Transforming the Primary Care Setting to Better Serve Patients With Chronic Diseases

Many Americans suffer from one or more chronic diseases-hypertension, diabetes, depression, asthma, arthritis and others. With the aging population chronic diseases are becoming even more common. With the increase in obesity (a Wall Street Journal article put the percent at about 30% in 2006), there is a dramatic increase in diabetes and heart problems in all populations. Yet, it seems that by and large that the U.S. healthcare system is poorly set up to deal with this situation, especially at the primary care level. Generally, primary care practices are set up to deal with patients who have acute care needs, although some are adopting new approaches to overcome this. Primary care physicians and staff are trained to deal with health problems that present themselves at a single visit; long-term management of a chronic disease has been overlooked.
There are several good reasons that primary care practices should become more adept at treating patients with chronic diseases. Of course with better long-term management of a chronic disease, most patients will improve their general health; they will not be hospitalized as much or be impaired in their daily lives to the degree that many are now. Physicians will not only reap this benefit, but they will also improve their income as they meet more goals of pay-for-performance plans of insurers; many goals focus on chronic disease measures. Too, physicians will have more time in their practice as they will not have to see patients whose chronic diseases are under control as often. In an article by Truls Ostbye in the May/June 2005 edition of the Annals of Family Medicine it was shown that a patient with uncontrolled hypertension had on average 12 visits per year to his physician. A patient with controlled hypertension only visited his physician on average twice a year.
What kind of changes are necessary in a primary care setting to better treat patients with chronic diseases. One good source of the changes is found in the Chronic Care Model delineated by Ed Wagner, MD. Benefits Of Vitamin Supplements (You can find a detailed description of this model in “Organizing Care for Patients with Chronic Illness,” found in Volume 74, No. 4 of the Milbank Quarterly.) The basic principles of the model are:
1. Self-management-patients have a central role in determining their care.
2. Decision support-treatment decisions need to be based on explicit, proven guidelines for long-term chronic disease management.
3. Role clarification-determination of who delivers what service in the treatment of the disease. Often someone other than the physician will deliver a part of the care.
4. Use of a registry-registries makes sure that that proper care is delivered at the right time.
5. Community-alliances are formed with community agencies that can lend support in helping Public Health Topics For Research Paper patients. This can include state programs, schools, businesses, faith organizations.
6. Organization of healthcare-an environment should be created which encourages the growth of healthcare sites which treat patients with chronic diseases.
Transforming a primary care practice to consistently adopt these strategies is difficult. One way to do so is to employ the tools of Lean Quality Improvement. This approach recognizes that changing any system, whether service or manufacturing, requires cultural changes with strong leadership. The transformations take significant time, must be well documented, and care taken to avoid backsliding. For instance, one might start the transformation by designating someone with strong leadership skills and sufficient authority to initiate change as the champion of the process of change. Then, staff should be trained to use some of the basic Lean tools, as process improvement and kaizen, and taught to work in teams which meet frequently. Once the stage is set, I think that a good starting point would be the use of registries. These are software that list the patients with chronic diseases and for each patient the dates for assessments that are due; once the date is near or past the registry alerts someone in the office of the situation. The patient needs to be notified to make an appointment for the assessment at the office or arrange to have the assessment done elsewhere, at a lab for instance. In order to use the registry well, the primary care office needs to determine who uses it, who updates it, and who contacts the patient and how. A phone call to the patient usually works very well. Lest you think that registries are expensive software, I know of a site online that has good ones for free. Also, the American Academy of Family Physicians on their website shows how to make a good one using Microsoft Excel, a piece of software almost all offices have.
Registries are very effective for all patients, not just those with chronic diseases. Recently I called my primary care physician for a prescription refill and was told by the nurse that my annual physical was due. I was vaguely aware that it had been due soon, but the nurse with the aid of the office’s registry said I should make the appointment soon. We did so while I was on the phone. I was pleased that the office cared about my health and anticipated my needs.
It is well and good, you might say, that transforming offices to better handle chronic care patients is important. However, you believe that the office where you work has neither the time nor resources to get this done! This might not be the obstacle you imagine. There may be free resources available for you to get this done. For instance, I am presently working on a committee of healthcare professionals to establish a center which will help the physician organizations in our region make these transformations. Further, one insurer in my state (Michigan) is willing to help primary care practices by providing money to hire a specialist to help lead the practices through the required changes.
If you work at a primary care site, the changes I recommend may sound daunting. However, the benefits will be well worth it. Besides, by transforming your practice to use a Chronic Care Model you will also learn to use quality improvement tools that can be used in other areas. As you adopt the methods of continuous quality improvement, satisfaction with your practice will grow.