Transforming Office-Based Care
I often search the medical literature using Medline [www.medline.com] and subscribe to their weekly newsletter highlighting newly published articles of interest. Recently, they featured a very thought-provoking article by W. Perry Dickenson, MD that had a number of implications for prosthetic-orthotic care.
The article began with the following quote from an Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health Care System for the 21st Century: "The American health care system is in need of fundamental change". The writer went on to state that "Patients often do not receive the care that they need; services are underused, overused, and misused, all causing potential harm for patients and cost to the system. Furthermore, the startling increase in healthcare costs has once again become front-page news, and more and more people question whether we are getting what we pay for." These same pervasive forces will ultimately affect P&O care too, but we can minimize the negative impact by planning now to take a proactive stance before these problems filter down to affect our patients directly.
Dickenson makes the case that primary care physicians are finding it increasingly difficult to fully meet their patient's needs. Do these concerns have a familiar ring? "Our ability to establish quality relationships with our patients has been increasingly challenged by patients' frequent changes in health plan affiliations and by the decreased time that we have to spend with them. Primary care clinicians are being asked to provide more care in less time, and it is becoming impossible to spend the necessary time to obtain the personal knowledge of patients and their families upon which solid therapeutic relationships are built." He goes on to note that, because of their acute care orientation, primary care physicians often find it difficult to manage patients with chronic needs:
"Patients do not have the information that they need to manage their conditions, do not receive monitoring and treatment shown to improve their prognosis, and frequently fall between the cracks in the system. The chronic care model developed over the past decade includes a number of interventions that have great potential for helping with this problem, including the use of chronic disease registries, tracking systems, decision support, group visits, and care management. However, these interventions often require fundamental changes in the configuration of care and have not been widely adopted by primary care practices."
The IOM report concludes that, "These quality problems exist not because of a failure of goodwill, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized." The IOM proposes that healthcare practices should be reorganized to deliver treatment that is :
- safe
- effective
- patient-centered
- timely
- efficient
- equitable
Gordon Moore, MD, a solo family practice practitioner, quit his group practice due to frustrations with "burdensome paperwork and regulations, increasing costs, declining reimbursement, decreased time to establish relationships with his patients, a lack of balance in his personal life, among other factors." To combat these problems, he opened a micro-practice where he is the only employee.
According to Dr. Moore, open-access scheduling and the other innovative changes he instituted as part of his practice redesign have allowed him to "cut expenses, remove barriers for his patients, increase his efficiency, see fewer patients for longer appointments, and leave more time for his personal life. He now sees approximately 10-12 patients a day and is able to spend the necessary time to build relationships and deliver more personalized care to his patients." Interestingly, the reduction in the hassles and costs of maintaining office staff have permitted him to earn a comparable living despite seeing far fewer patients per week.
The American Academy of Family Practice has produced a video titled, " Idealized Design for Clinical Office Practice" that is available at www.aafp.org; additional information on this topic can be found at www.ihi.org. Many of the recommendations of the AAFP may have applications to P&O practices too. They include:
- email communication with patients
- group medical visits
- morning huddles and staff meetings
- patient education through the Internet
- use of computerized records and other tools for clinical information
- open access for appointments
- use of measurements and indices to monitor and improve care
You can read the entire article by Dr. Dickenson online at www.medscape.com for more information.
