Evolving Value-Based Primary Care Based on Innovative Research
By Catherine Duncan
In the Joe R. and Teresa Lozano Long School of Medicine at UT Health San Antonio, the Department of Family & Community Medicine’s dedication to conducting research to improve primary care can be traced back to one humble individual.
In 1984, David A. Katerndahl, MD, MA, FAAFP, left private practice to enter the academic world of medicine at UT Health. He developed the division of research in the Department of Family & Community Medicine.
Carlos Roberto Jaén, MD, PhD, FAAFP, professor and Dr. and Mrs. James L. Holly Distinguished Chair, Patient-Centered Medical Home, said Dr. Katerndahl “really laid the foundation for academic development and knowledge generation for what we do today. We are evidence-based and grounded in research. We evaluate and put that into practice.”
Dr. Katerndahl retired in September 2021 with 37 years of service to the university.
Until recently, Dr. Katerndahl was one of the few primary care physicians in the country funded by the National Science Foundation, Dr. Jaén explained. “Dr. Katerndahl’s studies on intimate partner violence used very advanced methods of complexity science to try to understand the patterns of what produces the violence and how you can prevent it.” He had more than 200 research papers and book chapters published throughout his career.
The recently retired physician-researcher created and established in 1995, while leading the North American Primary Care Research Group (NAPCRG) Committee on Building Research Capacity, the Grant Generating Project. The project was designed to equip family medicine and primary care researchers with the skills needed to successfully develop and submit grants for research funding.
“While it is no longer under his leadership, the Grant Generating Project is responsible for helping primary care physicians receive $1 billion in funding. To me, that makes him a giant in family medicine,” said Dr. Jaén, who decided to come to UT Health in 2001 because of Dr. Katerndahl.
In 2011, Dr. Katerndahl was awarded that year’s Maurice Wood Award, a lifetime achievement award for outstanding contributions to primary care research, from the NAPCRG.
Dr. Jaén said primary care today at the Long School of Medicine is committed to creating a healthier future for all patients, families and community members. “We are always innovating and inventing, but we do not work in a vacuum. We go beyond the clinic; we go to patients’ homes. We provide resources. For example, we have strong ties with the San Antonio Food Bank.
“We have terrific faculty who are motivated game-changers in addressing health disparities and health inequalities. We bridge the gap that can sometimes be the difference between life and death for our patients,” he explained.
Dr. Jaén said the Department of Family & Community Medicine also is dedicated to motivating medical students and family medicine residents to perform research to improve patient outcomes. Starting in 1997, the Residency Research Network of South Texas linked UT Health’s family medicine department with four family medicine residency programs in South Texas. In 2004, the program, now named the Residency Research Network of Texas (RRNeT), expanded to 10 residency programs across the state.
“RRNeT brings together residency programs from across Texas to perform research when and where a need is identified. These residents are finding the answers not in the laboratory but in the experience of patients facing illness or health disparities,” he said. “We are serving as a resource for the entire state.”
Dr. Jaén said the research and clinical work at UT Health reflects the resurgence of interest in accepting the value of primary care as a common good, which means everyone should have access to it. The National Academy of Sciences, Engineering and Medicine published this year “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” which Dr. Jaén had the opportunity to review prior to its release.
“We intend to continue to lead in this area. We need to get to a point where primary care is a first thought—not an afterthought. Everyone needs it, whether you are insured or not. The whole idea of the common good is an important part of this,” he said.
“As a leader in primary care at this institution, I am extremely thankful for the support we get from Dr. (Robert) Hromas (medical school dean) and Dr. (Carlos) Rosende (executive director of the physician practice). They understand the importance of primary care. In too many places, it is marginalized. Here we are part of the key strategic objective for UT Health Physicians. We want to make sure we do the best we can,” Dr. Jaén added.
Ramon S. Cancino, MD, MBA, MS, FAAFP, director of the Primary Care Center for UT Health Physicians, the physician practice of the Long School of Medicine, joined UT Health in 2017 and brought with him experience in health care reform, especially leveraging value-based care models to enhance delivery of primary care. He oversees six UT Health primary care locations in San Antonio and the surrounding areas.
Dr. Cancino, associate professor/clinical, said UT Health primary care physicians work in care teams to provide value-based care to all patient populations. “Nationally, health care is moving from a fee-for-service model of care to one that focuses on health care outcomes resulting from high-quality and high-value care,” he said. “For any organization to do well at value-based care, there must be a strong primary care foundation.”
The goal is for patients to develop a relationship with the health care system through primary care, Dr. Cancino said. “That is where a strong bond between patient, physician and health care system can grow because we focus on maintaining continuity of care,” he added. “Therefore, delivering the best care includes ensuring patients receive a high-quality experience while we care for them and have access to health care services when they need it.”
An example of UT Health’s value-based care model is UT Health Primary Care Center’s approach to the Delivery System Reform Incentive Payment (DSRIP) Program in Texas. DSRIP, a Medicaid transformation waiver program, incentivizes hospitals and providers to improve access to care and improve the quality of care for Medicaid enrollees and low-income uninsured individuals.
“We coordinated processes across multiple UT Health Physicians departments, including Quality and Health IT, to deliver value-based care in alignment with the state contract quality metrics. For the past two years, we received full valuation for that contract effectively bringing in new revenue and, more importantly, ensuring that patients who have some of the highest needs are getting the highest-quality care possible for health issues such as diabetes, hypertension, immunization, depression, and cancer screening. These results were sustained and the DSRIP work set us up to do value-based care for all of our patients,” he explained.
The next step was to create a care management program, Dr. Cancino said. “Using advanced data analytics and a state-of-the-art electronic health record, we identified and linked our highest-risk patients with nurse care managers who help patients and physicians achieve health goals. To do this, care managers coordinate care with hospitals, behavioral health consultants, community health workers, and other physicians,” he added. Physicians and support staff communicate with the care managers about patients multiple times a day, especially at times patients are at highest risk for poor outcomes such as after being discharged from a hospital.
An important component to Primary Care’s strategy was enhancing access to care. “We offer early morning, late afternoon, and weekend clinic hours and the option to have in-person or telemedicine appointments to ensure patients have multiple options to receive our care.” During the height of the COVID-19 pandemic, Dr. Cancino states the Primary Care Center started a virtual urgent care program, On Demand Urgent Care, which allows any UT Health Physicians patient the ability to access care instantly from home. “Primary care does not end when patients travel outside the four walls of the clinic. It continues to support and anticipate their health needs.”
Neela K. Patel, MD, MPH, CMD, chief of the Division of Geriatrics and Palliative Care, also saw the need and the success of changing the models of care in primary care and geriatric care.
“Geriatric care is primary care but also a specialty that is very integrated with hospital care and palliative medicine,” she said. “In taking caring of our patients, we need more help than just medication. We decided to start at the hospital because our patients are older and are frequently admitted to the hospital because of COPD, complications from diabetes, strokes, Parkinson’s and other comorbidities.”
By working first on their relationship with hospitals, the geriatricians were able to create lines of communication with hospitalists in all hospitals. “We do everything we can to keep them from having to go to the ED. We give them appointments the same day and do home visits. If patients really need to go to the hospital, we talk to the ED doctor and explain who we are sending and why. We make sure the ED doctor has our contact information,” Dr. Patel explained.
The UT Health team has created a list of rehab centers for patients to go to after the hospital stay, she said. “We also help patients who need home health care and hospice care at the end of life. We have developed personal relationships with companies in town that provide health care items, including hospital beds, oxygen and gel pillows. Our relationships help patients get what they need in a timely manner.”
Her team also does outreach and assists patients from the Mays Cancer Center, home to UT Health San Antonio MD Anderson, and the Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Disease at UT Health.
To better reach their patients—especially those with cancer and dementia who were impacted by the COVID-19 pandemic—Dr. Patel and her team implemented a new model of care that they call the CARINOS (cariño in Spanish means fondness or tenderness) Model and tweaked it to also be home-based.
Now called CARINOS en Su Casa (in your home) Program, the first letters in CARINOS represent: Compassionate care across all clinical settings, Advocacy for patients and families, Respect for what matters most to older adults, Intentional redesign of processes to meet patients’ needs, Nurtured relationships with families and community partners, Older adults are wise and know what they want, and Supportive care for the patient and family members.
“We took the program to the patient’s home because telehealth was not possible for many patients. They are technologically challenged or do not have the internet access needed especially in underserved areas. Now 50 percent of the practice consists of home visits, 45 percent outpatient and hospital, and 5 percent telemedicine,” she said.
“When you do the home visits, you are actually seeing what is going on and how they are doing. Given the culture we are in and the fact that 64 percent of our patients are Hispanic, some of them do not want us to come into their homes. In the CARINOS en Su Casa Program, we are using promotores (Spanish speaking community members who received specialized training) as a bridge. We started this last year with a Nancy Smith Hurd Foundation grant that we received to help us hire a community health worker.
“As physicians, we found these barriers when we went to the home visits. They sometimes didn’t want us to come or they don’t tell us what we need to know. We needed to understand this barrier and how we should provide culturally congruent care that is respectful. We hired a community health worker who lives in the area and has rapport with the patients and their families. They go with the physician to the home and then they go back on their own,” she said. Patients speak more openly and honestly to the community health worker (CHW) without the doctor there. Then the physician can be filled in and knows how to better care for that patient, Dr. Patel added.
Rebecca Jones, PhD, assistant director of the Institute for Health Promotion Research (IHPR) at UT Health, said IHPR Director Amelie G. Ramirez, DrPH, chair of the medical school’s Department of Population Sciences, helped develop the model more than 20 years ago showing that health care providers must understand the social determinants of health to try to remove barriers in order to improve patient care outcomes.
“We have done the research to prove that the promotores model helps holistically address the needs of our patients. IHPR has been able to refine this health model,” she said. “The work we do tears down the walls of the clinic and allows us to extend the clinic into the community.”
IHPR—which investigates causes of and solutions to the unequal impact of cancer, obesity and social determinants among Latinos in South Texas and beyond—has completed multiple studies over the years looking at the effectiveness of CHWs/ promotores in helping patients navigate the health care system.
UT Health Physicians turned to Dr. Jones and IHPR to share expertise already gained in working with CHWs and promotores. Traditionally, CHWs and promotores were embedded in the community or nonprofit organizations, she said. Now, they wanted to make them part of UT Health’s value-based care team. “We have a team of four community health workers who support the primary clinics and value-based care contracts.”
Dr. Jones said the community health workers and promotores with UT Health Primary Care are focused on the patients’ needs and barriers and serve as a trust bridge with the primary care team.
“When we reach out to a patient—whether for their depression, cancer screening or medication adherence—we are always asking questions to learn about determinants of health. We are trying to reduce the barriers so we can help providers with the shared goal of improving health outcomes.
“Together, with Drs. Jaén, Cancino and Patel, we can all use what we learned in research to further improve how primary care evolves for all of our patients,” Dr. Jones added.