Mennonite Health Journal

Empowering Patients: New Paradigms for the Urban Underserved

Nathan Beachy, MD

from Mennonite Health Journal, Vol. 16, No. 2 – May 2014

Editors Note: This article is based on a based on presentation given by Nathan Beachy, MD, and his wife, Rochele Beachy, MD, at the MHF Regional Meeting held on March 29, 2014 in Dalton, Ohio. See biographical statement at end of article for more information.

A story is often told of a group of water rescue workers who came to a rapidly flowing river. They immediately found a person who had fallen in and was in danger of drowning. Putting their skills into action, they proceeded to rescue the person and bring him to safety. No sooner than the man was safe and sheltered, there came the cry of another individual in the same desperate straits in the midst of the river rapids. So naturally, they rescued that person as well.

Based on their experience on day one, the rescue workers decided to stay around for another day and make sure others were safe. Sure enough, by mid-morning they pulled out two additional people and by the end of the day, four more. The rescue workers decided that a full-fledged rescue station was needed and so they established a permanent presence in that location. The work continued, as with compassion and care, this tiny group of persons rescued more and more people from the churning stream.

One day, after a particularly grueling stretch of one rescue after another, one of the workers got up and walked out. “Where are you going?” the rest yelled. “There are still many more people to be rescued!” “I’m going upstream,” the worker yelled back. I want to find out why so many people are falling into the river in the first place!”

“Going upstream” is a metaphor for new paradigms that are emerging in America today, especially in the area of healthcare. In the United States healthcare system, we spend at least 30 percent more than any other healthcare system in the world although study after study tells us how much money and effort we could save if we would “go upstream” and focus as hard on preventing illness as curing it. Going upstream would include immunizing all our children, being sure that pregnant mothers were well nourished, getting a reasonable amount of exercise, and recognizing that tobacco, alcohol, sugar, and most junk foods are slow poisons.

At the Mennonite Health Assembly in Atlanta in 2003, Dr. David Hilton was the keynote speaker. Dr. Hilton had spent ten years in rural northeastern Nigeria doing several surgeries a day and watching over 90-100 inpatients. He said that he had a moment of clarity when he looked at the health of the community in year ten and realized that the people he served were no healthier than when he arrived. Yes, he had helped some individuals, but the general health of the population had not changed.

It was then that he looked at the definition of health from the World Health Organization (WHO). WHO defines health as a “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This has been WHO’s definition since 1946 and it has not changed.

Some years later Dr. Hilton lived and worked in Geneva where he had many contacts at WHO. He discovered that despite the definition cited above, he could not find anyone there who even knew anyone that was working on the sense of well-being. Everyone was working on a specific disease.

Why do I tell you all of this? What does it have to do with empowering patients in underserved urban areas?

I knew that I should really find ways to look upstream. Yet, during the day I was busy seeing patients at an office a few miles from our house on Cleveland’s east side. Often, I wasn’t finished documenting what I did until late into the evening. (Thanks to electronic medical records, the documentation can now be done at home.) Yes, I did try to listen very intentionally to each of my patients per Dr. Hilton’s statement that listening well may be the most important thing we do. But I was so busy “operating the rescue station” that I didn’t have time to look “upstream.”

A year and half ago I was presented with the opportunity to do health care in a different way. I moved from a satellite MetroHealth facility to the MetroHealth Medical Center. Rochele stayed at the satellite office we shared with 4-5 other providers and although she had a full patient panel often took on the patients I had cared for during the previous 15 years. This was a mixed blessing. I often heard about the difficulty “my patient” had caused her, but also heard through her that I was deeply missed. I had initially suggested that she come join me at the main campus, but it was apparent to us both after a few months that we (mostly Rochele) were needed and deeply appreciated in our community. Not everyone gets to hear that while they are alive.

My new work resulted from a grant called MEDTAPP (Medicaid Technical Assistance and Policy Program) which was initiated by Ohio Governor John R. Kasich as a way to spread Patient-Centered Medical Homes (PCMH) to urban underserved areas and attract primary care providers to work in those areas. My job was to implement a PCMH model. I was seen as having expertise because I had studied the PCMH model after hearing Dr. Doug Eby speak at a Mennonite Medical Association / Mennonite Nurses Association convention in Colorado.

Doug has been in Anchorage, Alaska for over twenty years and works for the Southcentral Foundation, an Alaska Native-owned nonprofit health care organization.   Southcentral Foundation assumed responsibility for the healthcare of native Alaskans in their region from the Indian Health Service in the late 1990s. They have implemented a healthcare system that exceeds the PCMH model and is recognized internationally and nationally, winning the Malcom Baldridge award for healthcare in 2011. I call it PCMH 8.0 when I discuss it with medical students and residents.

In the summer of 2012, Rochele and I were able to go to Southcentral Foundation’s conference on the Nuka system of care and in good Mennonite Your Way fashion, stayed with Doug and his wife Rosene (who happens to be my second cousin). So from here on, if you read something compelling in this article, Doug or someone at Southcentral Foundation probably said it first.

As I moved to MetroHealth and started work on the MEDTAPP grant, we researched novel ways to deliver care outside the normal office visit. These included shared medical appointments or group visits, team based care, using behaviorists as an integral part of the care team, home visits, and focusing on “superutilizers.” Here, I would refer you to some of the work that Dr. Jeff Brenner has done in Camden, New Jersey which was highlighted in a New Yorker piece by Dr Atul Gawande called “The Hotspotters”  (Gawande, 2011).

Our approach was to do all these things at once: to have group visits of super-utilizers with a team based approach using behaviorists incorporating the principles of a PCMH. Those principles include:

• Patients having a personal physician
• Healthcare with a “whole person” orientation
• Increased quality of care
• Increased access to care
• Care that is integrated and coordinated among all providers
• A different payment model

One caveat is that our “different payment model” was that the grant paid our salaries and we were not able to bill Medicaid; however, we were implementing all the other items on the list to some extent.

Our team was two full time physicians, two full time social workers, a program coordinator who had been a medical assistant prior to this assignment, and a registered nurse who is a care coordinator.   We also use a dietician especially for a diabetes group, a yoga instructor for chronic pain, and additional guests as well. Medical students are often part of the group for a month or two and they are required to give a presentation to the group on a medical issue.

We used our electronic medical records to find out which patients had high emergency department and/or hospitalization rates. Our social workers contacted them and did an interview and invited them to come to group visits. We had to contact approximately 30 patients to get a group of 5-10 patients. The groups were divided by condition, namely COPD, chronic pain, and two diabetes groups. They meet weekly for 6 weeks and then have a week off and then we repeat.

We have seen marked reductions in hospitalizations and emergency department visits. Other things that we are measuring include self-reported depression, anxiety and self–efficacy scores all with validated standard scales such as the PHQ-9. We have seen marked improvement in every parameter.

What do we do in the groups?

The first thing that we do is to make sure the group is a place where patients’ control is recognized. We review the WHO definition of health and state that this group is about finding “health” or “well-being” in the context of their chronic condition. We discourage providers from wearing white coats or ties as a way to “level the playing field.” We have the group set the rules, which usually include being respectful of each other, no interrupting, no cursing, etc. We also make sure that everyone knows the importance of maintaining confidentiality. We have some topics that we touch on with every group such as optimizing sleep patterns, mindfulness, forming habits, and the science behind habits.

There are other topics that are condition-specific such as inhaler use for COPD patients, yoga for the chronic pain group, and a diabetic diet for the diabetes groups. However, many topics we discuss are generated by the groups. They may want more information on garcinia cambogia, for instance, so we do research from a credible source and give them the information they need to make a decision.

Why does this work?

Dr. Eby has a graph that he shows with acuity, or how sick a person is, on the X axis and control over decisions that affect one’s health on the Y axis. Then there are two lines on the graph one representing the patient (or “customer-owners” as they call them in Alaska) and the other line representing the healthcare system. What the lines show is that when acuity is high the system/doctor is in control. This would be in the emergency room, the operating room, or in an acutely ill hospitalized patient. However, when acuity is low, which is most of the time, the doctor is not in control at all. It is the patient who has the control, albeit influenced by their culture, their family, and all the other things they encounter on a daily basis.

Often in outpatient medicine, because of the way we as medical professionals are trained, we still act like we are in control. We may see a patient once every three months for 10-15 minutes and we tell them to eat right, exercise, and take their meds correctly, and then we expect that they will do it just like we said. That just does not usually work, in my experience. When we consider that 70 percent of healthcare is delivered as outpatient care and yet we use a model of delivering care that does not take into account the truth that the patient is in control, it is no wonder that we get less than optimal results. In the groups, I have discovered that patients are much more likely to believe each other than me, because the other person knows what they are going through in a way that I cannot. I am there to serve as a referee and make sure that what people are taking away from the group is accurate and useful in some way.

The inpatient high acuity situations are often handled in a very proscribed fashion. That means there are protocols and we assume we just have to get the protocols right, improve them, break down every step, and figure out the most efficient way to carry out that process. This has been likened to throwing a stone at a target. In that situation it is all about doing it the same way every time. We should gauge our arm velocity, our release point, and the angle of our arm so that it is as close to identical every time. That works well in those high acuity situations.

In the outpatient setting, where most healthcare happens, it is a different situation. This can be likened to throwing a bird at a target, and as soon as you release the bird, it can go anywhere it wants to. That means that our jobs are much more about coaching and making the target more attractive. One of my medical students suggested to me that we could just throw the bird really hard. It seems to me that is what our health system already does in many cases. If our “birds” don’t fly straight to the target that we (the healthcare providers) have determined should be their destination, then we call them noncompliant and the opportunity to significantly improve their health fades.

Partnering with our patients to map out their health journey is time-consuming, but is likely to give better results in the long run. The other thing about birds is that they travel in flocks and we ignore the power of groups to change behavior at our peril. One of my favorite African proverbs is this one: “If you want to go fast, travel alone; if you want to go far, travel with a group.” Empowering patients is thus, not so much about struggling to get individuals into compliance as it is in building together more healthy communities.

Citation:

Gawande, A. (2011, January 24). The Hot Spotters: Can we lower medical costs by giving the neediest patients better care? Retrieved May 13, 2014, from The New Yorker: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

Corrections

from Mennonite Health Journal, Vol. 16, No. 3 – August 2014

Several corrections are noted in the Mennonite Health Journal article from the May 2014 issue entitled “Empowering Patients: New Paradigms for the Urban Underserved.” These corrections have now been made in all of the online versions.

• Dr. David Hilton’s name was misspelled. In the article, it was “Hylton”;it should have been “Hilton.”
• The definition of health from the World Health Organization (WHO) has been corrected to read “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” The earlier version referred to “emotional and spiritual” realms.
• Dr. Hilton worked for the World Council of Churches in Geneva and not for WHO, as indicated in the earlier version. However, he presumably had many contacts at WHO and this is likely what he was referring to in his 2003 speech at Mennonite Health Assembly in Atlanta.

Documentation for these changes comes from the following sources:

http://eip.uindy.edu/profiles/hilton_david22_25.pdf
http://hmassoc.org/wp-content/uploads/wd04hilton.pdf
http://www.who.int/governance/eb/who_constitution_en.pdf

A hearty thank-you to Ray Martin who initially called our attention to these needed corrections.

About the author

Nathan and Rochele Beachy have been practicing Family Medicine the past 20 years at MetroHealth, the county hospital in Cleveland, Ohio.  Prior to that they served a 3-year term with Mennonite Central Committee as rural physicians in Panyam, Nigeria.  They returned to Nigeria for 6 months in 2003 to work at Faith Alive, an HIV clinic in Jos.   They are members of Lee Heights Community Church and have three children: Jared 24, Marita 22, and Caleb, 20.