Specialists and Medical Assistants are part of Population Care: Day 4, @KPNorthwest

Imagine that it’s 7 pm, you’re a patient in urgent care, or a health professional in urgent care, and you know or are told that you/the patient needs a pap smear to screen for cervical cancer. You/the patient is there for a lacerated finger. Would it/should it get done right there?

What if you’re a patient in cardiology or a cardiologist, and you know that you/the patient is behind on colon cancer screening. You/the patient is there to check out chest pain. Would it/should it get ordered in that visit?

On our last day at @KPNorthwest , we wanted to observe in a specialty care medical office and were directed to one with a novel patient care model – immunodeficiency/HIV at East Interstate Medical Office.

It’s novel because these specialty care providers have primary care providers in residence, not the other way around. In an orientation to the service by Colleen Finnegan, MD and Jim McDonald, FNP, I was updated on modern HIV care. It has gone from “patients who are dying to patients who are aging.” It is normal here for an HIV specialist to refer a patient to a primary care colleague for certain issues, and along the way create mutual understanding about the total health picture for a patient.

The Huddle

Primary Care Huddle, UNITE HERE!, New York City, 2008

We started the morning with the medical assistant / provider huddle conducted by Jim McDonald, FNP, who is a primary care provider and HIV specialist both, and Margot, one of the medical assistants on the team. I didn’t take a photograph to respect the confidentiality of the patient information around us, but here, I’m going to post a photo of a huddle from 2008 at UNITE HERE! in New York City.because it looked very similar. It was the proactive, prepared health care team, assisted with technology.

We saw the same panel support tool used in primary care, used in this specialty care environment, and the sentiment emerged from Jim that we have heard all week, that clinicians have the ability to know what a patient needs, and not forget.  Why should basic prevention needs be unknown in a specialty setting at the same time they are known in a primary care setting? They shouldn’t.

Knowing changes your view of when and where to practice population health

Both Margot and Jim work in urgent care settings, and something that Margot said was very interesting to me – she said, “My view has changed (since using this tool).”

She was referring to her work in urgent care, where the scenario at the top of this post might end with, “not this time,” but now could end with,”let’s do it,” based on her experience incorporating this tool into her specialty practice. I think that’s impressive, having the data changes things. She also wanted me to know, though, that the data by itself doesn’t change things – the support of managers is important, and for her, she said, “You really feel supported in bringing all of the care to the patient.” She also mentioned that in her experience, patients are enthusiastic about having needed preventive care as part of other visits.

The other thing she said that really impressed me was,”I was able to get up to speed in this specialty practice quickly, because I knew what we were tracking (via the PST tool).” If this tool didn’t exist, she said, it would be harder to know where in the chart to look for each patient that she prepped for the day’s work.

There are implications for recruitment, retention, and operational efficiency in supporting coordinated population care.

Specialized needs for specialized populations

I mentioned “basic prevention needs” above, and it is known that patients in specialty settings, like HIV, have more specific prevention needs, for example, women should have a pap smear every year, not every 3. Colleen explained to me that there’s new evidence that the HIV virus itself is implicated in heart disease, independent of HIV medications, so cardiac disease prevention must be monitored differently.

Situations like this will lead to variants of tools with different measures, same intent – keep patients healthy, have the ability to know, get to 100%.

Don’t forget to shadow nursing staff

Medical assistants Margot and Satya Chitty allowed me to spend time shadowing them in their population care work. They talked about how they are included in understanding the patient’s needs, and I watched as they used the panel support tool as a guide to prepare for productive visits (and other interactions, remember, this is Kaiser Permanente, virtual care is supported).

Elaine Crittenden, RN, reminded me so much of Roslyn Marshall, RN, from Georgia Health Sciences University, who I asked about how she adjusted to so much change in that system to integrate patients, and she just said,”There’s always something new to be done.” Elaine, Margot, Satya, Ruth (the other MA) had that feel.

There are places, many more than people think, where health professionals are excited by better tools that help them deliver not more care, better care, more comprehensive care, more respectful care.

Why we’re here anyway

I have to close with a reflection on my conversation with Colleen Finnegan, MD. Within a few minutes of meeting me she told me her personal story about why she wanted to care for this group of patients for as long as she’s been a doctor, and how she approaches a new generation of HIV patients, who, unlike our generation, have different models and experiences to draw from.  These are all challenging things.

As I was listening, I ran through names and faces of people / patients with HIV that I cared for / have known, too.

I am sure every health professional has a story or stories like this that brought them to the field, and that is why I still say that everyone in health care is an exceptional person by definition, they have to be for a job this challenging. What these tools/technologies teach us is that our patients are exceptional, too.

Portland, OR

This is my last post about the visit to @KPNorthwest to learn about population care (one more coming up about my visit to the Portland VA, another great integrated system). Thanks for a great week in a terrific system with great teachers. I wrote these posts because I think this care can be made possible for any patient in any health care system, let me know what you think in the comments.


Social Work and Pharmacy, Too

Attached is a comment from Diana Antoniskis, MD:

"I just wanted to highlight one thing that didn't get expressed in your blog and that's the fact that both Social Work and Pharmacy are INTEGRAL parts of our team-based care here in the IDC. In fact, I doubt if any of the providers could go a day (or even a few hours) without utilizing the services they provide to us and our patients. Our clinic was started over 20 years ago as a truly multidisciplinary team and I want to make sure everyone knows that we need the expertise of ALL the people on our team to provide excellent care to our KPNW members with HIV."

Agreed, and thank you for the great work and for having us!

I've been a patient at the Kaiser IDC clinic for15 years. Positive for 17 (but the first two were the monotherapy AZT years…) The care and attention to detail this clinic shows is amazing. They once called me just to let me know I need more iron and suspected I must be a vegetarian and suggested iron supplements. They keep me tuned up like a racing touring car 🙂

Strange thing is that HIV folks in this clinic are often healthier than the general population.

I love my HIV docs. Thanks for keeping me alive and healthy!

L D,

Thanks for taking the time to add your perspective about staying healthy with good support. I love the analogy!


Ted Eytan, MD