On one hand, we're on the threshold of an incredible era in personalized medicine with scientific breakthroughs making possible highly individualized care that could advance both quality and years of life.
On the other hand, the providers who will be at the nexus of helping individuals manage their personal health--primary physicians--have rarely been stretched so thin.
While major efforts are underway to attract and train more primary physicians, the practice of primary care itself is changing to make more productive use of time and resources.
"To be effective, we have to think in terms of care teams and smarter use of information technology," William Curry, MD, MACP, Governor of the Alabama Chapter of the American College of Physicians and professor of internal medicine at UAB, said. "There has been a progression with technology. With telephones, questions could be answered without the need for another face to face visit. However, managing the flow of information through telephones as demand has grown is a headache for both practices and patients. Now online patient portals allow secure electronic messages between patients and practices and some store information like reviewed labs that patients can check whenever the like."
For elderly patients who may need the assistance of family members in keeping track of medications and appointments, the patient can choose to share their password if needed. However, there are some patients who may need more.
"This is especially true in complex cases with multiple chronic conditions that may be layered with factors related to socioeconomic determinants of health," Curry said. "They can fall through the cracks between not having insurance and not qualifying for alternatives. They may not have access to medications, transportation and food security. If they can't afford computers and have no family nearby, they may need more help to get better and stay well."
Care coordination began in hospitals with pre-discharge planning and post-discharge followup to reduce the risk of readmission. The concept is now expanding into medical practice.
"Reimbursement is no longer a matter of volume of care," Curry said. "It's about the value of care we can offer to help patients stay well. Care coordination saves patients from the risk of avoidable illness and makes better use of health resources. This is true for both hospitals and practices.
"It ties back to the evolution of the primary physician as a team leader. In addition to physician assistants and nurse practitioners who can take on responsibilities that help patients stay healthier and free up time physicians can use where it is most needed, lay staff can be trained as health coordinators and navigators. It's like they say in football. The game may be won or lost on basic blocking and tackling. Simple logistics like making sure patients can get their medications and have transportation for their appointments can make a difference."
Some practices are using technologies like patient check-in kiosks to free up staff time that can be shifted to care coordination. Complex cases may require extended care coordination, from phone messaging and video links to home health visits by nurses.
"It is also important to identify the patients most at risk and in need of extended coordination," Curry said. "Many physicians can name patients who are most likely to run into frequent problems. For others, it can be a matter of looking at utilization and frequency of ER visits. There are also computer algorithms that can be helpful predictors.
Extended coordination take time, but it pays off.
"When patients have a problem that couldn't be prevented, it's easier to fit in an unscheduled appointment. When physicians have to call to find a hospital bed for a patient who needs highly specialized care, it's much easier if the hospital isn't on diversion because too many beds and ER rooms are full of patients with diabetic emergencies or heart failure exacerbations that didn't have to happen," Curry said.
As anyone who has spent time with patients reconciling medications can attest, another area where coordination is helpful is in handoffs between specialists, allied health care, hospitals and primary care practices.
"We had hoped electronic medical records would do more to get everyone on the same page," Curry said. "It's easier when we are using the same system. When there are different formats, it is possible to do a workaround to create a longitudinal record, but this is an area where we hope to see more streamlining in the future."
Another aspect where coordinating with specialists and other care can get difficult is when patients who can't afford to pay and have no insurance need help with a serious medical issue.
"We see this often in some of the safety net clinics," Curry said. "If we have a patient who needs a neurosurgeon or cardiologist, we have to find someone willing to take them on without reimbursement. Physicians are compassionate people, but having to call the same people all the time makes it difficult.
"A new program called Project Access is helping patients get the care they need. It's a combined effort between the Jefferson County Medical Society, UAB, St Vincent's and a number of clinics and physicians in the area. Project Access is an excellent way for physicians who want to participate in a worthwhile effort to help with the number of cases they feel they can take on."
Curry expects more progress down the road. "So much is happening in research right now that will make such a difference in the care we will be able to offer patients," he said. "Keeping in touch with the translational medicine pipeline brings us information on new treatments and advice we can give our patients to help them live healthier lives."
