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Posted by Ishani Ganguli September 5, 2013 11:30 AM
Chidimma Ozor calls Valerie for their twice-weekly check-in.
"How’s it going? How have your sugars been?"
"Not great. I checked first thing this morning and the meter just said 'Hi.'"
"What did you eat for dinner last night?"
Chidimma perked up. "Green?"
"Not so good."
Valerie feels dizzy. She can’t see right, she has no appetite, and she’s been vomiting for the past few days. Chidimma hands the phone to me and after a few more questions, I’m on board with the plan she’s communicating loudly with her eyes: bring her in.
Valerie, 57, is a former hotel guest room attendant and a longtime smoker. She has high blood pressure, high cholesterol, diabetes that she struggles to control, and failing kidneys that her nephrologist told her will soon require dialysis. But she also has Chidimma, the health coach who has been helping her manage these problems, and the rest of her primary care team at the Culinary Extra Clinic (CEC) in Las Vegas.
An hour after the phone call, Valerie makes her appearance at the clinic. She's strikingly tall with large, trusting eyes and a gravelly voice. As we walk her to an exam room, I notice that her swollen ankles spill over the tops of her white tennis shoes. She sits patiently as we fuss over her, checking her blood sugar (still "Hi") and her blood pressure (low for her). Within ten minutes, her doctor brings in a transport team to get her to University Medical Center, the hospital that knows her best from a recent admission.
I spent the past week and a half with the Culinary Extra Clinic, one of the earlier runs of Iora Health’s ongoing experiment with direct primary care. I wanted to learn more about Iora’s care model, one that shares some similarities with the clinic where I work but is targeted to unique populations. http://www.iorahealth.com/practices/
The Cambridge-based company, co-founded by Dr. Rushika Fernandopulle and Christopher McKown, opened its pilot practice in 2007 for local casino and hospital workers in Atlantic City. On the opposite side of the country, the Vegas clinic sits across the highway from Denny's and Carl's Jr. burgers, on the north end of the Strip where most of its patients earn their livings. Since February 2012, the CEC has contracted with the health fund of the Culinary Workers Union to provide primary care for some of its sickest members - 1100 or so to date. To enroll, patients must have chronic illnesses like heart disease or a history of frequent hospital visits.
Similar to other Iora practices that have since opened across the United States, the Culinary Extra Clinic charges the fund a flat monthly fee for each patient, eliminating the paperwork required (and perhaps the perverse incentives inherent) in billing for every service. This also means that its interdisciplinary team can be creative in the ways it delivers care. There are the ever-popular Zumba and yoga classes. The clinic offers frequent and varied touch points (texts, phone calls, in-person visits) with health coaches like Chidimma as well as with the family practice doctors and the clinic's social worker. The health coaches, in particular, are a unique strength of the Iora model. They seem to play the composite role of medical assistant and community health worker. The coaches have diverse backgrounds - one was a former Spanish translator for the governor of Nevada, another worked in the culinary industry herself - and are trained on the job.
Though results are still pending on the Las Vegas experiment, the Atlantic City site demonstrated early successes with patient experience of access to care and staff communication as well as with managing chronic illness. Patients who enrolled with markedly elevated blood pressures dropped their pressures by an average of 40 points after a year with the practice. Nearly fifty percent of smokers quit in the same year. The clinic even calculated that total health care spending dropped by 12.3% compared to a similar population, which it attributed to fewer hospital admissions, emergency room visits, and outpatient procedures.
Such outcomes seem to stem, in part, from a shared understanding at Iora that their patients have difficult lives that are impossible to untangle from their health. Effective care, it follows, hinges on strong relationships and close communication. I was impressed, in particular, by the CEC's efforts to address the entire spectrum of primary care from preventive health to the end of life, especially at the seams - the care transitions - where patients are at their most vulnerable.
In Vegas, every morning begins with a "huddle" rung in by the day's volunteer leader with the refrain: "Who needs our help?" Team members sit at a cluster of tables facing a wall-mounted flat screen monitor, their MacBook Air laptops open to Iora's in-house electronic health record. The nurse innovator pulls up the "crisis list" and each patient's health coach or doctor pipes in when a name is called. One patient has all but moved to California and a health coach threatens, only half joking, to scoop her up in her car and bring her back into CEC care. Another is in the intensive care unit of a local hospital fighting an uncurable cancer - he and his wife had been on the brink of choosing hospice care and his coach now calls them daily to gently re-introduce such options. Valerie is on the list - she was admitted to UMC, as we'd expected, for a complication of her diabetes. She's feeling much better and will be discharged the next day.
The clinic is smoothing out some of the wrinkles inherent in a practice that sees 40-70 high-risk patients daily: When the team began offering walk-in visits, wait times for these visits as well as for scheduled appointments grew unsustainably long. So the clinic's medical director, Anjali Taneja, created a separate team including a doctor and two health coaches to focus on the walk-in visits (they are still working out the details). Not having walk-ins was never an option, however: in focus groups, patients said they loved the flexibility of these visits and they understood if a doctor was delayed taking care of bigger emergencies.
Valerie comes back for a post-discharge visit on my last day at the clinic. She is wearing gold hoop earrings, a sky blue t-shirt, and a smile that she hadn't been able to muster the first time I met her. We encourage her to attend the diabetes diet class run by one of the docs in the clinic. Chidimma promises to call in a few days to check on her blood sugars and her new nicotine patch. Valerie stands up to leave for her next appointment and we wish her the best, knowing that (at least for Valerie and her care team) this is far from goodbye.
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About the authorIshani Ganguli, MD, is a journalist and a third-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She studied biochemistry and Spanish at Harvard College and received her More »
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