costs paid by third-party payers for obese people were $1,429 higher than for those of normal weight.³

HealthTeamWorks has developed a clinical guideline on adult obesity to help providers address this often-difficult issue with patients. Easy to use and comprehensive, it covers clinical assessment, diet, physical activity, weight-loss medications, surgery, tips for families, goal-setting and approaches to counseling that engage the patient. An associated action plan for patients allows providers to work with them to set goals for reaching a healthy weight. Goals pertain to nutrition and physical activity; the provider can assist with the care-team support section, which has spaces for referrals, medications and community resources.

The guideline assists clinicians regardless of the cause of a patient’s obesity: genetics, inactivity, poor diet/eating habits, lifestyle, quitting smoking, pregnancy, lack of sleep, medication, age, socio-economic issues or medical problems.⁴

Because obesity represents such a major public health problem, and because losing even a modest amount of weight can prevent or improve morbidity, it’s imperative that clinicians address the issue with patients.

Sources
1. Centers for Disease Control and Prevention. Overweight Obesity — U.S. Obesity Trends. www.cdc.gov/obesity/data/trends.html, accessed Nov. 15, 2011.
2. Centers for Disease Control and Prevention. HealthyPeople.gov. Nutrition and Weight Status. http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=29#141, accessed Nov. 15, 2011.
3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Aff September/October 2009 vol. 28 no. 5 w822-w831.
4. Mayo Clinic. Obesity. www.mayoclinic.com/health/obesity/DS00314, accessed No. 22, 2011.

Palliative care addresses pain and control of symptoms, seeking to improve quality of life during a treatable illness and during the dying process. Palliative care joins patients, healthcare professionals and families in a partnership to anticipate, prevent and treat suffering. More than pain control, palliative care should encompass physical, intellectual, emotional, social, and spiritual needs to promote a patient’s self-sufficiency.

HealthTeamWorks recently developed a clinical guideline on palliative care that is intended for, but not limited to primary care providers. This two-page, convenient reference is free for download or in hard copy form. As with all HealthTeamWorks guidelines, it is not meant to replace a clinician’s judgment or establish a standard of care.

Palliative care can begin in primary care setting

Palliative care can begin in the primary care setting, as early as diagnosis of a potentially life-limiting illness. It can be delivered along with curative or disease-modifying treatment. Because palliative care focuses on identifying treatment goals and managing pain and symptoms, primary care clinicians are ideally suited to initiate and coordinate it. Noting the importance of specialists, however, the guideline gives indicators for referral to specialty-level palliative care or hospice.

The guideline differentiates between palliative care and hospice care. It suggests questions that providers can use, adapt and revisit throughout the progress of illness to address the key elements of palliative care. These are:

• Advance care planning;
• Pain and symptom management;
• Emotional-social-spiritual needs and challenges;
• Caregiver burden; and
• Coping with decline and eventual death.

Expert panel developed guideline

HealthTeamWorks developed the palliative care guideline by convening a committee of physicians, advanced-practice nurses, and professionals in behavioral science, health communication and social work. Participants represented 11 Colorado organizations, including private practices, hospitals, hospices, the University of Colorado and healthcare insurers.

The committee identified existing evidence-based guidelines on palliative care and conducted a literature review on the topic. Its members built the guideline around key issues that providers need to know to deliver appropriate care, as well as what is not now being done that could make the most difference to improve care.

Following HealthTeamWorks’ usual procedure, a focus group of primary care physicians reviewed the guideline draft and made suggestions. HealthTeamWorks’ board of directors and membership reviewed the revised guideline, made further revisions and then gave final approval. The result is a carefully crafted, closely evaluated clinical tool in an easy-to-use format.

A beginning palliative-care tool set for clinicians accompanies the guideline.