Achieving practice improvement with whole-person care

Most clinicians in primary care understand that the future of American medicine is already upon us. Old models of care are being squeezed out and new requirements imposed.

One of the most sweeping changes in policy, practice and payments is to move us rapidly away from the fee-for-service toward value-based care. While this transition is hard, it may also be an opportunity to strengthen person-centered care and raise revenue.

But what we don’t know — and what frightens many of us — is this: How do I go about changing my practice in the fundamental ways required to adapt to a quickly shifting reality; and how do I protect myself and my practice from financial peril during this unprecedent transition?

Make no mistake that we as providers cannot ignore this upheaval, and our inaction will likely lead to stagnation and loss. But more resources are available today than even a year ago to accomplish this work.

The vision of the future of health care is laid out in a 2021 consensus study by the National Academies of Science, Engineering and Medicine, which declared that to practice high-quality primary care and create genuine population health, then we must practice whole-person care. This is not just another report; it is a blueprint for primary care that will soon be mirrored by Biden administration policy and payment changes.

The research cited by NASEM and others makes clear that the kind of care we provide in a typical medical office contributes only about 15% to 20% of overall population health. Why? While our practices are set up to treat or control disease, we are not set up to help patients improve their overall health and well-being. All of us, every day, see the negative impact of lifestyle, behavior and the social determinants of health that drive many chronic diseases.

Most of the conditions we deal with day in and day out such as obesity, diabetes, hypertension, CVD or chronic pain and mental health conditions need behavioral and lifestyle approaches to significantly improve. To create health, we need to fill our medical bag with the tools and resources that effectively impact the causes. A treat and street or pill and procedure approach that is encouraged by fee-for-service models of payment keeps us from addressing these causes.

This month, the Center for Innovation in Family Medicine (CIFM) and Tufts University School of Medicine Office of Continuing Education (TUSM OCE) released an online CME course to assist practitioners who are looking for ways to improve whole person care. They have created a dynamic step-by-step guide to achieve the goal of “practice improvement,” refreshing a medical practice and helping your team to reinvent the way we treat our patients.

This new course, “Implementing Integrative Health in Primary Care,” teaches how we can effectively address the drivers of health and enables participants to earn CME credits. Moreover, this type of CME is crucial to maintaining primary care licensing, due to the new requirement many physicians now must document practice improvement and demonstrate that they are implementing new procedures.

The days of recertification requiring only answering multiple-choice questions are becoming a thing of the past. But CIFM and TUSM OCE’s course covers far more than just keeping your license. NASEM’s study of primary care concluded that effective whole-person care not only increases patient satisfaction, but also can reduce physician burnout that plagues too many of us.

If those factors don’t motivate you, consider that Medicare and other payors are reducing their payments for services, but they are also beginning to offer generous incentives to those practices that create processes to address whole-person care. These changes will force us to change the way we practice medicine. The course focuses on overcoming three common factors that have prevented meaningful change: basic inertia, the need for behavioral change, and the fear of financial loss.

CIFM and TUSM OCE’s five-module curriculum provides clinics with specific common-sense tools that have been demonstrated to be effective in practice improvement. A fundamental means of starting the process is to rethink your basic interactions. I suggest you begin by asking your patients to complete a brief Personal Health Inventory, a practice adapted from the Veterans Health Administration’s highly successful Whole Health model that has been adapted and used in non-VA primary care practices across the country and has been demonstrated to substantially reduce costs and improve patient satisfaction. The assessment begins by asking patients to rate their physical, mental, social, behavioral and spiritual health on a scale ranging between “great” and “miserable.”

My patients have embraced this approach because the inventory also asks them to write some thoughts on their motivations for health: What do you live for? Why do you want to be healthy? From there, the patient-clinician conversation can transition to specific behaviors and lifestyle factors that they might want to change. This often opens the discussion to options such as diet, exercise and sleep, stress management and mind-body practices, and other non-drug treatments such as acupuncture and manipulation.

In my practice, this conversation can be part of an annual “integrative health visit” that addresses the personal, social, behavioral and environmental factors that cause most chronic diseases. This visit helps patients clearly identify the goals and behaviors needed to accomplish those changes. It also deepens my relationship with patients and provides a way for physicians to bring joy back into practice and, increasingly, also get reimbursed for the time needed to implement this approach.

New models are also available for teams to help patients reach their goals — and these team-based innovations are increasingly reimbursable: health coaches provide evidence-based guidance and motivation. The use of psychologists, social workers, nutritionists and fitness coaches can revolutionize practices, either in person or via telehealth. Online educational resources, new apps and tracking devices are useful for aiding behavior change. Group visits are an excellent option for patients with chronic conditions, providing peer support and team learning. And they are increasingly reimbursable.

I know this can sound overwhelming, but these are time-tested practice improvements that create advanced primary care and focus on the whole person — exactly what the NASEM primary care report calls for. These innovations can be effectively implemented in all clinical settings, from large, enterprise-size health systems to small private practices. Yes, change is not easy, but it starts by taking small steps. Move into the future, one step at a time.

References:

• Clinician as a healer in primary care: Introducing whole person care into your practice. https://healingworksfoundation.org/clinician-as-healer-in-primary-care/. Accessed Feb. 10, 2023.
• Implementing high-quality primary care: Rebuilding the foundation of health care. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care. Accessed Feb. 10, 2023.
• Whole health. https://www.va.gov/wholehealth/. Accessed Feb. 10, 2023.