Norwalk – Rebecca Mizrachi has a new opening line when she sees a patient: “How can I help you today? What do you want to talk about?”
The open-ended greeting, with a nod to customer service, is a subtle change. But it’s not all that’s different about how the Norwalk Community Health Center family nurse practitioner practices medicine.
She’ll now spend 40 minutes with certain patients – those with multiple chronic diseases or dozens of trips to the emergency room in recent months.
They talk about the patient’s goals, broadly; “going back to school” might come up in conversation before the patient’s hypertension. They talk about barriers to reaching those goals, such as not having transportation or child care – things that aren’t medical but could play a role in whether the patient shows up to appointments or gets prescriptions filled.
And outside the visit, Mizrachi will meet with others who work with the patient. The patient’s “care team” is viewed broadly, including professionals from the local hospital and, in some cases, a case manager or probation officer.
It’s part of the health center’s WeCare program, an initiative launched last year as a pilot program. It’s still in its infancy and small; as of December, 44 patients were receiving active case management.
But in shifting how care is delivered, the program has implications for how the health center treats all of its patients – and it’s an example of what a major, ongoing change in health care delivery could look like, a shift that could, ultimately and in varying ways, affect all patients in Connecticut.
It’s a mix of new technology and data analysis – identifying which patients need higher levels of support – and old-fashioned relationships, conversations and trust – both between the patient and clinician, and the various health care and social service providers who work with the patients. There’s a big role for people outside the traditional health care team, including those who staff the front desk and can make the difference between a patient’s getting an appointment or falling through the cracks.
“Working together is really kind of the key to taking care of these vulnerable people,” said Dr. Tait Michael, medical director for community behavioral health at Western Connecticut Health Network, which includes Norwalk Hospital. “We’ve tried doing it in silos and it doesn’t work.”
‘From volume to value’ and keeping the lights on
One barrier to getting past the “silos” in health care – in which there’s little coordination between providers – is the way care has been paid for, Michael and others say. The current system largely pays for each visit, service or procedure, rewarding volume but not outcomes or care quality.
The health care system is now undergoing a major shift toward models that instead tie compensation to patient outcomes and keeping patients well, rather than waiting until they’re sick or in crisis. The term “person-centered care” has become a buzzword.
But the exact way to do that is still being worked out – as is the model for paying for it. (Much of that shift has been pushed by federal health policy, including provisions of Obamacare. What direction the Trump administration takes remains to be seen, but many in the industry expect the overall shift to continue.)
And for health care providers, making the shift means figuring out how to take on a new model while still getting paid largely for the old methods. In a system that still pays by the visit, for example, spending more time with each patient or holding meetings with a patient’s other providers can be a hit to the bottom line if it means seeing fewer patients.
“Health centers have wanted to be able to do this for a really long time, but they also have to think about how they’re keeping their lights on,” said Deb Polun, director of government relations and media affairs at the Community Health Center Association of Connecticut. Community health centers provide primary care, behavioral health and dental care, largely serving people covered by Medicaid or those without insurance.
The association oversees a federal grant intended to help Connecticut community health centers make the shift to a system more focused on keeping patients healthy, rather than just treating them when they’re sick. (The funding comes from an office created by the federal health law, so its future is subject to the same uncertainty as other provisions of Obamacare.)
One of those models for what care might look like under a new system is Norwalk Community Health Center’s WeCare program.
Flipping the visit
Here’s how a typical patient visit used to start for Mizrachi: She would see a patient on her schedule for the day. Perhaps she would remember having gotten some alerts when the patient was in the emergency room. She might make a mental note to talk to the patient about behavioral health services, but also notice that the patient has diabetes and high blood pressure that’s not under control.
“You might walk into the room with the best intention of saying, ‘Hey, I know you’re going to the emergency room a lot,’” she said. “They say, ‘Oh my gosh, my knee’s killing me. I walked three miles to get here today. I really just want to talk about that.’”
That’s one thing the longer appointments help with – time to address more of the patient’s concerns. And there’s also the shift in focus: Instead of starting with the medical concerns, they begin with what is most concerning the patient. It gets back to her greeting. The message is: “There might be a few things that I think are important, but let’s shift the focus, and you tell me what you want to do.”
There’s a practical reason.
If you don’t address the problems that matter to the patients, Mizrachi said, “you probably won’t see them again.”
As part of the WeCare program, patients come up with goals. They’re often not medical. One patient with chronic pain from a musculoskeletal disorder set a goal of being able to finish school; doing so would require getting her pain under control. Some patients want to get stable housing or to make it to AA meetings. For others, the goal is as simple as getting to their next appointment.
Asking questions about ways to get to the goals can help identify concrete things that stand in the way. Perhaps the patient who has been missing an appointment needs a bus token or someone to watch her children.
And, Mizrachi hopes, the process can help build trust with the patient.
As they build rapport, she brings up other things, like suggesting a mammogram or other screening they’re due for. “You sort of build the relationship first, and then you integrate that stuff later on,” she said.
A big role for data
If relationships are a key to the program, having data is just as fundamental: It’s how those running the program figured out which patients to include, and what issues needed addressing.
A Medicaid claims database identified patients with high health care expenses. A search of the health center’s electronic medical record system found those with five or more chronic conditions. They also asked clinicians for their five most complex patients for whom they could use more resources.
The initial search netted 292 patients. One had 75 emergency room visits in less than a year. Most have a diagnosed or undiagnosed psychiatric condition and problems with drugs or alcohol; alcoholism is most common. Many have chronic pain.
After prioritizing patients, they invited those deemed highest need into the program. As of December, 53 patients had been deemed in the highest-priority category, and 44 were actively participating. The most common reason for patients to decline the invitation was substance abuse.
WeCare is one of several initiatives in the state aimed at high-cost, high-need patients. But some of the principles could be applied more broadly to the whole patient population, said Dr. Tiffany Sanders, the health center’s chief medical officer. Down the road, she said, all new patients could be screened and assigned a level of risk – from someone who needs a program like WeCare to someone with fairly routine needs. That’s one part of the program that could ultimately be adopted broadly in medical care, not just at the community health center.
“It’ll allow us to rethink how we deliver care in general and be more proactive,” rather than waiting to be alerted when a patient goes to the emergency room 10 times, Sanders said.
Rerouting frequent ER visitors
Another thing the data identified: About half of the health center patients’ emergency room visits occurred during the day, while the community health center was open.
So they asked patients who go to the emergency department often why they did.
Some didn’t feel connected to their primary care providers.
“Some of them actually said, ‘Well, I know Staci from the hospital, and I like seeing her in the emergency room,’” Mizrachi said. She tells them they can see Staci Peete – the coordinator of the Community Care Team at Norwalk Hospital, which works with at-risk patients – at the health center instead.
Some faced barriers getting an appointment at the health center; Mizrachi acknowledged that the phone system isn’t ideal.
So part of the WeCare team’s work has involved those who staff the front desk – the first people who communicate with patients.
To help keep them from falling through the cracks, WeCare patients are now flagged, so if they call or walk in, the person who talks with them makes sure the patient can be seen.
“It can be very frustrating to call twice and say, ‘I really need an appointment,’” and be told that time or date won’t work, Mizrachi said. And for patients who go to the emergency room often, that can be one more thing pushing them back to the ER.
WeCare also has benefitted from efforts to improve communication between Norwalk Hospital and the health center. Until recently, the hospital had no idea which of its patients were supposed to be connected to the community health center but didn’t show up for their appointments, said Michael, from Norwalk Hospital. And the health center didn’t have a good sense of how many times its patients were going to the emergency room. Now if a WeCare patient shows up in the emergency room, Mizrachi gets an alert so she can get the patient an appointment soon after the ER discharge.
How is it going?
So far, emergency room visits among WeCare patients have dropped, one measure Mizrachi considers important. Many patients’ blood pressure got under control after they started the program. But Mizrachi is looking for a way to capture more qualitative measures, the sorts of things that more closely align with patients’ goals. For example: Four patients who had been long-term alcoholics went to rehab for the first time in their lives.
Not all patients have had such breakthroughs. The program worked with one older patient who had a habit of drinking, then going to the local bus stop and passing out, which would land him in the emergency room. The man’s family is all out-of-state, and those working with him tried to reconnect him with his family and get him into detox.
“But he’s not ready yet,” Mizrachi said.
So the team still talks about him when they hold meetings, but they focus on how to make sure he’s safe when he drinks, rather than getting him to stop. And they moved him to a less-active level of case management so they could devote more attention to another patient.
For now, Mizrachi has been playing the role of case manager for many patients. Making the program sustainable probably will require having case managers at the health center, and expanding it will take resources, she said.
Ultimately, she hopes the model could become more preventive, finding a way to flag patients at risk of losing their housing or at risk of becoming frequent emergency-room users. Community agencies say they do a good job getting resources to people who have become homeless, but not before that, when they’re living in a car or staying with friends.
“Any of those preventive measures is where I would like for us to be,” she said.