Tuesday, February 4, 2014

What Happens When No One is There to Coordinate Your Care?

We often don’t realize how important something is until we need it and we don’t have it. It is very helpful to have someone, or even better some team, to coordinate your care when you have a medical problem and multiple care providers who may have differing opinions of what you should do. I was reminded of how important having a primary care physician and his or her team (like the patient-centered medical home) can be for patients when I recently went to visit a woman who is a close friend of a friend when she was admitted to the hospital.

This individual had an acute medical problem but did not have a primary care physician. So, when she found herself acutely ill, she decided to visit an urgent care center. Since she did not have a problem for which she could get a quick prescription for an antibiotic (the forte of urgent care centers), she was told to go to the Emergency Department. Once in the ED, she was assessed quickly and had a number of tests, but her diagnosis was not clear and she was in significant pain. She was admitted to the hospital for observation and more consultations. She was discharged feeling better and with the belief that she didn’t have a life threatening problem. But she was discharged clearly in need of someone to manage her ongoing care which included appointments with a number of specialists.

Who will now reconcile the varying opinions of specialists that she will see? Who will serve as her guide? Who will filter the specialist opinions through the lens of other things going on in her life?

Oftentimes, people don’t understand the importance of being connected to good primary care until they need it most. Urgent care centers fill the need for getting in and out. They exist because the economic model makes sense to insurance companies - the companies pay Urgent Care Centers less than they pay Emergency Departments. It is also true that they pay Urgent Care more than they pay your doctor for the same visit (which is one of the reasons why primary care offices have not historically stayed open late). But the Urgent Care Center doesn't have your records and they have no ongoing relationship with you. They don’t know you. 

Primary care physicians practicing in the patient-centered medical home now have more resources to actively manage the health of their patients. They have teammates including nurse care managers and care coordinators who can help connect things and make it easier for the patient to make the best decision. The team is available into the evening and via the patient portal also during the night. They have all of the patient’s medical information and can make sure others have it when they need it. (Had the patient that I visited been a patient of one of our medical homes the GBMC ED physician would have been able to see her history). The physician is the captain of the team but the other team members play important roles by coordinating patient appointments, ensuring patients stay on their diets or on course with a medical regimen to optimize chronic conditions; and others help with prescription refills, referrals, and more. A recent article in the New England Journal of Medicine calls the patient-centered medical home “advanced primary care.”

Had the patient that I visited been in one of our medical homes she may have still needed the hospitalization but it would have progressed more smoothly. And, although she still would have been in pain, she would not have had the added anxiety of navigating through the maze on her own.  On discharge, it would have been clear who was going to be there for her.

So, the case of my friend’s friend is a prime example of why it’s beneficial to have a primary care physician who practices in a well-designed system to coordinate your care. You never know when you will need it.

In the coming weeks, I’ll be talking to patients, care managers, physicians and care coordinators at some of GBMC’s patient-centered medical home practices to see just how this system is working to treat everyone the way we want our own loved ones treated.

Have you had experience with this system of “advanced primary care?”

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