The first-ever UCSF and Partners Primary Care Summit brought key players to the table to discuss how to improve patient-focused care in San Francisco as part of national health reform.
“Instead of being in our parallel universes, can we recognize our common aspirations in primary care and learn from each other?” asked Kevin Grumbach, MD, kicking off a recent gathering at the UCSF Laurel Heights campus.
Grumbach, chair and professor in UCSF Family and Community Medicine, addressed the 160 or so people in the audience who work at three major health delivery systems in San Francisco in which UCSF is involved: the San Francisco Department of Public Health, UCSF Medical Center and the San Francisco Veterans Affairs Medical Center. UCSF residents, medical students, and nursing students also attended the summit.
Grumbach said he goes to meetings where everyone is aiming to transform primary care from physician-centered practices to patient-focused teams. And yet Grumbach observed that there’s a stunning lack of cross-fertilization across the three systems, all of which involve UCSF health care providers and trainees, giving rise to the idea for a summit.
“President Obama said we need more and better primary care as a fundamental goal of health reform,” Grumbach said.“… We’re here to decide: How do we lead this national movement, beginning with our work here in the Bay Area?”
Through presentations in the auditorium and breakout sessions, people shared their successes and frustrations.
Catherine Lucey, MD, vice dean for education in the UCSF School of Medicine, said she jumped at the chance to participate in the summit because it's "essential that the education system within UCSF tailor its curriculum to ensure that our students and residents are contributing members of all the delivery systems with which we work. And these new models of primary care transformation are giving us the opportunity to rethink what kind of skills our students and residents need to have as they come out of training."
Lucey stressed that the main purpose of medical education is not to train doctors to have great careers but to improve the health of the community.
Ultimately, the primary care system that we develop here will not only meet the needs of our people within San Francisco, but can be exported to meet the needs in cities across the country."
She said people frequently ask why more doctors don’t go into primary care. To answer that question, she spoke of a book titled “Drive: The Surprising Truth About What Motivates Us,” which found that mastery, autonomy and purpose were key factors. However, she said that medical students and residents in primary care stints often don’t think they can master or shape their environments.
Primary Care Lessons From the Field
Tom Bodenheimer, MD, MPH, director of the Center for Excellence in Primary Care at UCSF and a professor in Family and Community Medicine, talked about the study he and his UCSF colleague Rachel Willard, MPH, did, “The Building Blocks of High-Performing Primary Care: Lessons From the Field.”
They conducted intensive site visits at seven high-performing primary care practices and collected data on 16 others — finding all these practices used a similar in approach based on certain principles which they codified as the 10 building blocks, which ranged from empanelment and data-driven improvement to engaged leadership and prompt access to care.
Creating teams is crucial, Bodenheimer said, with all members — including physicians, medical assistants, nurses, pharmacists, behaviorists and receptionists — sharing responsibility for the quality of patient care.
“The culture shift is really profound,” said Bodenheimer, who insisted that the crisis in primary care can be solved without the projected need for 40,000 new primary care physicians if practices redesign their model of care.
“Patients are not going to go to practices that look like a 78 rpm record,” he said. “They’re going really, really fast and there’s not much on them. … We’re not telling people to change. We’re reporting on the characteristics of the change that is inevitably happening.”
At the San Francisco Veterans Affairs Medical Center (SF VAMC), that change includes Patient Aligned Care Teams (PACT), group visits, team huddles, phone visits, e-consults, clinical reminders and mental health providers in primary care clinics. Grumbach said he was impressed with the VAMC presentation and that the organization had really shot ahead on quality of care.
“Increasingly, we realize you can’t do it on your own anymore. … Primary care needs to operate in a high-functioning system,” said Joshua Adler, MD, chief medical officer at UCSF Medical Center and UCSF Benioff Children’s Hospital, as part of a panel discussion by systems leaders on organizational readiness and capacity for primary care transformation.
“I do believe the first few years of health reform will bring a lot of frustration in terms of access,” said Tangerine Brigham, the city’s deputy director of health and director of Healthy San Francisco.
Lucey, who gave the afternoon’s keynote address, said the 20th century doctor was typically a lone ranger — autonomous and rugged. “But the hero physician cannot and should not be the model we’re striving for now,” she said. “So, if the hero physician is out, who’s in? I think, in fact, what has to be in is the physician who understands, can work within and continuously improve a system of health care designed to be patient-centered and to deliver the highest-quality care.”
Much in that vein, Margo Vener, MD, MPH, introduced plans under development for a UCSF Primary Care Leadership Academy for Medical Students.
“Unfortunately, a substantial number of students do lose interest in primary care before matriculation. That feels a little bit like a lost opportunity to us,” Vener said, explaining part of the rationale for the academy.
At a morning breakout session on “Care management of complex patients,” Tammy Hendrix, LCSW, coordinator of the Homeless Patient Aligned Care Team (HPACT) at the SF VAMC, said collaborating with community partners had worked well in aiding homeless vets.
“Partnering with cops has been particularly helpful,” she said, “for finding vets and also helping them not get picked up and sent to jail.”
Hendrix said it’s crucial to hire the right personalities, who are adept at building trust and able to sit down in the street with people or meet under freeways.
Value of Networking With Hard-to-Reach Patients
Elizabeth Davis, MD, assistant medical director of the General Medicine Clinic at San Francisco General Hospital and Trauma Center (SFGH), also emphasized the value of networking with the people in the lives of hard-to-reach patients.
An intensive care management program at UCSF, which was designed in March and began enrolling patients in late May, targets the highest users of the emergency department, inpatient and outpatient services.
“I’m embedded in a primary care clinic,” explained Anne Thibault, RN, MS, NP, complex care coordinator in the Division of General Internal Medicine at UCSF.
So far, 18 patients are enrolled in the innovative program, with 50 likely by the end of the year.
“They have very chaotic lives,” Thibault said. “You have an action plan, they agree and then life gets in the way.”
The work is labor intensive. As an example, she mentioned a disabled patient living in a downtown single-room-occupancy (SRO) building who was depressed and anxious and had a terrible tremor. She liked to read, visit museums and go to Golden Gate Park. Thibault decided to get her some audio books — hoping that will be a way to reach her.
At a morning session on “Care Transitions,” Ning Tang, MD, described how a comprehensive UCSF program to take care of discharged patients, developed over three years, had made inroads in such areas as reducing readmission to the hospital, securing follow-up appointments and notifying primary care physicians when their patients went home.
Tang, medical director of ambulatory quality and safety at UCSF Medical Center, said giving nurses a bigger role had paid off in many ways and that having them talk to patients in follow-up visits about things like medication reconciliation and care coordination had freed primary care physicians to focus on other clinical issues.
In five simultaneous afternoon sessions, participants addressed how to engage students, residents, interprofessional teams, the community and a national effort. When everyone reconvened at the end of the day, each session had produced two big ideas that could lead to quality improvement and systems change.
In the group devoted to residents, participants suggested creating a repository for projects, such as a wiki, to tap into all the projects going on and figure out what works and what doesn’t.
“It’s a great idea,” said Hali Hammer, MD, medical director of the Family Health Center at SFGH. “Part of quality improvement is not reinventing the wheel.”
Based on the universally positive feedback from participants, Grumbach and Lucey plan to make the summit a regular event. “We achieved one of our major objectives — creating a learning community among people committed to transforming primary care,” Grumbach said.
"Ultimately, the primary care system that we develop here will not only meet the needs of our people within San Francisco, but can be exported to meet the needs in cities across the country," Lucey said.