The last day of a shadowing experience is always a little like a graduation – it’s where you’ve slept on what you’ve seen (which is why it’s important to spend more than a day shadowing), and then you watch things come together at the highest level of the health care system, where the patient is.
On day 3, we went to one of Kaiser Permanente’s newest medical offices, in Parker, Colorado, where we shadowed Brent Arnold, MD, who’s an internal medicine specialist that thinks more like a family medicine specialist (in my opinion).
We ended our day meeting with John Merenich, MD, the parent of Colorado HealthTRAC and his team to discuss what we saw and learned.
The Care Gap revolution
The phrase in the title of this post was expressed to me first by Sean Riley, MD, on day 2, and then embellished by Brent. Here, they are identifying care gaps, dissecting them, using them to measure their success as doctors, and working to eliminate them.
The term “care gap” describes any missing recommended care either in prevention of illness or management of chronic conditions. It’s been known for some time that Americans typically receive about 55 % of recommended care (!) the rest have gaps. I don’t see a lot of discussion in non-integrated health care about closing these gaps, or even that they exist. Instead, it’s still the drive to see more patients, to take care of more acute problems (“whatever comes in the door”).
In my visits to Portland and Orange County, I heard about care gaps and closing them a lot, and now at Colorado, I finally had the “a ha” that this has been a slowly building change in thinking, and now it’s a full revolution. It’s happened because of (a) the ability to know about patients in an integrated care system and (b) the ability of patients, nurses, doctors, and the health system to innovate together.
John Merenich verified my “a ha” with what he’s known for a long time, by reciting the mission statement of his team, which is “Deliver Knowledge about Care Gaps and Care Gap Solutions for any Member Population.” I am not that smart and my ideas are not that unique, after all :).
Here’s what it looks like to me:
Physicians marginal, Teams phenomenal – we learned at our time with this team that the most dedicated physician can probably be 50 % successful in addressing care gaps. There are just too many other places and ways they could be addressed in the practice and health system, and why would a physician not want to take advantage? In a team based model, physician, nurse, medical assistants strategize about the entire problem (people having care gaps) and figure out how to inform patients, how to close care gaps.
Part of every interaction – Brent had 10 years of experience in the hospitality industry before becoming a physician. He said that not addressing care gaps is like “not filling up their tea after it’s half empty.” The drive then, is to think about an interaction as incomplete unless care gaps are addressed. Ask yourself about your last physician visit or interaction with the health system – were you informed about what your care gaps were and how to solve them?
Focusing on those who come in to be seen won’t close care gaps for an entire panel – At Parker Medical Office, Brent tells us how his team is running multiple PDSA cycles to understand how to close care gaps for as many people as possible. He says, “If you focus on only the patients that come in to be seen, you’ll help 100 patients a week, that’s not enough.”
I sat with the desktop medical assistant as she called to tell patients about requested medication refills. In each conversation, care gaps are mentioned – “I see you are due for a mammogram, can we schedule that for you?” I asked what that feels like, to bring up a topic that seems unrelated to the reason for the call. I’m told that mammography is a little bit harder to discuss, mostly because of the perceived discomfort of the procedure itself, but overall, not difficult. They are tracking the response to the messages given via phone, as well as secure e-mail on kp.org, to see if care gaps are getting closed. They are.
The emergency of the heart attack is being replaced by the urgency of the care gap – The way they organize around them is telling – they created an acronym in their PDSA’s: CLOT, which stands for “CLick, Order, Tell (Inform)” – Click into the population care system to review care gaps, order needed tests, inform the patient. The analogy is a clot to stop the bleeding that comes from care gaps that are unattended to.
Midway through our conversation, Brent says, “I know I’m preventing heart attacks!” And…he’s right. they are:
So the thing that American health care can be so good at, rescue care, emergency care, can be redeployed toward preventive care, to keep people well before they get sick, to save lives.
Watching in the context of patient care
I shadowed Brent and his medical assistant Amanda, as she roomed patients, addressing their care gaps, then with a follow-up as part of the visit by Brent. I’l say that these conversations are not always easy, especially when a patient has not been engaged and may have multiple, potentially life threatening, care gaps.
However, they ask, every time. And they keep asking, because eventually the mammogram does get done, the colon cancer screen is turned in. And even in the asking, the patients say meaningful things about how they see their health and where it’s going – things that would not have been brought up if their care gaps were not brought up – the care gap conversation creates a space for listening to patients, too.
On the last patient that Amanda roomed, we walked out and she said, “This patient didn’t have any care gaps, sorry I couldn’t show you how I handle them this time.” I said I think that’s more of a cause for a congratulations than an apology, and great to learn what it looks like and feels like when patients can be successful in being healthy.
This is the last in the series of posts from my visit to learn about population care in the 21st Century. Thanks a ton to the members, staff, nurses, physicians of Kaiser Permanente Colorado (@KPColorado) for being such willing educators and excellent performers.