A Plan for Every Patient

There is always one moment in childhood when the door opens and lets the future in.

– Graham Greene

When I started medical school in 1993, primary care was the next big thing.  The magical transformation of medicine to a patient-centered system chock-full of value for all stakeholders would be wrought by capitation, primarily through wellness, public health, and muscular primary care.  Since then, false starts and retrenchment have abounded.  It’s hard to contain the excitement I feel, after five years of concerted preparation, for the coming change to MassHealth on April 1^st.

With what services would LCHC be considered ready for value-based payment (VBP)?  The state has released the outline of VBP introductory goal for all practices, divided into 3 tiers from basic to ambitious.  Amongst the most relevant: integration of behavioral health (therapy and prescribing) with televideo capability, universal buprenorphine certification with next day access for medication-assisted treatment, access to basic dental care, after-hours primary care, same day urgent care, clinical pharmacy services and long-acting reversible contraception within the primary care setting, non-medical social needs or social determinants of health (SDOH) screening, and care coordination.

LCHC has spent the last five years preparing for the new paradigm, under the guidance of our Accountable Care Organization , Community Care Cooperative.  Unsurprisingly, we have the elements in place that the state recommends for Tier 3, the most demanding transformation.  We can dedicate ourselves not to building the required services, but to delivering them to patients, to meaningfully impact not only their experience of the system but also their quality of life.  The most dramatic paradigm shift is moving our sightline from patient visits, to thinking holistically of a patient’s life: what do they know about the health of their community?  Are they able to get exercise safely, to sleep soundly, to adequately access transportation and nutritious food?  Are their jobs of high enough quality to allow them enough time with their children, to engage in activities that strengthen their communities?

The ultimate goal for Lynn Community Health Center is, through ever more involved collaborations, to become an engine for wellness and self-advocacy both for each individual patient and for the community.  The first step in that journey is quite prosaic.  What does each individual patient require to achieve their health-related goals?  In our current care model, at most and including all contacts, we might see a patient once a week for 60 minutes during acute moments in their lives, or about 0.6% of the time that week.  And that is for complicated patients.  The average yearly number of visits per patient is about five visits, or about 0.2% of the typical patient’s life.  What is happening to our patients between visits is of much more consequence, particularly if we are discussing lifestyle changes.  That prosaic first step in primary care transformation means becoming an institution whose presence in that “in-between visit” period will dwarf what occurs in the visit itself.  How do we help patients navigate big life changes, such as new diagnoses, hospitalizations, the loss of a job, a downturn in the condition of a loved one’s new dietary requirements within the family?  How do we even find out and document what is a meaningful change for an individual patient, and what they would like of us?  How do we support our patients during the major transitions in life: graduations, births, marriages, deaths, job changes, retirements, clear as well as ambivalent losses?  Understanding the physical, emotional, and spiritual needs of patients can help our care teams provide optimal care and improve outcomes.

The new paradigm is a monumental change.  We are moving from being professionals focused on individual illness and injury to being an institution promoting and supporting family and community wellness.  The patient visit is no longer the parenthesis which defines our work.  We are called to move into that as of yet unknown space, our patients’ lives between visits.

What areas have you wondered about improving?  What experiments have you tried or heard of?   What scares you in this new paradigm?  What are your hopes?

Art by: https://tanglewoodpta.org/