Primary Care Medicine: Principles and Practice The Present and - PowerPoint PPT Presentation

Primary Care Medicine: Principles and Practice The Present and Future of Primary Care: Optimizing Joy, Quality, Equity, and Payment Coleen Kivlahan, MD, MSPH Primary Care Medicine: Principles and Practice 1 Primary Care Medicine: Principles and Practice 2 We Are Primary Care (2015 MEPS data) What Makes Us Great? § Independent practices serve 55%, hospital-owned practices serve 19%, and nonprofit/government/academic-owned serve 20% of all patients in USA. § Six attributes of care delivery distinguished the high-value cohort (attained § Solo practices 25% of patients, practices with 2–10 physicians served 53% of patients. statistical significance) § 41% served in PCMHs. • decision support for evidence-based medicine § Practices with EHRs cared for 90% of patients, using secure messaging with 78% of patients. • risk-stratified care management § Practices participating in ACOs/capitation served 45% of patients • careful selection of specialists § Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, • coordination of care § Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2– 16]). • standing orders and protocols § 10% smoke, 58% employed, 29% mean BMI, 60% self rated health excellent/VG, 38% public insurance/uninsured, 47% with HTN, 16% with DM, 15% with cancer • balanced physician compensation 2015 MEPS data Journal of General Internal Medicine, 04 December 2017. pp 1–6. Characteristics and Disparities among Primary Care Practices in the United States. David Michael Levine 3 Leading Together in Primary Care: Learning Labs 4 Leading Together in Primary Care: Learning Labs Exploring Attributes of High-Value Primary Care, 1 4/2/18 Leading Together in Primary Care: Learning Lab

How often do you communicate with your patients through a patient portal? a) Daily Time to Vote b) Weekly c) Never Primary Care Medicine: Principles and Practice 5 6 Leading Together in Primary Care: Learning Labs How often do you use telehealth Do you use a scribe or its visits to replace office visits? equivalent in your practice? a) Daily § Yes b) Weekly § No c) Never 7 Leading Together in Primary Care: Learning Labs 8 Leading Together in Primary Care: Learning Labs 2 4/2/18 Leading Together in Primary Care: Learning Lab

Overall, based on your definition of burnout, I am in primary care and am excited to how would you rate your level of burnout: go to work on most days: 1) I enjoy my work. I have no symptoms of burnout § True 2) Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out § False 3) I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion 4) The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot 5) I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help 9 Leading Together in Primary Care: Learning Labs 10 Leading Together in Primary Care: Learning Labs I am actively engaged in practice The Present redesign at my care site: Burnout high but stable Practice and Care Redesign § True Experimentation § False EHR use for asynchronous and telehealth visits Documentation burden Continuity importance 11 Leading Together in Primary Care: Learning Labs Primary Care Medicine: Principles and Practice 12 3 4/2/18 Leading Together in Primary Care: Learning Lab

It’s Not Just Us What is Burnout? Overall prevalence of burnout was 41% Rates of burnout in our teams : physicians (49%), nurse care managers Exhaustion, depersonalization, low sense of (42%), MAs, LPNs (32%), and admins (36%) accomplishment We are more burned out when we are part of under-staffed teams with frequent turnover , and when we are over-empanelled . Nearly half of all U.S. nurses and physicians Burnout prevalence was 30% lower for those working on fully staffed teams with no turnover and caring for an appropriate panel compared Contributes to lower patient satisfaction, worse patient other practices. safety, take sick leave, depression and relationship problems at home and work Helfrich CD et al, The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. JGIM July 2017 32(7): 760-66 Primary Care Medicine: Principles and Practice 13 Primary Care Medicine: Principles and Practice 14 The VA’s efforts to Reduce Burnout? How Do we Fix It? Share the Work! System fixes: § PCP burnout was positively associated with PCP reports of performing two discrete tasks without reliance on team members: (1) intervening on patient lifestyle factors Burnout improved with workflow interventions , and with targeted QI ( p = 0.002) and (2) educating patients about disease-specific self-care activities ( p < 0.001). projects . § Other variables significantly associated with PCP burnout ( p ≤ 0.05) included team Interventions in communication and workflow communication, team knowledge and skills, satisfaction with team, age, female gender, and years of practice. Dissatisfaction is far worse in countries with multipayer private insurance systems § The extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members and which tasks were performed by the PCPs without reliance on team members are associated with PCP burnout. Journal of General Internal Medicine January 2018, Volume 33, Issue 1, pp 50–56 Primary Care Tasks Associated with Provider Osborn, R. Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs. Health Aff December 2015 34( 12): 2104-2112; Linzer, M. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. Burnout: Findings from a Veterans Health Administration Survey Linda Y. Kim JGIM Aug 2015 30(8): 1105-11 Primary Care Medicine: Principles and Practice 15 16 Leading Together in Primary Care: Learning Labs 4 4/2/18 Leading Together in Primary Care: Learning Lab

Resilience to Burnout Joy Has to be Our Priority We practice medicine for the patient interaction and the intellectual Addressing burnout is necessary, but not sufficient. challenge Deploying curiosity is an opportunity with each patient We all believe that health is more than the absence of disease. Curiosity (continuous learning) is sensed by the patient and family, leading to improvements in both patient and physician satisfaction Joy in work is more than the absence of burnout. Joy in work is a shared Curiosity, mindfulness and reflection, as daily renewal behaviors, may responsibility at all levels of our organizations. constitute an effective antidote to burnout. (IHI President and CEO Derek Feeley Aug 2017) Schattner, A. Measuring Burnout in Primary Care Staff. JGIM Aug 2015 30(8): 1062 Primary Care Medicine: Principles and Practice 7 Primary Care Medicine: Principles and Practice 10 Face to Face Visits, remember those? “We physicians often root our hope in our patients’ outcomes, feeling confident when they recover, and we leave ourselves open to despair when outcomes are not good. In fact, it is the shared journey, the ever-evolving process, which offers both patient and doctor an opportunity to grow, learn, and discover. Therein lies hope for patient and clinician alike. In these profound moments, we bear witness to the relationship in an act of fidelity, not to the outcome, but to the Other. Our perspective shifts away from ourselves. It is here in this moment of deep empathic connection that many of us find hope and meaning that remains not only the patient’s greatest solace but also the clinician’s best remedy to burnout. In our willingness to be open to the unexpected, to be surprised, we must relinquish control and give the gift of curiosity, or even suspended disbelief.” Finding Hope in the Face-to-Face. Jennifer Y. C. Edgoose, MD, MPH1 ⇑ and Julian M. Edgoose, PhD2 Ann Fam Med May/June 2017 vol. 15 no. 3 272-274 19 Leading Together in Primary Care: Learning Labs 20 Leading Together in Primary Care: Learning Labs 5 4/2/18 Leading Together in Primary Care: Learning Lab