Helping patients help themselves

In many ways, Greenhouse Internists is like the thousands of other primary-care and internal medicine practices scattered across the country. The five-physician practice based in Philadelphia serves about 9,000 patients, the majority of whom have at least one chronic illness, such as diabetes, high cholesterol or high blood pressure.

And like their peers in other practices, Greenhouse physicians are pressed for time. Richard Baron, M.D., the practice's president and CEO and one of its internists, made headlines in April when he published an article in the New England Journal of Medicine about primary-care offices' crippling load of follow-up calls, e-mails, laboratory report reviews and other noncompensated activities.

What separates Baron's practice from so many others, however, are the strategies its physicians are now able to employ in the effort to help patients manage their chronic diseases. Greenhouse is part of a three-year, patient-centered, medical-home pilot program organized through Pennsylvania Gov. Ed Rendell's Chronic Care Commission.

The initiative includes six payers and 31 other practices in southeastern Pennsylvania. Over the course of the pilot, Greenhouse expects to see an increase of about 15% in gross revenue from supplemental payments provided for things such as patient self-management support, performance reporting and referral tracking, Baron says.

The overarching goal of the program is to give physicians the resources they need to improve communication with patients and help them set goals and realistic, actionable plans for making lifestyle changes and managing their diseases' symptoms.

“Self-management is critical,” Baron says. “The patient spends one-tenth of 1% of their time in the doctor's office and the rest of the time on their own. Coming up with good ways to engage them and encourage them to take control and make changes is very important.”

To incorporate self-management strategies into their practice, Greenhouse has used funds from the pilot to hire a health educator, who then trained medical assistants in motivational interviewing techniques to use in helping patients set personal goals. They also customized their electronic health-record system with an action-plan form that offers sample goals, such as better medication compliance and dietary choices, based on the patients' conditions.

After medical assistants take patients' vital signs, they ask whether they are interested in making changes to better take control of their illness or illnesses, Baron says. If the patients are open to change, the assistants solicit more specific behaviors that the patients think they will be successful at adopting, such as walking around the block once each day or eating less sugary foods. The form in the practice's EHR provides conversation prompts for the medical assistant, and patients leave with a printed document that details their goal and the strategy they will use to get there. Assistants can follow up with patients later.

Implementing the changes has taken significant time and money, Baron says, and, under the existing payment structure, he says he doubts Greenhouse's approach would be feasible in other practices.

“Changes to the payment system are essential, and I am optimistic that these enhanced models of primary care will eventually be paid for,” Baron says. “Primary care can be of very high value, but only if it is structured and paid for differently.”

The stakes are high, says Thomas Bodenheimer, M.D., adjunct professor of family and community medicine at the University of California at San Francisco. According to figures he cited in a 2009 article in Health Affairs about the growing burden of chronic illness, more than 130 million Americans are living with at least one chronic disease, and more than 60 million have multiple chronic diseases. According to the Centers for Disease Control and Prevention, chronic disease care accounts for more than 75% of all medical care provided, and those numbers are expected to grow.

Those trends are sobering, especially when considering that 50% of patients leave the physician's office without fully understanding what they were told, and only 9% of the time do patients participate in clinical decisions, Bodenheimer says.

“Research shows that just providing a pamphlet is not enough,” Bodenheimer says. “People need to have the skills to use tools like an inhaler or glucometer; they need to know what those numbers mean in relation to their health; and they need to know what to do if there's a problem. That takes time.”

The importance of empowering people to take an active role in the care of their chronic illness is central to the concept of the patient-centered medical home, a coordinated approach to primary care that incorporates other professionals, led by the family physician, and places particular emphasis on the patient's central involvement. As the notion of patient-centered medical homes has garnered more attention in recent months, pilot programs such as the one in Pennsylvania have sprung up in other states, including Colorado, Michigan and Ohio.

Self-management is also an integral part of the Chronic Care Model, developed by Ed Wagner, founder and director of the MacColl Institute for Healthcare Innovation and senior investigator at the Group Health Research Institute, Seattle.

The Chronic Care Model's approach involves the community, an empowered patient and a proactive, physician-led clinical team to provide safe, timely, evidence-based care, says Eric Larson, executive director of the institute and senior researcher. In addition to disease self-management, the model also emphasizes the need for clinical information systems, decision support and delivery-system design.

“The Chronic Care Model is an idealized way to provide primary care, and the medical home, although the concept certainly existed before, has become a way to realize the model and put it into practice,” Larson says.

Lack of reimbursement is not the only obstacle, according to Judith Schaefer, research associate at the Improving Chronic Illness Care program at the Robert Wood Johnson Foundation. Helping patients to set their own goals means taking into account what is important to them in a way that is respectful and free of judgment and that is not always easy for clinicians, she says. Patients often show up in primary-care offices feeling defensive and ashamed of their lack of progress, Bodenheimer says. Action plans are one way to suggest they make very small changes so that they are more likely to see positive results.

Small successes breed more success, he says, because they build up patients' confidence and provide momentum. For instance, he says, telling a person who has diabetes and drinks 12 sodas a day to stop consuming soda entirely would likely backfire. Instead, Bodenheimer asks patients, “Is there anything you could do about your soda drinking that might help your diabetes?”

“We do a lot of work with small amounts of exercise, smaller portions and medication adherence,” Bodenheimer says. “Sometimes we say things like, ‘If you can't take these eight medications, how many can you take?' That drives physicians crazy, but we need to focus on small changes and putting the patient in control.”

Self-management also is a key determinant of patient safety in the ambulatory setting, according to Robert Wachter, M.D., professor and chief of hospital medicine at UCSF and author of several books about patient safety. In a 2006 editorial in the Annals of Internal Medicine, Wachter highlighted several differences between patient safety in the hospital and in physicians' offices. The biggest difference, he said, was in the role of the patient.

“When a patient is in the hospital, we know where they are and we have control,” Wachter says. “There is some patient engagement, but ultimately the burden is on providers. In the ambulatory setting, the engagement of the patient is much more important. They can improve upon and also contribute to errors.”

Also, whereas hospitals have specialized personnel—chief information officers and infection-prevention specialists among them—with whom to tackle safety concerns, physician practices are much more limited in their choices, Wachter says.

And for people with multiple chronic illnesses who are prescribed a complicated regimen of medications, the potential for adverse events is significant, says Urmimala Sarkar, M.D., an assistant professor of medicine at UCSF.

“For patients who have multiple chronic diseases, the situation is much more complex,” Sarkar says. “If someone takes too much of one of their medications but has reduced kidney function because of another health condition, that mistake could easily land them in the emergency room.”

Future success in providing safe and effective primary care will depend heavily on whether there is a system in place that offers incentives for patient education, says Wachter, who refers to pilot sites such as Greenhouse Internists as a “laboratory for understanding primary care.”

“These pilot programs are essential because they show us how successful medical homes can be,” Wachter says. “The truth is that medical homes will be too expensive for the system as it is set up now. There has to be a way to capture payment.”

Some advocates, however, say self-management education is best accomplished outside of the physician's office in community settings such as senior centers or libraries. Kate Lorig, a registered nurse and director of the Patient Education Research Center at the Stanford University School of Medicine, Palo Alto, Calif., is a well-known proponent of this approach.

About 15 years ago, Lorig created the Chronic Disease Self-Management Program, or CDSMP, in which patients with a number of chronic illnesses meet for free sessions that run for 2 ½ hours, once a week, for six weeks, and are taught by trained nonclinician educators who also have chronic conditions.

On-site training and licensing fees for Stanford's self-management program run $1,600 for each health professional and $900 for each layperson with chronic illness. Commissioning training services off-site is more costly, and the bill can exceed $15,000.

There are more than 50,000 CDSMPs in nearly all 50 states and 20 countries, Lorig says, and studies have shown improvements in health outcomes, symptom management and communication with physicians following completion.

“The truth is it is not the clinician's job to help patients with self-management,” Lorig says. “They would like to do it, of course, but they just don't have 14 hours.”

The Community Health Alliance of Humboldt-Del Norte, a network of providers, consumers and advocates based in Eureka, Calif., has implemented a localized version of Lorig's program called Our Pathways to Health. People with chronic diseases such as diabetes and obesity can sign up for the free, peer-led course and learn how to better manage their own health, says Alan Glaseroff, M.D., chief medical officer of Humboldt-Del Norte IPA, Eureka, and a member of the alliance.

“We started out trying to find ways to use motivational interviewing and action plans in our own practices, but then we came to the conclusion that the best person to deliver this message is a peer and not a physician,” Glaseroff says. “I think the focus now should be looking at ways that we can build up community resources that physicians can refer people to in order to help them succeed.”

Betsy Stapleton, a former nurse practitioner who serves as a volunteer peer leader in the Pathways program, says organizers are trying to appeal to local providers by billing themselves as the “easy button to press” when patients need education. The key element, she says, is ensuring patients are taking responsibility for their care and the best way to do that is to show them someone who has the same illness and is successfully managing their symptoms.

To date, the Pathways to Health program has more than 300 graduates and has been transformative for the rural community, Glaseroff says. But he also acknowledges that community-based self-management programs run into the same payment wall as those initiatives that take place in physician offices.

“We have some grants and a lot of volunteers, and that is not a sustainable model,” Glaseroff says.

Peer groups are great, says Bodenheimer of UCSF, but they run the risk of attracting the patients who are most motivated to make a change. Community groups fill an important role, he says, but the first line of health management support should take place in the primary-care setting.

Even though fewer and fewer medical students are choosing to go into family practice, those who do are expressing increasing interest in patient-centered care, says Maureen Gecht-Silver, M.D., director of patient education and community medicine in the department of family medicine at the University of Illinois at Chicago College of Medicine.

Gecht-Silver leads a three-session, self-management learning program, mandatory for all second-year family medicine residents, that stresses action planning, motivational interviewing techniques and collaboration with patients. Residents work directly with patients to identify their chief concerns and help with problem-solving strategies, she says.

“Our department of family medicine is very interested in becoming a patient-centered medical home, and we see lots of positive changes coming,” Gecht-Silver says. “People are getting more familiar with the terminology, and I have medical students that are signing up for the sessions by choice.”

Self-management is also a key component of the Joint Commission's Disease-Specific Care Certification program, launched in 2002, which aims to improve care for patients with chronic diseases. However, 95% of the organizations that have pursued this certification are hospitals, says Charles Mowll, the commission's executive vice president of business development, government and external relations. Future incentives, pilots and eventual payment changes could allow more physicians offices to seek certification, he adds.

At Greenhouse Internists, the staff is keeping its fingers crossed and hoping that funding for self-management education programs won't run out when the pilot expires, Baron says.

“This used to be a conversation only had by primary-care physicians, but now purchasers and payers seem to be realizing that the way we have handled primary care up until this point has been bad for patients and bad for the value that the system can deliver,” Baron says. “That realization is the most hopeful thing that I see on the horizon.”