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“Rats and roaches live by competition under the law of supply and demand; it is the privilege of human beings to live under the laws of justice and mercy.”  

– Wendell Berry

I use an attention-catching quote in this post to bring your mind’s eye into focus.  A primary care capitation system is not automatically guaranteed to be focused on equity and justice.  It is both our privilege and our responsibility to design a model that is truly patient-centered and anchored in social justice.  As we succeed, our version will be the one naturally adopted throughout the state and the nation.  The potential impact for patients and families living in communities served by health centers throughout the United States is breathtaking.

One keystone concept defined by the Ideal Care Model (ICM) design team is the LCHC patient journey map.  The patient journey map captures 22 steps involved in the full cycle of the patient journey and represents one LCHC team sharing in the responsibility to nurture the whole patient to wellness through a common set of moments before, during, after and between encounters with the health center.  This map will serve as a guide for the ICM design team on where to focus time and resources.  Of those steps, the ones most ripe for radical transformation, lie grouped under the “Between Visit” section of the journey.

In our current system, we are financially incentivized for work that occurs when the patient is seeing a clinician.  Everything else (sharing labs, responding to patient portal messages, arranging referrals, answering the phone, helping patients deal with the infinite variety of barriers imposed by a complicated medical system), is done as an adjunct to that clinician encounter or supported by separate grants.  Under the coming system, we will be encouraged to think of the patient’s life beyond the office, to imagine how we can reach the patient “between” formal encounters.  Health problems like obesity, hypertension, diabetes, depression are influenced by the living and working environment in which our patients live.  In the “between visit” arena, we will get to know the patients’ health-related social needs: do they have the transportation they need to attend to medical issues, enough healthy food, the legal help to address unsafe housing issues?  If the answer is no, we will have the resources and the community partnerships to intervene significantly and positively. Knowledgeable staff will link the resolution of these issues to the lifestyle goals pursued by the patients, and to the management of the diseases and conditions affecting the patients’ families.

Any predictable need (health screenings, cancer prevention, immunization, lab work) would occur without the necessity of a physical encounter with a clinician to serve as the anchor.  Chronic disease management will extend beyond the visit and into the community.  Measures that will empower our patients towards better health such as assistance with food shopping and cooking classes, exercise classes, support groups, administrative support with systemic bureaucratic demands, and engagement of family members and loved ones are examples of the efforts and resources we will be able to offer in this new model of care.  As we move out of the shadow of a fee-for-service world, we will need to take our next steps forward as One LCHC, with unified goals and purpose, thinking and acting together to serve and protect the patient through the journey.  Each staff member will have a role in the new care model and will have the opportunity to actively participate in shaping this new model of care.

Nevertheless, whatever the system in which we function, there is a limited number of resources available.  Of the many desirable interventions mentioned above, which should we prioritize?  How will we integrate them and work as one orchestrated team within the One LCHC system of care?  Which team members will perform them?  How much time will it take?  Are there functions that will be reassigned?  Are there new roles that need to be created; if so what, when and how?  These are some of the challenges faced by the ICM team.

What are your thoughts?

Dr Kiame Mahaniah
Kiame Mahaniah


About Kiame

Inspired by a childhood divided between a war-affected third world country – the Congo – and a high performing first world one (Switzerland), as well as parents intimately involved in rural development NGOs, Dr. Kiame Mahaniah brings a deep passion for social justice and the fight against inequities to his work as CEO at the Lynn Community Health Center in Lynn, Massachusetts.

More About Kiame

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