Providers moving toward a value-based care system are finding success in engaging patients by applying the best-practice experience from primary care physicians (PCPs), as summarized in Lumeris’ Accountable Primary CareSM Model, also known as the Nine C’s®. A powerful, proven framework for delivering the Triple Aim Plus One—better health outcomes, lower costs and improved patient plus physician satisfaction—this model embraces the four pillars outlined in the Institute of Medicine/Starfield model and expands them into Nine C’s of Accountable Primary Care Delivery.
In my previous blog, I discussed the first three C’s, focusing on the importance of first Contact, Comprehensive and Continuous care. In this blog, I discuss the next three C’s that cover advocating for patients, building credibility and collaborative learning.
C4—Coordinated care: Advocate for patients at every care transition.The PCP should let patients know he or she wants to make this system work well. That includes protecting patients from care that they do not need, and, when necessary, referring them to facilities and specialists with whom the PCP would entrust his or her own care and that of family. The PCP and care team can discuss how they will follow the patient’s care, be their advocate, and help them and their families understand every step of the way. The PCP and care team can also ask them to alert the office to any coordination concerns so that they can be solved.
C5—Credibility and trust: Adapt your behaviors and communications to build trust.The PCP should invite questions at each interaction and use tools that gather the patient’s perspective, helps set goals and manage expectations. The PCP can also take visible steps to help patients reduce anxieties, resolve ambiguity and become ready to follow care plans, such as providing notes at the end of visits for their use at home. A letter that spells out commitments, expectations, and recommendations for an accountable primary care practice can also be given to the patient. Many patients accustomed to fee-for-Service care have no idea how much their PCPs want to be engaged in their care, and the important role of family as the PCP’s eyes and ears (early warning system).
Dr. Thomas Hastings, an accountable care internist, says “I always try to dig deeper than their ostensible agenda. Several times throughout the visit I ask: ‘Is there anything else?’ I try to do more listening than talking. I try to make the patients feel that they have been respected and heard.”
C6—Collaborative learning: Share educational tools and recommend reliable sources. The PCP should explain how he or she collaborates closely with the health plan and that questions about information the patient receives from their plan are welcome. The PCP and care team can talk about how they monitor and share information about safety, quality, processes, prices, costs and outcomes of care, and provide tools that engage patients and eliminate complexity, such as Healthwise clinical content that Lumeris makes available to clients’ networked physicians.
Care teams should coordinate care for their patients that is comprehensive, including managing any necessary transitions. Patients and family members are valuable in this exchange, especially for chronic conditions. Credibility is extremely important with patients, and too often, physicians overlook the importance of patient trust because they simply aren’t incentivized to care. Finally, patients need information that they can understand and follow, and care teams that have the tools that are easily available to provide patients with what they need.
In the next blog, I will discuss the final three C’s that focus on cost, capacity and physician and patient satisfaction. As you can see, all of these C’s are building to how Lumeris helps clients achieve their population health management solutions based on the Triple Aim Plus One better health outcomes, lower costs and improved patient plus physician satisfaction.