Toni Martin has been thinking a lot lately about how one could make a primary care practice truly responsive to patient needs. She’s 86 and has diabetes—“under control with diet and exercise”—and osteoporosis.
“I’m just aging. My doctor put it very well. He said, ‘Toni, the parts are wearing out.’”
Her insight is that patients should get screened by another practice clinician before they see the actual doctor, so the caregiver can surface the real issues ahead of the patient’s rushed, and sometimes intimidating, session with the authority figure.
“There’s a nurturing thing that’s missing,” she muses.
Finally, she sat down and drafted a work sheet “to make your visit more satisfying and more productive,” as she says. It consists of nine questions, starting with: “How are you feeling right now?” She hopes it will help patients learn to take a stronger role in managing their own care, as she has done over the past five years.
Martin has an unusual perspective from which to advance her views. She is one of two patient representatives participating in a process of “primary care renewal” at the office of Bruce Kessler, MD, in Eureka, California, near where she lives in Humboldt County on the foggy Redwood Coast.
Every two weeks Kessler hosts a brown bag lunch for his staff and the patient partners in his practice. Today, Martin introduces her work sheet and hands it around. The staff aren’t immediately receptive to the idea—“I ask every one of my patients those questions every time,” says Tonya Sauer, a medical assistant—but Kessler intercedes, saying, “Let’s do a PDSA” (shorthand for Plan – Do – Study – Act, a tool for analyzing fast changes in procedures developed by the Institute for Healthcare Improvement).
This kind of patient suggestion-making and process improvement is a key element in Primary Care Renewal, a program intended to create medical offices that patients will want to engage with instead of just shuffle through. “We’re trying to think in terms of population management and best practices,” Kessler says.
Primary Care Renewal (PCR) is one of the prongs of a wide-ranging patient care improvement initiative that the Humboldt County medical community has launched with assistance from Aligning Forces for Quality, a national program organized and funded by the Robert Wood Johnson Foundation.
Other pieces of the program include the Surgical Rate Project, to understand why Humboldt County has higher rates of certain procedures than expected; the Care Transitions Program, to help patients discharged from the hospital manage their care more effectively; and Our Pathways to Health, a chronic disease self management program to help patients better manage their own health. Outside of Aligning Forces for Quality, the Humboldt community is also engaged in the Priority Care Project, to ensure that patients get the right care in theright way as soon as possible.
Under the Aligning Forces framework, each program is designed to raise awareness to providers and the public of the importance of quality improvement; report data and analysis publicly; and engage patients and consumers in quality improvement.
This patient-centric focus includes various inducements for Humboldt residents to get screened for colon cancer, a disease with an unusually high incidence and mortality rate in Humboldt County.
In the five years that Humboldt has been working on these Aligning Forces initiatives, some things have gone well. Diabetes is better controlled, patients are more involved in their care, the health care community is more collaborative, and there’s a greater awareness of the importance of cancer screenings.
There have been plenty of challenges: physicians distracted by the exigencies of running a practice and making payroll are not always favorably disposed to the latest quality process improvement imposed on them. Getting all community providers to share data can be tricky. Practitioners get worn out, retire, or move away.
Nevertheless, the local health care community continues to move forward, analyzing data, publishing reports, and applying process improvement techniques to see whether this or that incremental change might unlock some hidden insight that will hit the oft-cited “Triple Aim” promulgated by the Institute for Healthcare Improvement: to improve the patient experience of care, improve the health of populations, and reduce the cost of care.