The Future of Innovation in Primary Care
Using Advanced Primary Care Model to Overcome Patients’ Health Challenges
The Patient-Centered Medical Home is the best current model of primary care, where a team of medical assistants, nurses, behavioral health specialists, and physicians collaborate to address the specific needs of each patient. Everyone stays informed sharing an electronic health records system.
That model is not good enough, says Carlos Roberto Jaén, M.D., Ph.D., one of the initial proponents of the Patient-Centered Medical Home (PCMH). The PCMH does not take into account the barriers faced by disadvantaged patients to even access it. The PCMH team is poorly designed to help the patient who cannot even get to a clinic, just from lack of transportation. Dr. Jaen suggests an innovative alternative called Advanced Primary Care.
“We’re inventing Advanced Primary Care here. We don’t have a patent, but we could,” Dr. Jaén said of the model being pioneered at UT Health San Antonio’s Joe R. and Teresa Lozano Long School of Medicine, where he is chair of the Department of Family and Community Medicine.
Before the PCMH, primary care practices were centered on the clinician, he explained. The payment system forced the physician to see more patients to support the medical practice. Contrast that to the PCMH, “We’re here for the patient,” said Dr. Jaén.
“Although I may have direct responsibility for you as my patient, I also sufficiently trust my team that if I can’t see you, one of my teammates will,” explained Dr. Jaén, one of the original innovators in primary care medicine. The PCMH concept tested by Dr. Jaén in collaboration with five academic health centers benefitted from studies in over 500 primary care practices. He and Robert L. Ferrer, M.D., M.P.H., FAAFP, the department’s vice chair for research, collaborated in the first National Demonstration of the Patient-Centered Medical Home, which was published in a special supplement of the Annals of Family Medicine in 2010. Both have been elected to the prestigious National Academy of Medicine because of their innovative contributions in developing the PCMH.
Since the Panama native came to San Antonio in 2001, Dr. Jaén initially adapted the PCMH model to serve the area’s large Hispanic population. “You have to adapt to the community you are serving. What works for you may not work for people who live in the poorest zip code in San Antonio where people are socially deprived and die 20 years earlier,” he explained. He found that the PCMH worked well for those who could access it without difficulty, but less well for those who had barriers to such access.
That’s exactly why he implemented the Advanced Primary Care model at the Robert B. Green Clinic of University Health System, UT Health’s main hospital partner. This model better serves San Antonio’s marginalized population, which often lack insurance, cannot afford transportation or co-pays, and may even be homeless. This clinic is sited in the inner city, with easy bus access and close to the major homeless shelter. The clinic often provides bus or taxi vouchers to make sure the patients can make their appointments. The clinic provides services to about 10,000 unique patients a year.
Advanced Primary Care was initially funded through a Delivery System Reform Incentive Payment (DSRIP) federal grant, an expansion of Medicaid in the Affordable Care Act. “It provided state Medicaid dollars to do things that weren’t traditional health care,” said Dr. Ferrer. “We’re incorporating approaches from sociology, epidemiology, and human development economics in the context of family medicine and primary care. For example, we’re learning that it’s not only important to understand what people do—diet and physical activity, for example—but also what feasible opportunities they have to engage in healthful activities.”
They hired doctors, nurse practitioners, physician assistants, clinical pharmacists, registered nurses, behavioral health consultants, and psychologists to be part of the primary team. However, the most important addition were the community health workers (CHWs), who are called “promotores” and serve as lay health workers. They visit the patient at their homes to help set up transportation, assist in obtaining medication, check blood glucose levels and blood pressures, assess the diet, and suggest activity routines.
“South Texas has a rich history of community health workers,” Dr. Ferrer explained. “These are lay people, often from the patients’ neighborhoods, who have been trained in helping fellow community members live healthier lives.”
Carolina Gonzalez Schlenker, M.D., M.P.H., a thought leader in community health worker circles, helped organize the program. “These CHWs are highly integrated as part of our team. They do home visits, and they bring the patients’ stories to our clinicians,” said Dr. Jaén.
The physicians shared research results from their “lab” at the Green Clinic after they sent the promotores into the homes of nearly 1,000 patients. The lessons learned included:
Healthy Eating: Food insecurity is common. Some patients don’t live near supermarkets. These “food deserts” make finding fruits and vegetables difficult, while fast food is abundant. The clinic collaborates with the San Antonio Food Bank to provide healthy foods and a teaching chef. The promotores are able to review the household’s refrigerator contents and encourages families to eat healthy together and socialize to promote each other’s health.
Reliable Transportation: If a promised ride doesn’t materialize or the public transportation system is inadequate, the promotores provide shuttles or vouchers.
Physical Activity: Some patients live in unsafe neighborhoods where promotores create walking groups or health clubs.
Household Issues: If the roof is caving in, they have caregiving responsibilities or need to find a job, patients prioritize those challenges over their medical needs. Social service agencies can be contacted to help.
“Besides improving individual’s health, we’re hoping to reconstruct good family dynamics and strong community,” said Dr. Ferrer.
Are there metrics that validate this model? A study of 960 patients with previously uncontrolled diabetes demonstrated that patients whom promotores were able to engage for 12 weeks of intervention saw sustained improvements in blood sugar control over four years. Those patients also had fewer ER visits and hospitalizations. Thus, a limited engagement by the promotores resulted in health benefits that last far beyond the initial engagement. This is the opposite of most other interventions in the social determinants of health, where the effect is limited to the time of the intervention alone and then disappears after the intervention ceases.
“Those improvements in health, with the associated cost savings, are good news,” said Dr. Ferrer, “because they provide a way to financially sustain the program. Health insurers see the logic in investing in better care up front to prevent costly health events later.” In fact, the promotores’ work is now funded under such a shared savings arrangement.
Drs. Jaén and Ferrer realize eight promotores can’t change the entire city of 2 million, but they are working on ways to scale this endeavor by reaching into the schools, churches and community centers, where many patients might gather to share with each other what worked well for a specific unhealthy habit. Promotores are much less expensive than clinicians, and they can extend the clinicians’ reach to where the patients live, and where health habits are formed.
One other important aspect of this research is that the data guides iterative improvements in the model. The Advanced Primary Care program is annually assessed and re-designed. The lessons learned from each research program define the next generation of the model. Thus, the model itself calls for continual self-assessment and self-improvement.
“We are very clear in our mission to improve the health in the community,” said Dr. Jaén. A presentation of the key findings of the Advanced Primary Care approach at the North American Primary Care Research Group, the premier international primary care research organization, was selected to be presented at the Society for Academic Primary Care at the United Kingdom. The approach is being used to train promotores in South Texas and will be implemented in other departments of family medicine in the U.S.