Editor’s Note: Iora Health was named 2016 John Q. Sherman Award for Excellence in Patient Engagement winner for Dartmouth Health Connect, an innovative project that is transforming the way healthcare is delivered. The model has eliminated fee-for-service and is transforming traditional care: Instead, the practice focuses on building partnerships and deep relationships with patients. Their efforts are getting remarkable results as you’ll read below. To learn more about Iora Health’s Dartmouth Health Connect, read their complete Sherman Award nomination.
When Mary first presented to our primary care practice, burdened by chronic illnesses and jaded by long-standing challenges to effectively self-managing these, she frankly acknowledged her lack of trust in conventional health care, and more concerningly her loss of faith in her own abilities.
Weighing close to 300 pounds, living with diabetes that was poorly controlled (despite large requirements of insulin spread across multiple daily injections), feeling “judged” and even de-humanized in prior clinical settings and also judging herself negatively in the context of perceived past failures, Mary had little confidence that her new care team could support the kind of personal transformation that she so deeply needed and desired.
But our primary care practice, Dartmouth Health Connect, was established by Iora Health in 2012 upon the core conviction that personal health transformation is indeed possible–though this depends upon a model of health care delivery, which is also fundamentally transformed.
We all recognize that the present U.S. health care system is deeply challenged in its capacity to meet both the illness and the wellness needs of individuals and communities. “Fixing” this system requires more than small adjustments at its periphery. Rather, clinical care in general, and primary care in particular as a centerpiece of any effective system, must be re-built from the ground up, with robust and empowering relationships as the very foundation of this re-build. The vision of Iora Health is to restore humanity to health care and our ambitious mission is to transform both health care itself and also the individual lives that health care serves, through a new model of high-impact relationship-centered care.
An Invitation to Transcend Traditional Barriers
As she subsequently shared with us, Mary very quickly appreciated our invitation to partner with her in a respectful, collaborative and truly creative manner. She perceived our willingness–indeed our intent–to remove system “barriers” which traditionally have stood between patients and their own engaged empowerment.
The first barrier to fall was a financial one. Transformation of care begins with transforming the business model that supports this care. The very nature of fee-for-service payment runs counter to the goals of wellness-focused primary care, so we have fully removed fee-for-service from our new model.
The great majority of our patients are employees (or family members of employees) of Dartmouth College, which as a self-insured organization and also as the second largest employer in our region, bears ultimate responsibility for the health care costs of its employees. We have formed a value-driven partnership with the College, providing “capitated” primary care to all eligible employees and dependents. Dartmouth pays us a straight per-member-per-month fee, in exchange for which we provide full primary care to all members with no billing to our patients. We see individuals once per year or fifty times per year or at whatever frequency is most appropriate in each case, to ensure highest quality, optimally accessible and most personally engaging care.
For Mary, this means no financial paperwork, no co-pays, indeed no charge at all for any service we provide within the four walls of our primary care practice. This altered payment structure shifts our clinical interactions from transactional to a truly relational experience that is enthusiastically embraced by our patients, who perceive the removal of financial barriers as an obvious invitation to deeper engagement. The model also is highly valued by our care team. Altered payment does not, in itself, solve the perennial problems of health and health care, but it frees us up, together with our patients, to apply our creativity to better address those very problems. It permits us to shift our attention away from the traditional fee-for-service “needs of the visit” (“what must I do to bill most aggressively etc.”) and instead toward the relationship-focused needs of this patient (“what can I do, in the office or in groups, or by phone or video, or during walking visits or home visits, to meet Mary’s specific needs?”). Imagine the possibilities!
Health Coaches and Expanded Relationships
Among the new solutions we can creatively deploy, our most essential is our use of embedded health coaches. Like every new patient at Dartmouth Health Connect, Mary was assigned a personal health coach at her first visit. Coach Lisa is not an external consultant but an integrated member of our care team, hired for her core empathic skills and charged specifically with eliciting Mary’s personal wellness goals (“I want to lose weight. I want to get off this insulin. I want to feel better about myself,” Mary reported). By partnering with Mary over time to gradually achieve these goals, Lisa utilizes motivational interviewing and shared decision-making techniques, combines these with content knowledge in specific health domains and integrates all the above with deep compassion and interpersonal sensitivity.
With Lisa’s prompting, Mary identified some early behavioral targets that she felt to be achievable. These involved small changes in the carbohydrate content of her diet and a commitment to brief walks during lunch hour. She checked in frequently with her health coach, sometimes via 1:1 meetings in person and other times by phone or email. Occasionally, they would meet for a mid-day walk on campus together. In addition, the three of us together (patient, coach and clinician gathered around the same table) would discuss therapeutic adjustments during interval meetings of our entire triad. With time, Mary has grown increasingly motivated to monitor and to record her blood sugars throughout the day and to adjust her own insulin dosings based upon increasingly bold modifications of diet and activity. These safely supported “experiments” also have impressively enhanced Mary’s trust in her own capacities. In addition, our varied meetings provide opportunity for broader exploration of Mary’s values, care priorities, and emotional responses to evolving states of both illness and wellness.
Mary thus experiences an “expanded” care team where she feels deeply “known” and fundamentally respected by both her doctor and her coach. Patients do indeed feel known here and are both figuratively and literally embraced as “who they are.” Walk through our practice and you’ll witness warm handshakes evolving spontaneously into hugs. You’ll hear team members cheering aloud with patients when goals are achieved or are even approximated. Our staff celebrates “small victories” daily and intentionally during morning huddles.
Other Building Blocks of Engagement
Those huddles are another design feature which our new model permits and indeed upon which that model depends. Our team meets for a full 30 minutes each morning with leadership of the session rotated among staff members. In addition to honoring the small victories aforementioned, we review in detail our “worry list” of patients of active concern. Who may have been hospitalized or seen in the local emergency department? Who is struggling with acute family stressors and will benefit from new forms of support? Who needs a phone call or video check-in and by whom?
Recognizing the potential health burdens of personal isolation and also the power of positive affiliations to support wellness-oriented behaviors, we also run regular patient groups (to which families and friends are invited) on diverse themes, toward realization of self-care goals. Groups may focus on weight management, yoga, mindfulness meditation, advanced directive planning or other themes. Patients now feel comfortable not only participating in but also leading a number of these regular groups.
In addition, we sponsor a “Patient Advisory Group,” comprised of representative practice members whom we convene over dinner on a quarterly basis to advise us regarding community needs and new opportunities for practice innovation. We’re especially heartened to hear participants express their sense of co-ownership in our shared work, which applies not only to improvement of patients’ personal health but also to optimization of our service model itself.
We’ve endeavored to quantify the early results of our shared initiative. At a practice-wide level, clinical measures of chronic disease management have indeed improved and reports of patient satisfaction (and delight!) are gratifyingly high. Patients’ costly utilization of emergency room visits and hospital admissions have meanwhile trended downward (much to the happiness of not only patients themselves but also their employer and ultimate payer, Dartmouth College).
But the individual stories of patient success remain the most heartwarming reflection of our shared efforts. I’ll never forget the day when Mary lost her 100th pound! (Yes, her weight is now well below 200 pounds!) She looks and feels great. The warm glow in her eyes is contagious to passers-by. Her blood sugar levels have come down dramatically as have her insulin requirements. Indeed, from initial daily requirements (when we met her) of greater than 100 insulin units per day, she has weaned herself down (as of today’s blog post) to a mere two units per day and she is fully confident she’ll be insulin-free by the start of summer.
This last feature, Mary’s improved self-confidence, is for me the most compelling dimension of her ongoing transformation. She is lit up, alive, in a manner that she hasn’t experienced in years. And this newly manifested engagement–this deeply embodied empowerment–will carry Mary to further accomplishments she’s not yet even imagined.
Indeed, this light in her eyes, like a gift given back to those of us who have partnered with her, inspires us–her care team–to engage more deeply as well so that a virtuous cycle is created. Mary’s personal journey toward health transformation and our parallel team journey toward health system transformation are experienced excitedly by all of us as continually and mutually reinforcing.
This article is a great example of patient engagement. I member of a national patient organization, which advocates and educates renal patients. Trying to articulate the benefit of building trust and a relationship with patients is a concept that is contrary to the nature of the dialysis center business model. While I am a transplant patient I teach business strategy courses at a local university. The reimbursement is based on a bundled payment that is driven by providing in center hemodialysis three times per week for fours hours (max) per patient.
An integrated care model would be much more effective that would address ALL of the health needs of the patient. Home dialysis allows for more frequent and longer dialysis sessions but is contrary to the business model which produces much more revenue. Patient outcomes from home dialysis are much better. I am hopeful that the model you implemented will take root in the renal community and patient choices and patient outcomes become the priority. I applaud your efforts and your wisdom in documenting the results. Keeping the patient as the priority, in the long run, is what healthcare should be all about.