Patient- (not disease-) focused relationship over time: One attribute of high performing care

If you are interested in improving population health outcomes and by so doing reduce the trajectory of cost increases, it is useful to reflect on the foundations of high performing health systems. 

High performing health systems by definition achieve better population health outcomes at lower per capita costs than low performing health systems.  Good science tells us that high performing health systems stand on a foundation of good primary care.¹  Good primary care has four cardinal attributes:

• Access: People do not experience barriers to care
• Patient- (not disease-) focused relationship over time
• Comprehensive services: Most medical needs are met in the primary care setting
• Coordination: Primary care coordinates all care needs regardless of setting

Regarding the second attribute:  Patient- and not disease-focused relationship over time.  Most people agree that we are more than the sum of our organs or our conditions, yet we often mistake the management of disease for helping people get their best possible outcomes.

While disease goals and person goals are often the same, this is not always the case.  There are times when a person may choose to stop chemotherapy so that they may avoid the noxious side effects and spend their remaining time in more peaceful interaction with their family and loved ones. Strict adherence to disease guidelines may lead to intolerable side effects and some people choose quality of life over disease outcomes.

When we are working to help people achieve their best possible outcomes, we must work closely with them to discover what outcomes they desire.  The answer may not be “A1c less than 7” or “tumor shrinkage.”  Because we are professionals, we must point out when personal and clinical goals diverge, but if we want to follow the science behind better population health outcomes, it behooves us to remember that treating the person is more likely to achieve those outcomes than a focus only on the disease.

Here are some ways to operationalize this core attribute of high performing primary care:

• Make continuity of care a driving principle of scheduling (but not at the expense of timely access).

-Clearly define the link between patients and their primary care provider within the medical record and scheduling system so that schedulers can see and attend to that link.

-Continuity is a relationship between two people: Patients think of their primary care provider as a person, not a team, though they are willing in many cases to work with teams that work well together.  Some patients are willing to give up continuity for access, but this is not in the best interest of outcomes.  It is possible to have good access and good continuity.

• Consider “teamlets.” These are well-researched primary care teams that are more likely to simultaneously provide timely access and high continuity of care.²  A physician, a nurse practitioner working with two medical assistants and one nurse can achieve a high level of continuity, comprehensive care, person focused care and access (i.e. more likely to be a high performing primary care delivery unit).
  
  
• Use simple technologies to solicit patient input into what matters to them. People are quite willing to share those non-medical issues that get between them and optimal outcomes.³ The patient-reported factors enable a more informed discussion around the patient’s goals.  Soliciting and acting on these factors improves the probability of good outcomes.⁴

These are some ideas that can lead to better person-focused care over time, one of the four attributes of high performing primary care, which in turn is the foundation of high performing health systems and predictive of good triple/quadruple aim outcomes.

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.

¹ Starfield, Barbara, Leiyu Shi, and James Macinko. “Contribution of Primary Care to Health Systems and Health.” The Milbank Quarterly 83, no. 3 (September 2005): 457–502. doi:10.1111/j.1468-0009.2005.00409.x.

² Bodenheimer, Thomas, and Brian Yoshio Laing. “The Teamlet Model of Primary Care.” The Annals of Family Medicine 5, no. 5 (September 1, 2007): 457–61. doi:10.1370/afm.731.

³ Wasson, John H, Scott G Anders, L Gordon Moore, Lynn Ho, Eugene C Nelson, Marjorie M Godfrey, and Paul B Batalden. “Clinical Microsystems, Part 2. Learning from Micro Practices about Providing Patients the Care They Want and Need.” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 34, no. 8 (August 2008): 445–52.

⁴ Wasson, John H, Deborah J Johnson, Regina Benjamin, Jill Phillips, and Todd A MacKenzie. “Patients Report Positive Impacts of Collaborative Care.” The Journal of Ambulatory Care Management 29, no. 3 (September 2006): 199–206.