Patient motivation and engagement techniques for primary care physicians

Motivating patients to take their medications appropriately and to follow the plan laid out for their injuries, illnesses, or well care maintenance can be a challenge. Many patients are intrinsically motivated while others need additional encouragement and engagement from their primary care physicians. A number of techniques can help the primary care physician engage the patient more fully, including using electronic health records (EHRs) for patient engagement, communicating with the patient regularly, and using a unique approach called motivational interviewing.

EHRs for patient engagement give the physician and the patient the ability to communicate electronically. EHR tools, such as the Elation Patient Passport, offer an online portal for providers and their patients to securely share and communicate regarding their health information. Patients can access their visit summaries, medications, reports, and more online. Patients are also encouraged to ask their physicians questions to clarify follow-up instructions, for example.

The convenience in using an EHR for patient engagement can encourage patients to become more motivated to share additional information with their primary care physician and to follow their treatment plan after the office visit. Patients who prefer electronic communication may be more open to asking questions virtually.

Another technique that can help motivate and engage patients during the visit is the motivational interview, a conversation in which the primary care physician asks questions designed to encourage a hesitant patient to share additional details. The goal of the motivational interview is “not to solve the patient’s problem or even to develop a plan; the goal is to help the patient resolve his or her ambivalence, develop some momentum and believe that behavior change is possible.”

Motivating and engaging patients can be challenging but using techniques that make the patient more comfortable and that are designed to elicit questions and feedback can help the primary care physician better understand the patient’s situation and medical condition.

Greg Miller
October 16, 2018

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13% of patients live in an area affected by the primary care shortage

The primary care physician can be a critical factor in a patient’s healthcare outcomes. Playing a major role in patient care, the primary care physician is focused on well care, prevention, and early detection, monitoring a patient’s signs and symptoms and managing potentially adverse health conditions. Acting as a medical home for the patient, the primary care physician can take the lead in coordinating care, eliminating medication duplications, and reducing unnecessary tests and hospitalizations.

However, there is a growing shortage of primary care physicians across the country. A report published by UnitedHealth Group, “Addressing the Nation’s Primary Care Shortage: Advanced Practice Clinicians and Innovative Care Delivery Models,” shows that the shortage affects patients across both urban and rural areas. Statistics around the gaps in primary care access include:

  • Thirteen percent of U.S. residents (44 million) live in a county with a primary care physician shortage, defined as less than one primary care physician per 2,000 people.
  • Rural residents are almost five times as likely to live in a county with a primary care physician shortage compared to urban and suburban residents (38 percent vs. 8 percent).
  • Nearly as many urban and suburban residents live in a county with a primary care physician shortage as rural residents (21 million vs. 23 million).

The root of the shortage appears to lie in the career choices made by medical school graduates. The report states that in 2017, “only one in six medical school graduates – 5,000 out of 30,000 – selected a primary care residency program.” Primary care physicians who are currently practicing are aging out. According to the report, “over one-third of all physicians practicing today will be 65 or older by 2030.”

As the general population also ages, the demand for healthcare services will increase. The estimated shortage of primary care physicians could grow from 18,000 in 2018 to 49,000 in 2030, so the solution may be in nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs), who “represent a growing part of the nation’s primary care workforce.”

Greg Miller
October 8, 2018

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Useful apps for primary care physicians

There seems to be an app for everything now. The choices can be confusing, particularly when the independent physician is searching for the most useful and most reliable options. Apps can provide a wealth of updated information for primary care physicians, but they can also be time wasters that take up valuable space on an electronic device.

A recent article in Physicians Practice highlights three apps that “are of significance to the primary-care specialties”:

ASCCP Cervical Screening Guideline App (ASCCP) – A simple app designed for easy, quick access with four buttons for screening, management, algorithms, and definitions. The primary care physician can enter data about a particular patient to see the ASCCP strategies for clinical approach. Available algorithms cover almost every possible patient situation and condition.

USPSTF Preventative Services Database App (AHRQ ePSS) – An app that is “one of the most extensive and data-driven list of screening guidelines for patients based on demographic data (age, sex, sexual activity, pregnancy and tobacco use).” The primary care physician can use this app to determine what the patient should be screened for, including “what is most likely to increase their morbidity or mortality in a particular age group” based on data as basic as demographics.

Guideline Clearing House App (Guideline Central) – Designed to provide the most relevant guidelines for the physician’s specialty area. The app is a “comprehensive guideline database that is searchable” and allows the primary care physician to tailor those guidelines to a “specialty or particular conditions, as well as provide access to useful tools and calculators relevant to the guideline in question.”

While guidelines for screening and treatment seem to change frequently, these apps can help the primary care physician get current information in real time, based on patient data or data regarding the patient’s condition. For the primary care physicians who want fingertip-accessible information, these apps can be very useful.

Greg Miller
October 8, 2018

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Artificial intelligence and primary care

A significant amount of data is being gathered now in the healthcare industry, by patients who wear personal health and fitness devices and by primary care providers who use electronic health records (EHRs) in their practice. Though individuals can use this data to assess a patient’s condition and to recommend treatment plans and medications, artificial intelligence (AI) may soon provide more extensive benefits to primary care.

Artificial Intelligence for Health and Health Care, a recent study conducted by JASON, an independent group of scientists operating through the non-profit MITRE Corporation, focused on “how computer-based decision procedures, under the broad umbrella of artificial intelligence (AI), can assist in improving health and health care.” The subsequent report from MITRE “argues that AI application in health could help clinicians provide the best possible care, thus making high quality health care services available to all, and could increase people’s engagement in their own health.”

AI can process much more data than any human could, enabling it to look at the bigger picture of population health, for example. One goal identified in the MITRE report is “accelerating the discovery of novel disease correlations and helping match people to the best treatments based on their specific health, life-experiences, and genetic profile.”

As to patients becoming more involved in their own healthcare, AI in the primary care practice and smart devices worn by those patients will become “increasingly interdependent.” The report notes that, “on one hand, AI will be used to power many health-related mobile monitoring devices and apps. On the other hand, mobile devices will create massive datasets that, in theory, could open new possibilities in the development of AI-based health and health care tools.”

A challenge in the implementation of AI in the primary care practice is the disparity between human input and pure statistical data processed by AI. The report acknowledges that most data “concerning an individual patient is mostly obtained in forms designed to be accessible to medical personnel.” The patient’s medical record contains images of x-rays and visit notes input by the primary care physician. JASON acknowledges that the shift to AI for primary care will probably not happen completely within the next 30 years but, looking farther into the future, it could be very helpful in patient care.

Greg Miller
October 3, 2018

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Imagining a primary-care focused advanced APM

An integral part of the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP), the Alternative Payment Model (APM) is “a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.”

As reported by Modern Medicine Network, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted in late 2017 to recommend that Health and Human Services (HHS) test the Advanced Primary Care (APC) APM developed by the American Academy of Family Physicians (AAFP), an organization with a membership of more than 84,000 actively practicing physicians. AAFP notes that the potential impact of a primary-care focused advanced APM could be huge.

Interviewing representatives of AAFP, author David Raths asked several questions regarding the need, structure, and impact of the APC APM. Amy Mullins, MD, AAFP medical director for quality improvement, responded that “there needs to be an AAPM that will be available for the majority of primary-care physicians to participate in as an alternative to MIPS (Merit Based Incentive System). Dr. Mullins noted that “it is difficult to achieve wide adoption of a payment model if it is too complex and has a high reporting burden. This is magnified if physicians are not getting paid for doing this work on all of their patients.”

Michael Munger, MD, AAFP president, further explained that primary care physicians typically are paid based solely on the patient visit time. Inequities start to appear in the procedural codes when the visit might entail discussing several chronic conditions with the patient but a single procedure such as a colonoscopy is worth three times as much. Additionally, primary care physicians typically spend time coordinating care with specialty providers or managing conditions between visits, for which there is no procedural code.

The proposed APC APM model also addresses social determinants of health, important factors in primary care. Dr. Munger explains that “You cannot do effective population health management unless you are addressing social determinants of health. The ability to risk-stratify your population to look for individuals who have food insecurity or transportation needs or who don’t feel safe in their neighborhood lets you target your resources better. It also allows patients to better participate in their own chronic disease management.” He adds that the proposed APC APM model “really does recognize the importance of a prospective, risk-adjusted population-based payment.”

Greg Miller
October 1, 2018

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What Is Coordinated Care?

Coordinated Care is the meticulous organization of patient care activities between two or more participants (including the patient) that are involved in a patient’s care, used to simplify the appropriate delivery of health care services. Organizing a patient’s care involves the directing of personnel and other resources needed to carry out all required patient care activities, and is often managed by information being communicated to everyone that is involved within the patient’s care.

Why Is Coordinated Care Important?

Coordinating care is a strategy that can improve the effectiveness, safety, and the efficiency of healthcare. Targeted and well-designed coordinated care that is delivered to the right people can improve outcomes for everyone.

The main goal of care coordination is to meet the patient’s needs and preferences while delivering  high-quality, valued health care. This means that the patient’s needs and preferences are known and communicated to the providers treating them, and this information is then used to guide the delivery of safe, appropriate, and effective care.

Specific activities used to achieve coordinated care include:

  • Establishing accountability and agreeing on responsibility
  • Communicating and sharing knowledge
  • Helping with transitions of care
  • Assessing patient needs and goals
  • Creating a proactive care plan
  • Monitoring and follow up, including responding to changes in the patient’s needs
  • Supporting the patient’s self-management goals
  • Linking to community resources
  • Working to align resources with patient and population needs

Why Is Coordinated Care Needed?

There are two main reasons why care coordination is necessary; the first being that a lack of coordination can be unsafe, or even fatal for patients. When abnormal test results are not communicated correctly between a patient’s providers or between providers and their patients, or when prescriptions are issued by multiple physicians and there is a lack of awareness of the medications the patient is already taking, the risk for poor patient outcomes is high.

The second reason is that uncoordinated care is more costly for patients and the healthcare system itself. Lack of coordinated care can increase duplicate services and tests, increase the risk of preventable hospital admissions and readmissions, and also adds to the overuse of more intensive procedure.

Damien Neuman
October 1, 2018

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What is a Clinical Care Team?

The definition of a clinical care team is:

A clinical care team for a given patient consists of the health professionals—physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other healthcare professionals—with the training and skills needed to provide high-quality, coordinated care specific to the patient’s clinical needs and circumstances.

This team-based model requires a new way of thinking about clinical responsibilities and leadership, one that recognizes that different clinicians will assume principal responsibilities for specific elements of a patient’s care as the patient’s needs change; and while the team as a whole must ensure that all elements of care are coordinated for the patient’s benefit.

Who are these Health Professionals?

Clinical care teams usually include groups of physicians, nurses, physician assistants, clinical pharmacists, social workers, and other health professionals that help to establish new lines of collaboration, communication, and cooperation to better serve their patient’s needs.

Some of these team members are doctors or technicians who will help diagnose disease; others are experts who treat diseases or care for a patient’s physical and emotional needs. These health professional might be:

  • Doctors
  • Physician Assistants
  • Nurses
  • Pharmacists
  • Dentists
  • Technologists and technicians
  • Therapists and rehabilitation specialists
  • Emotional and social support providers
  • Administrative and support staff
  • Community health workers and patient navigators

Here we will give a brief introduction to these different types of health care professionals on the care team.

Doctors

Doctors, or physicians, are key members of the healthcare team. They have years of education and training. They may be primary care doctors who focus on preventive health care, or specialists who diagnose and treat conditions that require a specific area of knowledge.

Physician Assistants (PA’s)

Physician’s Assistants are licensed to practice medicine but are supervised by a doctor. They work alongside physicians to perform physical examinations, diagnose and treat illnesses, order and interpret diagnostic tests, prescribe medication, and assist in surgery.

Nurses

Nurses work closely with patients but their duties depend on their education, their area of specialty and work setting. There are three different types of nurses, Licensed Practical Nurses (LPN), Registered Nurses (RN’s), and Nurse Practitioners. Each of these differ because of their length and type of education.

Pharmacist

Pharmacists are experts in the field of medication. They work with physicians or physician assistants to ensure new prescriptions do not interact with a patient’s current medications, that the right dosage for a particular medication has been prescribed, and to answer any questions that the patient may have about their prescribed medication.

Dentist

Dentists diagnose and treat problems related to the teeth and mouth, along with giving advice and administering care to help prevent future problems. They instruct patients about the importance of brushing, flossing, fluoride, and other aspects of dental care.

Technologists/Technicians

Technologists and technicians have a more technical role in diagnosing or treating disease. Lab Technologists help providers diagnose and treat disease by analyzing body fluids and cells. Radiology Technologists help providers diagnose and treat disease by taking x-rays. Pharmacy Technicians help pharmacists prepare prescription medications but do not need any type of degree or certification.

Therapists and Rehabilitation Specialists

Therapists and rehabilitation specialists help people recover from physical changes caused by medical conditions, chronic diseases or injuries. Types of rehabilitation specialists include physical therapists, occupational therapists and speech therapists. Occupational therapists help patients perform tasks needed for every-day living or working and usually have patients who have physical, mental or developmental disabilities. Physical therapists work with patients when they have an injury, disability or medical condition that limits their ability to move or function. Respiratory therapists treat and care for patients with breathing problems like asthma or emphysema. Speech therapists work with patients who have problems related to speech, communication or swallowing. Lastly, recreation therapists provide a wide range of interventions and therapy that is designed to improve a patient’s functioning and keep them as healthy, active and independent as possible.

Emotional and Social Support

There are many healthcare team members who provide emotional and social support rather than physical support. These healthcare members are called mental health professionals, who help patients with the emotional aspect of living with a chronic disease. Psychiatrists are medical doctors who diagnose and treat mental, emotional and behavioral disorders. Psychologists deal with mental processes, especially when patients are stressed, but they are not medical doctors; instead they have a Doctor of Psychology (PsyD) or a doctor of philosophy degree (PhD).

Social workers that work in a clinical or hospital setting will help patients and families cope with the emotional, physical and financial issues related to having an illness. Depending on a patient’s needs a social worker may help coordinate services like housing, transportation, financial assistance, meals, long-term care, or hospice care.

Administrative and Clerical Staff

Administrative and clerical staff coordinate and facilitate patient care. They schedule appointments, answer phones, greet patients, keep medical records, handle medical billing, fill out insurance forms, arrange for laboratory or other diagnostic services, and handle financial records. These duties help to keep things running smoothly in a hospital or doctors office.

Community Health Workers and Patient Navigators

Community health workers link patients to primary care providers, health information, health screening, financial assistance or transportation. Patient navigators work with patients to minimize the barriers that keep them from getting healthcare. These barriers could be related to low income, transportation, childcare, language or ability to read forms or to understand the healthcare system.

Each of these care team members play an important role in coordinating and delivering care, and supporting each patient based on their needs.

Tyler Comstock
October 1, 2018

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How can virtual groups be beneficial?

With the goal of virtual groups being “to clinically benefit patients and to encourage collaboration”, the concept of virtual groups is still being fully defined by CMS. Ideally, virtual groups would allow individual physicians and small practices the ability to connect and pool together their resources when it comes to quality reporting and improvement. This provision would benefit the independent clinicians attempting to operate with the difficulties of reimbursement reform without taking away their independence.

Elation Health believes that virtual groups can and should be a powerful tool to not only create administrative efficiencies for the providers who participate, but also to encourage collaboration that improves the quality of a patient’s health care.

So far, this is what CMS has said about virtual group reporting within the Quality Payment Program, “Flexibilities and Support for Small Practices” PDF:

“Under MIPS, clinicians will have the option to be assessed as a group
across all four MIPS performance categories. The law provides that solo and small
practices may join “virtual groups” and combine their MIPS reporting. CMS is seeking
public comment on how virtual groups should be constructed, and anticipate being able
to implement virtual groups in the second year of the program. CMS wants to make sure
the virtual group technology is meaningful and simple to use for physicians.”

Elation Health believes independent provider-led initiatives like virtual groups should be at the focus of CMS’ strategy for implementing MACRA.

Additionally, because we are so excited for the addition of virtual groups into the MACRA Final Rule, we have provided feedback on the concept of virtual groups to CMS. In our comment we detailed specific suggestions for how CMS should implement these groups, including the metrics which should be utilized to demonstrate the effectiveness of virtual groups and their impact on care quality and health outcomes.

To learn more about how Elation is supporting independent physicians, read the full text of our comment here.

Greg Miller
October 1, 2018

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Frequently asked questions about primary care physicians

What is a Primary Care Physician?

A Primary Care Physician is considered a patient’s main doctor and is responsible for dealing with the majority of their health care needs and/or concerns relating to their general health. If their patient has a problem that is more complex than the PCP can manage they will refer them to see a specialist in the area of the health issue.

What health care needs do PCPs manage?

Primary Care Physicians give their patients yearly physical exams and conduct preventative health care; they also inform their patients on what future health care problems they are at risk for developing based on family medical history. They also provide patients with information on how they can prevent or decrease risk for those medical problems.

PCPs will also take care of any non-emergency problems their patients may have, like a cold that has gotten worse over time or pink eye, they can fix you up with some medication and remedies for feeling better. They will also manage and monitor and chronic health issues their patients may have like high blood pressure or acid reflux disease.

What is the importance of the PCP role?

The most valuable role Primary Care Physicians have is their ability to coordinate care. If a patient has complicated medical problems, needs multiple specialist physicians, and is in and out of the hospital they will need to have good care coordination.

PCPs knows what each of the specialists are doing and makes sure they’re not duplicating tests or procedures that have already been done by another specialist. PCPs also make sure all of a patient’s prescriptions are absolutely necessary and all are compatible with each other. Care coordination is such a large part of a patient’s health care but isn’t given that much thought by the general public.

Is the time spent with patients and quality of care being received satisfactory?

Due to the fact that most doctors only make money by prescribing, testing, scanning, and seeing as many patients as they can, they do not get to spend quality time with their patients to understand their health care problems. This is dangerous in the case of unnecessary testing and prescribing, and it is also dangerous because the lack of communication in the doctor-patient relationship impacts the quality of care. Sadly, this is the works of the American health care system, not the physicians.

Greg Miller
September 24, 2018

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Value based care and population health management

The Centers for Medicare & Medicaid Services (CMS) continues to emphasize the need for independent physicians to provide quality care that is reimbursed not on the basis of the quantity of patient visits but on the quality of patient outcomes. Many commercial insurance companies are following suit, emphasizing reimbursement for value-based care over individual visits.

A recent article published by the Healthcare Information and Management Systems Society (HIMSS) noted that “Population health management has been widely discussed as the solution to help healthcare organizations reach value-based care goals.” Additionally, the article states that “there are three keys to a successful program: data analytics, technology adoption and the inclusion of the patient as a partner.”

Population health management involves tracking data on individual patients within a population group. Healthcare IT News reports that the “concept of population health first came about in 2003 when David Kindig and Greg Stoddart defined it as ‘the health outcome of a group of individuals, including the distribution of such outcomes within the group.’”

The ability to manage data regarding the population can be a significant factor in the value-based care provided to those patients. HIMSS emphasizes that “real-time data enables clinical decision support which can help payers and providers address at-risk populations, and provide timelier interventions. Analytics help us find gaps in care and determine whether healthy outcomes were achieved.”

An electronic health record (EHR) solution enables the independent physician to holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time. Partnering with the patient to manage healthcare plans and medications improves the value of the care provided to that patient. In fact, most patients want to be more actively involved in decisions that affect their ongoing health.

Quality technology, data analytics, and patient involvement enable the independent physician to manage the population’s health to produce quality patient outcomes and to more successfully participate in value-based care.

Greg Miller
September 18, 2018

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