Sometimes a smile tells Dr. Emily Savage as much about a patient’s progress as the chart notes. As part of The Everett Clinic’s new Personalized Care Team that launched in May, Savage, a general internist, now has more time to interact with patients and collaborate with colleagues to customize care.
One success story: a middle-aged woman with a history of substance abuse, anxiety and chronic pancreatitis.
The team — which includes doctors, social workers, health coaches, a behavioral health practitioner, pharmacists and more — combined resources to address her challenges.
“She was so open and ready for help and support,” Savage says. “These patients are just like us and you can relate to many of their issues. We built trust rapidly and she’s been doing really well all summer. I see her in the hall smiling and it fills me with joy.”
The Everett Clinic began an institutional review in 2014 to address how to reshape itself to better meet the needs of different patient populations, and to address cost issues.
“The national statistic, which holds true in Washington, is that the top 5 percent of patients — those with complex cases, the frail and elderly — account for 50 percent of all healthcare costs,” says Dr. Erica Peavy, executive medical director for transformation at The Everett Clinic. “We recognized that we needed a more intensive care model and a team specifically designed to meet their needs.” The result was the Personalized Care Team.
Unique features include the incorporation of home visits; health coaches to help patients navigate everything from scheduling to insurance; longer appointment times; and close cooperation to cohesively treat needs from medical to mental, social and financial.
“The one-size model just doesn’t fit everyone,” Peavy says. “Health care isn’t so different from other industries, such as banking and travel, that experienced transformations to better meet the need of their customers. Now it’s our turn.”
Simplifying the complex
Since the spring, the new team has enrolled 250 patients and anticipates accepting 1,200. The majority of patients are over 60 years old.
The Everett Clinic developed a computer algorithm, which identifies potential patients based on having multiple conditions, medications and specialists. Providers also make referrals and patients can ask for the service.
“In the U.S., more patients are living longer, but with multiple, chronic diseases,” Savage says. “We’re often responding mainly to acute needs, but that’s not as effective overall for complex patients.”
Initial intake appointments are 60 minutes, sometimes upward of 90 minutes as the team reviews information with the patient.
“I’ve been on the hamster wheel of the clinic schedule where the day is booked solid with patients every 15 minutes. That doesn’t allow any flexibility,” Savage says. “It’s a wonderful and unusual experience to now have patients saying they need to wrap things up because it’s been so long!”
Common conditions of their patients include arthritis and musculoskeletal pain, diabetes, heart conditions, the impact of long-term substance abuse and mental health issues. Medications are frequently an issue, with some patients taking more than 20 prescriptions daily. The team includes a dedicated pharmacist who reviews every patient chart.
“It’s good to have a second pair of eyes,” says Trena Simek, the team’s pharmacist. “There is a lot to cover during a doctor’s appointment and limited time. A team approach allows me to pick up on things a physician can’t always focus on because they’re treating more urgent issues.”
Simek evaluates high-risk medications, interactions and side effects. Patients who are on long-term prescriptions may need dosage adjustments as they age.
Equally important, Simek reviews over-the-counter drugs, herbal preparations, vitamins and home remedies. She cites the example of iron and calcium supplements, which can be beneficial. However, if not taken at the right time, they can prevent the absorption of other medications.
“I want to be a resource to help patients make decisions that are actually helping them,” Simek says.
Beyond the stethoscope
Brittani Burns, the Personalized Health Care health coach, was initially unsure why a patient with congenital heart failure was not following up with needed cardiology appointments.
After multiple conversations, the patient shared that she had difficulty understanding the doctor. Burns accompanied her to the next appointment and facilitated communication.
“It was something relatively small and certainly fixable, which shouldn’t get in the way of proper care,” Burns says. “However, sometimes those conversations won’t come up in the course of a clinic visit.”
The health coach is a non-clinical member of the Personalized Care Team. Burns oversees 100-200 patients and facilitates everything from making appointments to navigating insurance issues, connecting individuals with community resources and accompanying them to appointments as needed.
“We’re finding more and more that the medical issues oftentimes have so little to do with the actual medical issues,” Burns says. “Some of it is social, financial, emotional. Moving forward, the best way for healthcare to succeed is helping change lifestyles.”
The social worker deals with issues ranging from housing to domestic violence. Savage recounts an instance of a patient fearing for herself and children due to a family member’s illegal activities, which the social worker helped successfully resolve.
“I was increasingly disturbed by the large amount of non-medical issues that I felt ill-equipped to handle, but impacted medical care,” Savage says. “I’m not a social worker or psychologist and I knew I needed to collaborate with a larger group in order to find solutions.”
Home visits are an option for all members of the team, which Burns describes as “a good way to see what’s really going in someone’s actual environment.”
“I think we went through a period where we were very focused on centralized care, but other countries such as England, France and Ireland still have robust home care programs,” Peavy says.
Health care institutions moved away from home visits under the assumption that it was not cost effective. However, there is evidence that, for some patients, expanding the model of care may save money in the long term.
“Seeing a patient at home and offering preventive care might cost less than having an infection turn into a catastrophic issue,” Peavy says. “Why not do a better job of translating costs into better outcomes for everyone?”
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