Text Messaging To Improve Adherance

Over the past year, I visited 50 practices in mostly rural PA.  I asked them if they collected email addresses or cell phone numbers from their patients.  Most assumed that patients don't want emails from their doctors or, since I work in Medicaid, that Medicaid patients can't afford to keep the same cell phone number.  The resistance to change was our usual human response.  However, here's an article from the NY Times showing the clinical value of text message medication reminders.

I don't know about you, but if my google calendar didn't text me a reminder, I would forget to get home on time and take my daughter to field hockey practice. 

Enjoy!

http://www.nytimes.com/2009/11/05/health/05chen.html?_r=1

Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

This study was published in the Annals of Family Medicine back in June 2009.  Some people think that we can increase primary care capacity through pay for performance programs.  There are examples of pay for performance programs where the targeted clinical metrics improved, however, it seems likely that primary care practices in P4P programs shifted attention from non-incentive areas to those with a reward.  There isn't much progress in a zero sum game.  As the baby boomers age and require more care, and if health care "reform" leads to more insured Americans, we must find a way to increase primary care capacity.  This article http://www.annfammed.org/cgi/reprint/7/3/254 discusses the early lessons from attempts to transform primary care practices into Patient-Centered Medical Homes.The Commonwealth Fund summarized the key points well here http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2009/May/Initial-Lessons-from-the-First-National-Demonstration-Project.aspx. 

From the Commonwealth Fund:

Key Findings

• Transforming a primary care practice into a patient-centered medical home requires wholesale practice redesign and continuous commitment to enhancing the patient experience. Transformation will likely include a host of interdependent components, such as new scheduling arrangements, better coordination with other parts of the health care system, more point-of-care services, and development of team-based care, among others. "Change is hard enough; transformation to a patient-centered medical home requires epic whole-practice reimagination and redesign."
• Developing and implementing an information technology infrastructure to support this transformation is more difficult and time-consuming than may be anticipated. Information technology is currently underdeveloped to meet the needs of the patient-centered medical home.
• Transformation involves a shift from physician-centered care to a team approach, in which patient care is shared among office staff.
• Rapid transformation can result in staff burnout, turnover, and financial distress.
• Moving toward the patient-centered medical home model is a developmental process that can take up to five years to achieve; successful transformation is highly dependent on local conditions that affect health care practices and their surrounding health care system.

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Addressing the Problem

Based on their evaluation, the authors make several recommendations to support practices in their efforts to adopt the patient-centered medical home model:

• Pilot programs should include up-front capital to help purchase and implement new information technologies, and ongoing funding to support personnel changes needed to implement better care management.
• Practices must determine the specifications and path toward achieving their own transformation, but facilitation through consultation and other services can play an important role.
• Professional organizations should help doctors acquire the patient and practice management skills needed to make this transformation.
• The National Committee for Quality Assurance may need to revise its process for recognizing patient-centered medical homes to encourage a more developmental approach at the practice level.

 Enjoy!

Increasing the ratio of nurse practitioners to physicians

Many practices have realized that mid-level practitioners can competently provide a subset of the care traditionally provided by physicians.  However, a practice with four physicians and no mid-levels would have to grow significantly to add four nurse practitioners and reach just a 1:1 ratio.  Imagine a large organization with 50 or more physicians and you see one problem with delegating appropriate clinical tasks with any scale.  Of course that is the "Build" answer to the Build vs Buy question.  Allina Hospitals and Clinics have taken a different approach, kind of a rent to own path.  Other large organizations may follow suit if it works well and they are able to shift care from their Emergency Departments to the Minute Clinics while maintaining continuity with their primary care physicians.

The blurb below is from the ACPE Daily Digest.  Enjoy!

Allina, MinuteClinic partner to coordinate care for patients, share EMRs.

The Minneapolis Star Tribune (10/30, Yee) reports that Minnesota's "Allina Hospitals and Clinics is teaming up with MinuteClinic to coordinate care for patients and expand medical services down the road." Under the deal, "Allina doctors will offer medical oversight to MinuteClinic nurse practitioners...and the two organizations will share electronic medical records." Still, "neither organization will take a stake in the other, nor will they pay each other referral fees."

        Allina and MinuteClinic "will forward patients to each other and integrate their healthcare delivery systems," the Minneapolis/St. Paul Business Journal (10/29, Newmarker, subscription required) reported.

Closing The Triangle

Today I drove to Wellsboro, PA.  Wellsboro is in Tioga County, just below the NY border.  The meeting was to share the experiences of the Tioga Partnership For Health with representatives from Altoona, PA.  The folks in Tioga have taken an inclusive, collaborative approach to addressing health and wellness in their community.  The three original leaders of the partnership were the hospital system, the county social service leadership and the President of Mansfield University.  Over the past 12 years, they have developed trust by letting people work on the things that interested them.  Some people worked on smoking in pregnancy, others worked on obesity or school menu choices.  Their community health center participated in three Health Disparities Collaborative projects through the Federal Bureau of Primary Health Care.  They have grant funded staff as infrastructure, providing support to their volunteer work groups and handling day-day tasks.  Remarkably, they have decreased their hospital admissions rate in each of the last three years.

Each of the Tioga representatives reinforced the idea of helping people get past their own perceived limitations of what the partnership could accomplish.  When people said something couldn't be done, they asked "If it could be done, what would it look like?"  This helped people break out of learned helplessness.  They also used phrases like non-linearity, letting people with similar interests volunteer to work together and the trusting relationships formed within the work groups allowed the groups to take chances. 

The Altoona representatives noted that in the past, they had two competing hospitals that each started wellness programs, but rather than work together, they ended up being short-lived, ineffectual tools for driving market share.  Now their hospitals are in one system, so they may have better chances of hospital community collaboration. 


At the end of our meeting today, the Tioga folks agreed to drive to Altoona and share their stories with Altoona community leaders.  Then we get to see what emerges!

Cool Clinical Stuff

Cool Clinical Stuff is about sharing neat things that can improve clinical and operational performance in primary care, while also improving patient and provider satisfaction. Sometimes the examples will be from other clinical arenas or from outside healthcare all together. My hope is that the stuff you find here will enhance the lives of those who provide and those who receive primary care medicine.

Enjoy.