We know how to be patient-centered, we just forgot

If you ask any random person on the street who the healthcare system is built around, they are likely to tell you many things, but very few of them will tell you the system is built around the patient.

The current delivery system is costly, does not excel at outcomes and is unsustainable in its fragmentation.

But it hasn’t always been this way. Tom Sherlock continues to find brilliant gems of history that show how some of our very first healthcare systems were built to support the right things – mainly the needs of the patient and the community. One example is from the Sisters of Saint Francis of Rochester, Minnesota who chose to adopt the philosophy that “the needs of the patient comes first”. When a tornado struck Rochester, the Franciscan Sisters provided care and saw the need for healthcare. According to their website, one Sister convinced Dr. William Worrall Mayo (Yup, that Mayo) to serve as director of a hospital to be built by the Sisters. They saw the communities need and did something about it.

But think about this for a second. There was never any question as to who should come first when there were healthcare needs in the community. The first question asked was not “how can we maximize volume to increase our revenue?” Nope, these Sisters built their entire system around the needs of the patient. This was natural to them – this was the right thing to do.

In our current system, it is almost impossible to build the system around the patient.

From an article I co-authored with Dr. Kavita Patel in the British Journal of General Practice:

“Elevating the patient to prominence within healthcare is fraught with complications that often have more to do with the US’ historical healthcare fragmentation than the desire to have patients more involved. Primary care, as the largest platform of healthcare delivery in the US is currently being modified through the lens of the patient-centered medical home. This change has helped underscore the central role of the patient and community in healthcare.”

But as I point out above, the problem of fragmentation has not always been present. Where are there opportunities to draw more attention to the patient in our current system?

It seems like the patient-centered medical home (PCMH) is just as good as any place to start. Again, from BJGP:

“The medical home can be the vehicle by which healthcare becomes more patient-centered. Will providers, payers, and policy makers take advantage of this opportunity to extend our knowledge around how we can further engage the patient in decisions that impact their health, or will there be increased resistance from providers who might be threatened by a loss of autonomy or financial risk? After all, the name chosen for this redesign was the ‘patient-centered medical home’ not the ‘provider-centered medical home’.”

It appears that within the context of the PCMH, we have an opportunity to enhance patient-centered care by fostering an environment of respect between that patient and the provider. This environment can allow for patients to be more active and involved in their care; an environment where we may see more “shared decision making” happening.

In a nice summary article on the PCMH, Holly Korda outlines the issue and then asks an important question:

“One of the key features of medical homes is a focus on coordinated, collaborative, continuous care.  Primary care practitioners, specialists, nurses, and other health care professionals are expected to work closely together in “flat” teams that discourage medical hierarchy and encourage cooperation, collaboration, team work.  This team is supposed to include the patient as an active participant in healthcare decision making.  After all, care in the medical home is patient centered … or is it?”

In one summary of the largest national demonstration project on the PCMH, authors conclude:

“The PCMH represents the essentials for better primary care, the improved delivery of chronic care, and active partnership with informed patients synergized by appropriate use of information and communication technology. Nevertheless, the PCMH model is still evolving and will need adequate capital funding from a combination of federal, state, local, insurance industry, and health system sources.”

So while we still have a system built around the wrong things (see here for an example), there do appear to be opportunities to bring our system back to the place where it all started – back to a place where systems were created around the patient, the community and their families. Oh, and did I mention that patient-centered care is associated with decreased healthcare utilization and lower total annual charges? – kind of important in the current healthcare milieu.

Let’s remember the Sisters’ philosophy of “the needs of the patient comes first” in any and all we do in healthcare. This philosophy should come first and drive our conversations, our decisions and challenge us to create the system we all deserve.

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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  • http://www.planetree.org/ JoelHigh

    The PCMH is an amazing concept! I believe that we need to work tirelessly to create a more patient centered healthcare system all around. Currently efforts are ongoing in acute care hospitals and long term care facilities in both the private sector and the VA system to transform our healthcare system. But as we transition to a system that is designed around preventative care and wellness it will become more critical that primary care is patient centered. The VA is redesigning its primary care around the model of Patient Aligned Care Teams (PACT) which is based on the PCMH model. They are having great success especially in places like Dallas Texas and specifically with OEF and OIF Vets. Clearly there is much work to be done but your post shines a bright light on the work that has been done and that still needs to be done.

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