DeMerger to be official April 1
Dean search expected to give VP more time for clinical leadership
Home Care services to operate separately
HOPKINS: One of the limitations of health care has been that the core offering is really only one option - doctors get together with patients in an exam or hospital room. For some patients and for some procedures, that may be exactly right. For other people, because of their personality, because of their disease or because of their needs, we need alternative models, including more effective use of groups, the Internet or even the telephone.
HOLMAN: One-on-one interactions between doctor and patient was an appropriate management tool when acute disease was the dominant problem. This works with something like a broken leg or a bout of pneumonia that is new to the patient. But with chronic disease, we should be exploring a new model, because patients have time to become "smart" about what's happening. And we have to be willing to incorporate this approach in our training. We have had medical students ask to come to our Health Partners sessions because I think they recognize that it is a model that will be useful to them.
HOPKINS: I've been wanting to apply the approach we use in Health Partners for a long time. My own interest started with a sort of epiphany while I was an intern in a county hospital. At 3 o'clock one morning, I realized I was writing what was essentially the sixth carbon copy of a history and physical of a patient who had yet another admission for COPD. When I realized that, I just went back and copied one of the previous admission notes, because it was still absolutely correct. Nothing had changed. The patient would have an acute episode, receive care and be advised how to care for herself. Then she'd go back out, continue to ignore her health and repeat the cycle two months later. I think most doctors-in-training must have similar experiences, when they say, "What are we really accomplishing here?" Our patients here can be sophisticated, but the principles aren't all that different from my county hospital experience many years ago.
HOLMAN: The background of Health Partners lies not only in our own personal experiences, but in three models, including one Stanford program, the Arthritis Self-Management Program - now the Chronic Disease Self-Management Program. This was spearheaded by several of us, but particularly Kate Lorig, a registered nurse and doctor of public health who is a researcher and health educator on our faculty. She was responsible for the content design. This effort showed that the learning experiences of patients helped them relieve symptoms, reduce the need for medical services and increased their ability to engage in normal activities. Similar results occurred at Kaiser Denver with group visits for chronically ill elderly patients under the leadership of John Scott. A third study by John Wasson at Dartmouth Medical School showed that appropriate use of the telephone diminished patients' need for office visits and hospitalizations, while improving their overall health. We believed that these models could be incorporated into regular practice.
HOPKINS: What we're doing is somewhat similar to what we did a decade ago at Midpeninsula Health Service. We would see groups of four or five babies and their parents for well-child checks. With children close to the same age there is a predictable agenda. We did the normal things we would do at a one-on-one well-child visit, but the logistics were somewhat easier to do in a group, especially when we distributed educational materials. The really added value was what these people did for each other: "Where do you get the cheapest diapers?" "My kid does that, too." Anxious parents would often find reassurance in the group. When children turned 2, they returned to routine visits. But sometimes the groups continued on their own, becoming babysitting cooperatives and general support groups.
Q: How did you set up group visits?
HOLMAN: We had John Scott from Denver Kaiser come here for two days with his principal nurse assistant and they met with all the doctors and the practice coordinators in primary care and explained how they do it and what their results have been. Our planning process has run out over at least two years, starting with meetings of all SMG and SFP doctors.
Q: This is an academic medical center where faculty members by definition are accustomed to teaching. Do you think a pilot here gives a falsely positive impression by using academic doctors to run or "teach" groups?
FORD: In the Denver pilot, the doctors were primary care doctors who had little or no teaching experience, little or no support from an academic medical center, but with appropriate training the project succeeded.
HOLMAN: The Denver experience was interesting. In a nutshell, what Scott did in the beginning was recognize that he had a large number of elderly patients who had 30 or more visits a year to the clinic. He did a very smart thing. He approached them and said, "You know, you use the clinic much more than most other people, and I conclude that we are failing you because you have to come so often. Would you be willing to come to a group and discuss with me what you think you'd like to get out of your medical care?" The patients, as here, essentially set the agenda. When Scott suggested his colleagues try this, they were reluctant. Many thought it would damage the doctor/patient relationship. He had a particularly vociferous opponent, but when he persuaded this man to try a group, he became a firm proponent. At Kaiser Denver this program became very successful. Success, by the way, is correlated strongly with the patients' desire to participate. There's a real issue of motivation that I'm sure we'll have to deal with, but we don't have enough experience to know about it yet.
Q: Do you run groups?
HOLMAN: No, not at the moment, although I'm hoping to start one in the specialty area of rheumatology where I practice.
Q: Joe, what is your role in this project?
HOPKINS: My immediate role is working with a group of 15 of my patients, varying in age from somewhere in their 40s to their 80s. Their chronic diseases include hypertension, arthritis, diabetes, back pain or combinations of these. It's challenging to hit the right balance between providing information - such as teaching them to understand their lab results - and encouraging them to help each other by discussing their experiences. It's insightful how much you can learn about patients you thought you knew pretty well by seeing them in a group setting. For instance, two of my patients decided they didn't want to come back to the group, because they found discussing their problems depressing. That gave me insight into possible denial. Another patient who never stops talking during individual visits wasn't forthcoming in the group. I saw a need to help bolster this patient's assertiveness.
Q: Paul, how have you found your group experience?
FORD: I've had two sessions now. We get a lot of help from Margaret, who provides a bare bones outline of each session. The patients are enthusiastic and have amplified my impression that patients are now driving many of the changes occurring in health care today. I think patients want a relationship with their health care providers that isn't locked in by a 10-minute office visit. Many of the patients who are becoming most proactive and are learning about their health care are often elderly people who in the past might have been used to a paternalistic relationship with their physician. One surprise we had was the ease with which most of our patients understood their chart notes.
WELLINGTON: We really haven't had patient confusion. We've been able to help patients use their own chart notes as a communication tool with all of their doctors. By the way, we encourage patients to keep notebooks to record medicines, questions, physician instructions, lab results, etc. They can open the notebook at an appointment and say, "These are the meds that I'm taking. Are you sure I should have this med that you are prescribing for me." Or, "I just had that lab test done last month and here is the result. Should we have this done again?"
FORD: Last week we explained all of the different lab tests and why we order specific tests to monitor certain conditions.
WELLINGTON: Not everything in the group is heavy. Paul's group is holding a patient presentation on humor. Two members of the group are getting together to plan the presentation and everyone in the group - including Paul - has to come back to the next session with a joke to tell the group.
Q: What are the demographics of your patient groups?
FORD: We seem to have pretty astute people in our group, but they represent a fairly wide cross-section - from emeritus Stanford faculty to persons who may not have attended college. I was a little worried about this when we started because I was wondering if a varied group of people could all interact.
HOLMAN: There is pretty good evidence that one's economic and educational status is not a predictor of success in this kind of program. We've found that the most educated patients and the least, when compared in studies we've done for the Arthritis Self-Management Group, do equally well. Kate Lorig now runs the arthritis self-management program for monolingual Hispanics, who are both poor and undereducated. This group does just as well anyone.
Q: Are the group visits primarily for older patients?
WELLINGTON: Many of the patients are older with a clear view of themselves as chronically ill. I would like to bring in more 30- to 40-year-olds who have chronic conditions they need to deal with on a day-to-day basis. These patients may not even see themselves as chronically ill, but they could pick up a lot of useful tips and perhaps generate enthusiasm and a positive outlook for everyone in the group.
WELLINGTON: Workshops and group visits can be complementary. They approach the same end in slightly different manners. The group visits tend to be a bit more patient-specific, since patients' physicians are available to provide limited specific medical advice. On the other hand, the workshops can provide more of a specific disease focus, offering information and then encouraging patients to share strategies that have worked for them.
HOLMAN: We know from the self-management program that when patients are asked what part of the program is most meaningful, they answer, "learning from other patients."
Q: Isn't that kind of ego bruising?
HOLMAN: Absolutely not from my standpoint. The more the patients know and feel confident about their own ability to understand their disease, to interpret its trends and to do things that aid them, the richer the doctor/patient relationship can be. That's because then you can work on issues that with uninvolved patients you can almost never get to.
Q: In a way, isn't it sad that doctors are so busy that patients must take over health management that physicians provided in the past?
WELLINGTON: There are several answers to that. First, like it or not, we are not going back to the old paternalistic system. Second, patients really do better when they empower themselves, so sad or not, on balance, we are probably better off.
HOPKINS: Twenty or 30 years ago the barriers to access had to do with paternalism and egos that inhibited many doctors from talking in terms patients could understand. Even though doctors spent a lot of time with patients, it didn't necessarily lead to having their needs met. Now, we are trying to address some very practical issues. For example, in our groups, we're giving patients e-mail addresses, we're giving them the direct lines that go to our practice coordinators so that they can shortcut what may be some inefficiencies in our communication system here. But I think, more important, we're also teaching them how to really understand what's going on with their diseases. We try to teach them how to use interactions with caregivers as efficiently as possible and teach them how to focus on what they really want and need from the health care system. This will give patients a better opportunity to have their needs met.
WELLINGTON: Having a practice coordinator who attends group visits and workshops has been enormously helpful because it puts a face to a name. These folks - medical assistants, LVNs or RNs - are now assigned to each primary care or family practice physician at the medical center. Having these folks at the group sessions changes the whole dynamic in a very positive way. When I first came here, practice coordinators would complain to me about being yelled at on the phone by frustrated patients. I don't hear that so much anymore.
FORD: We've been through the last five years of an HMO revolution, and people are angry. Part of the anger is directed at the doctors who contract with the HMOs. They don't distinguish physicians who contract with a plan from the plan itself. So there has become this almost adversarial relationship, or, at the very least, patients feel they have to become very aggressive to get things done. Patients believe they won't get their medications unless they call their HMO five times and fight with it. The chronic disease management process and these group visits have re-engaged patients and doctors to work together to solve problems involving access. Hopefully patients will understand what our limitations are. Group members want to solve problems that would prevent their doctors from being as helpful as they want to be. Q: What is the role of specialists in the group process? FORD: The program started with primary and family practice care. But this process would seem to be easily adaptable to a specialty model - Hal has said he plans to start groups for specialty patients.
Q: How did the name Health Partners come about?
HOLMAN: Originally we were going to call ourselves, Program for the Management of Chronic Disease, but a large number of patients declined to participate because they didn't think they had a chronic disease. When we pointed out that they had diabetes, for example, they'd say, "That's right. But I take my medicines and I feel fine, so I don't have a chronic disease." When we ask them, what would you call it, they'd say, "Well I have a problem" or "I have a condition." So we changed the name to Health Partners.
Q: Are any chronic patients excluded?
WELLINGTON: Not automatically, but some diagnoses may make group interaction difficult. Stroke aphasics would be limited in their ability to participate, and dementia and psychosis would probably require special consideration before we could put the group dynamics at undue risk. On the other hand, I think we could try to include a schizophrenia patient who was stabilized on medication.
HOPKINS: In my group we did eliminate at the invitation stage some patients I knew to be seriously confused, but at least one patient who is mildly confused is doing ok with the support of the group. That widened my envelope of who can be in these groups.
Q: Will you be expanding the program?
WELLINGTON: I would like to increase at least one or two group visits each month as we get additional physicians lined up and find time in their schedules.
HOLMAN: We're looking to hire another RN to expand what Margaret is doing.
Q: What other changes do you see in health care generally?
HOLMAN: Drop-in clinic visits and open appointments. Kaiser is experimenting with scheduling physicians available to see any patient who signs up to talk about a problem. FORD: I understand there are some attempts to work with open appointments locally.
Q: How do you reconcile billable hours with the time you spend working with groups?
HOLMAN: This is a very real problem that hasn't been solved. There is an effort being made by Kaiser and a couple of other institutions to get Medicare to reimburse for group sessions. Locally, what we do is give the doctors credit for three hours of time - two hours for the session and an hour of preparation or follow-up time. They are paid for those three hours at the rate they would be paid if they were working full-time in the clinic. This is paid out of the clinic budget, although we have the ability to make up for any losses from the grants. But about 60 percent of the patients in the practices are capitated, so we can justify the time spent on them. The Department of Medicine is willing to pay for our time for fee-for-service patients. Margaret's salary and other expenses are paid under a grant.
WELLINGTON: Helping to build patient confidence and skills can help everyone use their time more efficiently. If the caregiver feels confident that a patient can mange his or her illness effectively and can call up and articulately report new symptoms, you don't necessarily have to see that patient in the clinic. A patient can call you up and say, "I think I need to increase or decrease this med," or "I think my glucose is up or down."
FORD: You have confidence that when a patient calls you and describes a symptom, you may not need to see the patient and can depend on the patient to alert you to changes in his or her condition that would warrant a visit or evaluation by phone or e-mail.
Q: What if a patient says, "I don't want to get involved. Doctor knows best. Just take care of me?" HOLMAN: We do it.
WELLINGTON: It's unfortunate for them, but it's fine.
HOPKINS: I think some doctors might think this could never be done outside a large institution. I think that is probably not correct, as our experience with Midpeninsula will testify. There is no reason why a solo practitioner couldn't do this. I know one obstetrician who would invite prenatal patients to drop by Wednesdays for a brown bag lunch to talk about anything. It didn't curtail her billable hours at all, but it did augment the services to her patients tremendously, augmenting relationships and contributing to her enormous popularity in the community. People were beating down the doors to get into her practice.
HOLMAN: That's what is beneficial for us. I think if we make Health Partners successful we will attract patients, significantly augment care and even improve medical education - because new doctors will see a model that will work for them when they go out to practice.
