Stories of Most Significant Change: Patient, physician, and allied health perspectives on the patient medical home

Wed, Dec 4, 2019

PMH banner image.JPG

Primary care change is underway in many BC communities. We know that change in our health care system takes time and can be hard work. One of the best ways to succeed is to take the time to reflect on the challenges and learnings from those physicians, allied care providers, and patients who are working on the front lines – those who are implementing change first and who have lessons to teach us all.

One of the major changes taking place is the creation of patient medical homes (PMHs), which are the foundation of an integrated system of primary and community care.

A PMH is a family practice that works to incorporate the 12 attributes that define the provision of ideal patient care. One of the key attributes is the creation of team-based care, including the recruitment of allied health providers, into individual practices. Practices that have adopted PMH attributes will form the foundation of health care delivery within the broader primary care networks (PCNs) in local communities.

To support this change, we have woven together a series of stories that represent different viewpoints and learnings in the delivery and receiving of care in the PMH environment. “Stories of Most Significant Change” will take readers on a journey toward understanding how patient medical homes are removing barriers and helping to provide quality patient care around the province as well as creating environments where physicians can do their best work.

 

Reducing physician workload and improving work/life balance

Working in a team environment can greatly reduce the burden on physicians’ time. Physicians report that with team members’ support they no longer feel like they’re the sole person in charge of their patients’ well-being, and that they can count on team members to support patients with a wide variety of needs.

One physician said, “The most significant change for me since starting to work with a Nurse in Practice is that my work-life balance has substantially improved. I already feel like my patients are getting more comprehensive and timely medical care. The patients have told us that they appreciate being able to sit down with the nurse and talk about things without the time pressure.”

Another physician acknowledged the benefit of being able to refer patients to team members, sayingi “In the past, I would have had to supply all the care for each patient. For example, if I identified a patient with mental health issues, I would have had to make time to provide counselling, generally a 30-minute appointment. Now I can refer to a social worker who can do the counselling. We can now take patients on a walk-in basis, because the nurses can triage and do a lot of the preliminary work, allowing us to spend five minutes with a patient for urgent matters.”

These benefits are not lost on patients, one of whom acknowledged that their doctor has benefited greatly from the support of the practice team. “What we expected in the past was for doctors to be superhuman, which is ludicrous,” the patient said. “When our doctors get help so they can sleep and have a family life, of course the care they provide will be that much better.”

 

Increased capacity and access to care

One of the main goals of the PMH model of care is to create capacity in physician offices, and ensure physicians are freed up to provide services only they can provide. Family physician stories from the report indicate this goal is already being achieved. “On a professional basis,” one family physician explains,[i] “this model enables me to see more patients in a given time, which has shortened the waitlist for patients to be seen. On a more personal basis, I feel that we are supplying better care for patients. Nurses are spending more time, especially with complex patients, providing counselling on many time consuming issues like cholesterol and diet, which frees me up to see more acute cases.”

Another family physician clarifies,[ii] “When I was offered the opportunity to participate in the Nurse in Practice initiative, I saw it as an opportunity to work with a team, to allow me to focus on the things that only I can do. I thought that, as a team, we could each work to maximize our individual skills and provide a more efficient and holistic environment for our patients.”

Patients appreciate the holistic care they receive from allied health providers, and how this support has improved their ability to access a primary care provider. One patient explains,[iii] “When you’re already sick and start to have a sense of hopelessness, you do give up after a while, feeling like you can’t keep jumping through hoops, waiting such a long time to see the doctor. It used to take two to three weeks to book an appointment, and I would wait 30 to 60 minutes for a scheduled appointment. Now with the nurse, I wait only 10 minutes.”

 

Improved support for patients

Nurses interviewed acknowledge that the PMH model of care improves support for patients in a number of ways. One RN says,[iv] “Patients are seen more quickly—there is increased access. Patient health is also improving because patients have more time with a health care provider.”

Increased time with patients has enabled clinic care providers to identify more conditions they may not have previously discovered, for example,iv “a woman coming in for a well woman exam may be asked how she’s feeling, and this may lead to a conversation about depression and anxiety that would not have been diagnosed if I hadn’t had the time to talk with her.”

Social workers also play an important role in supporting patients. During appointments with a social worker, patients can get assistance with forms and benefits, and be connected with local programs and supports. The nurse acknowledged the invaluable support provided by their clinic’s social worker,iv saying “The social worker has been a phenomenal addition to our health care team. Someone who requires an hour of time to navigate long-term disability and mental health forms or challenges can now see the doctor, and then the social worker spends 30 to 60 minutes doing a thorough assessment and working on complicated paperwork for the patient if needed.”

This kind of support can have a tremendous impact on patients’ overall well-being. One social worker explains,[v] “I really see the value in having a social worker available to the general public. The change that I have been able to effect in people’s lives and healthcare has been striking. I’ve worked with patients on CPP disability who didn’t realize they could qualify as a person with a disability – I was able to increase their income from $800 to $1200 per month, an increase of 30%, in two appointments. That can make a huge difference in someone’s life and ability to function.”

 

Proactive care

When a team of care providers works together to support patients, the care they provide can be more holistic and proactive. Providers can spend time helping patients understand preventative measures they can take to improve their health, which in turn improves the health of communities overall. Nurses in particular can play an important role as educators, providing patients with the information they need to make healthy choices. One family physician noted,ii “I have learned that nurses are trained to be communicators and educators. This aligned with my goals for changes I wanted to make in my office, to provide additional education to patients to empower them to manage their health.”

Patients appreciate this proactive approach to care. One patient said,[vi] “What struck us about having a nurse in practice is that it’s probably the first time in our relationship with a family physician that the physician’s office has been proactive about health issues, rather than us presenting them with a problem.” In this case, the nurse provided the patient with proactive support and advice including “alternative therapy for the knee, what to watch for, and potential outcomes down the road,” says the patient. “She also provided diet advice to support ongoing heart health. The time the nurse has spent with us has made us feel respected and is helping us to lead a good life as seniors.”

Family physicians acknowledge the importance of providing patients with proactive care as well, with one doctor commenting,[vii] “Practices do well to help patients with their problems ‘here and now,’ but fall short of helping patients look ahead to ‘if and when.’ This is where an integrated team can best help a patient to improve their care and create a better patient experience.”

Read more patient, physician, community member, and allied care provider stories from the PMH “Stories of Most Significant Change” Evaluation.