Patients who once waited weeks to get an appointment now can usually get one within three days. They also know who their doctor is and which nurses and medical assistants will treat them.
It might be tempting to see Mid-County’s situation as symptomatic of just another overburdened public-health clinic. But that is not the case. The quality of primary care in the United States is deteriorating at all levels, according to numerous studies. Supported by the so-called “fee-for-service” insurance system, harried primary care physicians, in order to make a living, must rush from room to room to room, flipping though charts at the last possible minute, a mode of practice that an oft-quoted 2000 editorial in the British Medical Center’s journal, BMJ, dubbed “hamster health care.” (“Doctors are miserable because they feel like hamsters on a treadmill,” the piece begins. “They must run ever faster just to stand still.”) In a 2006 New England Journal of Medicine article titled Primary Care—Will It Survive? Thomas Bodenheimer, a doctor at the University of California, San Francisco, and one of the most prolific writers on primary care’s problems, summed up the system’s dysfunctions: “Patients are increasingly dissatisfied with the care and the difficulty of gaining timely access to a primary care physician; many primary care physicians, in turn, are unhappy with their jobs, as they face a seemingly insurmountable task; the quality of care is uneven; reimbursement is inadequate; and fewer and fewer US medical students are choosing to enter the field.” In a report the same year, the American College of Physicians put it even more bluntly: “Primary care, the backbone of the nation’s health care system, is at grave risk of collapse.”
Cockrell leads me to an office area where Dr. Deane DeFontes works literally elbow-to-elbow with a nurse, a medical assistant, and a team assistant, a spatial arrangement that is integral to the clinic’s medical home model. While doctors once worked alone in one room, they now work in teams; “co-location” fosters increased communication among team members. Each team manages a specific roster, or panel, of clients, addressing not only urgent issues but also any chronic conditions, a task made easier by the center’s electronic health records system. Doctors still rush from room to room to room (demand for appointments hasn’t dropped, and each team’s roster of patients is 10 percent too large), but instead of trying to glean essential information about patients while loping down the hall, the teams now “scrub” the schedules each morning in order to make sure records are in order and to make sure all of the patient’s preventive care, such as pap smears, mammograms, and cholesterol checks, has been performed.
Each month, Cockrell pulls data for teams covering everything from the percentage of patient no-shows (a statistic that can point to inefficiencies) to how often patients see their designated primary care physician (as opposed to a substitute). She also pulls preventive health numbers: the percentage of diabetics who have had their blood sugar tests within six months, for example, or the number of hypertensive patients whose blood pressure is under control. “One team just hit 91 [percent],” Cockrell says, referring to the percentage of diabetics who are up to date on their blood sugar tests. “It used to be, OK, well, if you need one of those tests, come back in three weeks,” says Suzanne Maroon, a registered nurse and one of DeFontes’s teammates. “Now it’s like one-stop shopping….It’s a much better service for patients.”
Patients who once waited weeks to get an appointment—a time lag itself is a barrier to providing good health care—now can usually get one within three days. Patients also know who their doctor is, and even which nurses and medical assistants will treat them. “It’s what care should have been all along,” DeFontes says.
After beginning the project with one team, Mid-County has spread the model throughout the clinic. Now Multnomah County is implementing the model at its East County clinic in Gresham. “The question was, Can we give good, affordable care when our resources are more limited?” DeFontes says.
The answer seems to be yes.
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