achieving the quadruple aim in primary care: challenges
TRANSCRIPT
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Achieving the Quadruple Aim in Primary Care: Challenges and Opportunities
J. Nwando Olayiwola, MD, MPH, FAAFPDirector, Center for Excellence in Primary Care
Associate Professor, Department of Family and Community Medicine
San Francisco General Hospital
University of California, San Francisco
@DrNwando
@UCSFCEPC
Arizona Alliance for Community Health CentersPhoenix, AZ – February 2016
Objectives
• 1. Understand current challenges in primary care and professional burnout
• 2. Understand a framework for high performing primary care, the Ten Building Blocks,and their relationship to the Quadruple Aim
• 3. Understand some potential opportunities to achieve the 4th aim
By the end of the
session, attendees
should:
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What happened to primary care?
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“There are close to a quarter million primary care physicians in the U.S.,
more than any other individual specialty, and about half the total number of all
specialists combined. Yet, somehow, primary care seems to lack the power
and social influence necessary to chart its own professional course.”
“The gulf is widening and the trajectory for many primary care physicians is entirely unsustainable for a host of reasons.”
Sources:1. Colwill et al., Health Affairs, 2008:w232
2. Petterson et al, Ann Fam Med 2012;10:503 3. Bodenheimer et al, Health Affairs 2009;28:64
Adult Care: Projected GeneralistPhysician Supply vs. Demand
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Results of Large Panels
Poor access for patients
Inconsistent quality
Lack of time to build relationships with patients
Clinician burnout
Sources: Linzer et al. Annals of Internal Medicine 2009;151:28-36; Dyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.
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Workload of a PCP
• Manages a panel of 2300 patients
• Interacts with at least 229 other physicians in 117 practices
• Would spend 21.7 hours a day completing evidence based preventive, acute and chronic care for their panel
The average primary care physician:
Sources: 1. Altschuler, J., Margolius, D., Bodenheimer, T., & Grumbach, K. (2012). Estimating a reasonable patient panel size for primary care
physicians with team-based task delegation. The Annals of Family Medicine, 10(5), 396-400.2. Hoangmai H. Pham, Ann S. O'Malley, Peter B. Bach, Cynthia Saiontz-Martinez, Deborah Schrag; Primary Care Physicians' Links to
Other Physicians Through Medicare Patients: The Scope of Care Coordination. Annals of Internal Medicine. 2009 Feb;150(4):236-242.3. Ghorob, Amireh, and Thomas Bodenheimer. “Sharing the care to improve access to primary care.” New England Journal of
Medicine 366.21 (2012): 1955-1957. 4. Ghorob, Amireh, and Thomas Bodenheimer. “Share the Care™: Building Teams in Primary Care Practices.” The Journal of the
American Board of Family Medicine 25.2 (2012): 143-145. 5. Baron, Richard J. “What's keeping us so busy in primary care? A snapshot from one practice.” New England Journal of Medicine
362.17 (2010): 1632-1636.
Source:
Bodenheimer, Thomas, Wagner, Edward H. and Grumbach, Kevin. “Improving primary care for patients with chronic illness:
the chronic care model, Part 2.” JAMA 288.15 (2002): 1909-1914.
Hamster Syndrome
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Source: Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377-1385.
Why Are We So Burned Out?
Source: Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US PhysiciansRelative to the General US Population. Arch Intern Med. 2012;172(18):1377-1385.Graphic © Medscape Physician Lifestyle Report 2013
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Standards, Incentives & Standards
NCQA
AAAHC
Joint Comm
URAC
MUState standards
Payer standards
Organizational standards
Evidence-based standards
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Who is Really Winning?
“On the other side are patients who are equally frustrated by providers who demand adherence to antiquated (often analog) processes around scheduling and redundant bureaucracies while the ubiquitous smartphone moves everyone further and further into a mobile and connected reality.”
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Some not so happy patients…
https://youtu.be/6udKmE84QSs
Source: AHRQ, Improving Primary Care Practice - http://www.ahrq.gov/professionals/prevention-chronic-care/improve/
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Our Goals Have Evolved
Triple Aim Quadruple Aim
Sources:
Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs 27.3 (2008):
759-769; 2). Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: care of the patient requires care of the provider.
The Annals of Family Medicine, 12(6), 573-576.
From Triple Aim to Quadruple Aim
In visiting primary care practices
around the country, the authors have
repeatedly heard statements such as,
“We have adopted the Triple Aim
as our framework, but the stressful work life
of our clinicians and staff impacts
our ability to achieve the 3 aims.”
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Reclaiming Primary Care
Source: Olayiwola, JN. Bringing Sexy Back: A Recipe for Sexiness Needed to Revitalize Primary Care in the U.S. San Francisco Medicine.
2015;88(5):21-23.
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Clinica Family
Health Services
Group Health Olympia
Multnomah
County Health
Dept
South Central
Foundation
Univ of Utah-
RedstoneNewport News
Family Practice
Cleveland Clinic-
Stonebridge
Quincy, Office of
the Future
West Los Angeles-
VA
La Clinica de
la Raza
Clinic Ole
Sebastopol
Community
Health
Martin’s Point-
Evergreen Woods
Harvard Vanguard
MedfordBrigham and
Women’s and MGH
Ambulatory
Practice of the
Future
North Shore
Physicians GroupMedical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont
Clinic
Mayo Red Center
Allina
23 high-performing practices
Source: Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. The Annals of Family Medicine, 12(2), 166-171.
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Thinking Differently: 10 Building Blocks of
High-Performing Primary Care
Source: Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. The Annals of Family Medicine, 12(2), 166-171.
Ten Steps to Prevent Physician Burnout
Institutional Metrics
Work Conditions
Career Development
Self-Care
Make clinician satisfaction and wellbeing quality indicators.
Incorporate mindfulness and teamwork into practice.
Decrease stress from electronic health records.
Allocate needed resources to primary care clinics to reduce healthcare disparities.
Hire physician floats to cover predictable life events.
Promote physician control of the work environment.
Maintain manageable primary care practice sizes and enhanced staffing ratios.
Preserve physician “career fit”with protected time for
meaningful activities.
Promote part-time careers and job sharing.
Make self-care a part of medical professionalism.
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Sources:
1. Linzer, Mark, et al. “10 Bold Steps to Prevent Burnout in General Internal Medicine.” Journal of General Internal Medicine 29. 1 (2014):18-20.
2. Shanafelt, Tatit D. “Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care.” JAMA 302. 12
(2009): 1338-1340.
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Evidence Based Ideas for Reducing Burnout
BUILDING SDH CAPACITY
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The Dilemma
Panel size too large for
average PCP to manage
Can’t reduce panel size due to worsening shortage of
adult primary care clinicians
Shortage = larger panels, poorer access for patients,
poorer quality, more PCP
burnout, higher health care
costs
More PCP burnout means fewer medical
students will be attracted to primary care
Unless we think
differently
An additional dimension: SDH
• Primary care providers (PCPs), particularly those working in safety net settings, face the demands of providing medical care while simultaneously addressing social determinants of health (SDH).
http://www.pdx.edu/social-determinants-health/
Sources: 1. King TE, Wheeler M, Fernandez A, Schillinger D, Bindman A, & Grumbach K. Medical management of vulnerable and underserved patients:
principles, practice, and populations. McGraw-Hill Medical Publishing Division, 2007.
2. Marmot, M. Social determinants of health inequalities. The Lancet 365.9464 (2005): 1099-1104.
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My patient JR• 46 year old undocumented Mexican man
with chronic seizure disorder on multiple seizure medications. Patient is illiterate and lives with elderly, Spanish-speaking parents. Presented for titration of seizure medications due to suboptimal levels. At visit, informed me that he and his parents were recently evicted from apartment, given 3 days notice. Squatting with sister (and her 4 kids) in a 2 bedroom apartment.
My Patient JR, Continued
My goals for the visit
• Manage the seizure meds
• Check levels
• Ensure seizure free-periods
JR’s goals for the visit
• Get housing assistance
• Find emergency and long-term housing solutions
• Inform clinic not to send mail
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It got worse…Patient evicted because landlord found higher paying tenant; eviction also illegal
Housing worker -needs minimum of $3300 per month to find 2 bedroom apartment in SF
Patient and parents unemployed, no income
SF affordable housing wait list minimum of 5 years – patient given list of places to call (illiterate, no phone)
“Doctor’s note” not likely to influence housing options
In the safety net, the “treatment” is….
Language and literacy
Legal support
Housing
Financial support
Food
Transportation
Clothing
Remember JR
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SDH and Primary Care
Sources: 1. Gottlieb, L., Sandel, M., & Adler, N. E. (2013). Collecting and applying data on social determinants of health in health care settings. JAMA Intern Med,
173(11), 1017-1020. doi: 10.1001/jamainternmed.2013.560
2. Hayashi, A. S., Selia, E., & McDonnell, K. (2009). Stress and provider retention in underserved communities. J Health Care Poor Underserved, 20(3), 597-604.
Few resources exist to address SDH systematically and comprehensively in underserved settings
Dimensions of burnout may be pronounced for PCPs working with vulnerable populations, organizational resources are low; emotional and material needs of patients are high
Leading causes of workplace stress for safety net clinicians in US were insufficient resources for patients and within the health center
Study Design & Methods• To understand relationships between clinician
perceptions of capacity to address SDH and clinician burnout
•Web and paper-based survey, October 2014–February 2015
•Approx 500 primary care clinicians (physicians, physician
residents, nurse practitioners, and physician assistants)
• 10 county, 6 university, and 3 VA administered health centers in San Francisco
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A Conceptual Model for Clinician Perceptions of Capacity
Familiarity
Awareness Beliefs
Agreement
Comfort
Assurance
Perceived Self-Efficacy
Expertise
Clinic Resources
Clinic Tools
INTERNAL FACTORSEXTERNAL
FACTORS
SDH CONCEPTUAL MODEL
Conceptual Model for Clinician Perceptions of Capacity to Address Patients’ Social NeedsOlayiwola et al. Adapted from Roelens et al BMC Public Health 2006
Social needs impact
my patients’ health
It is important to screen for
patients’ social needs in
primary care
I am comfortable screening
for patients’ social needs in
primary care
I have the skills to address
patients’ social needs in
primary care
My clinic has the resources
to address patients’ social
needs
Screening for and
addressing
patients’ social needs
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SDH Scale
a. I am comfortable asking about patients’ social needs (e.g., housing, food, childcare) as part of their primary care.
b. It is as important to address patients’ social needs as it is to address their medical needs in primary care.
c. I have the skills to address the social needs of patients through connecting them with resources, dedicated staff, or tools.
d. My clinic has the resources, such as dedicated staff, community programs, resources or tools to address patients’ social needs.
Addressing social needs: This section is designed to understand your ability
to address the social needs of your patients. Social needs include housing
security and habitability; food security; financial assistance and employment
benefits; transportation; childcare; utility assistance; and legal services.
Outcomes
• Maslach Burnout Inventory:
• Professional Efficacy
• Emotional Exhaustion
• Cynicism
Results: SDH Scale Questions
Strong beliefs that important to address social needs
Most are comfortable asking about social needs
Less confidence in personal skill to address social needs
Least confident in clinic resources to address SDH
Correlations suggest related yet conceptually distinct dimensions of perception^
Clinician
perceptions of
capacity to address
patients’ social
needs *
Belief that addressing
social needs is an
important role for
primary care
9.26 (1.20)
Comfortable asking
about social needs
8.67 (1.56)
Skills in addressing
social needs
6.92 (2.26)
Clinic resources
available to address
social needs
6.52 (2.68)
* Response options ranged from 1= Strongly disagree to 10=Strongly agree
Low to moderate correlationsSource: Olayiwola et al, Unpublished data
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Additional Analysis
Univariate Analysis
• Each of the 4 SDH items was significantly associated with:– Lower reported levels of
exhaustion and cynicism
– Higher levels of professional efficacy
Multivariate Analysis
• PCP perception of clinic capacity and resources to address SDH was the only one of the four SDH items to remain a significant predictor of burnout scores
Source: Olayiwola et al, Unpublished data
Key Conclusions• #1: PCP perceptions of greater clinic capacity
to address SDH are significantly associated with lower burnout on all 3 measures
• #2: Above is not mitigated by individual clinician beliefs, confidence and skills in addressing SDH
• #3: PCPs with more direct patient care-associations between perceived clinic capacity and burnout heightened
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ADDRESSING STAFFING RATIOS
VA PACT Study 2014
Study Design• Web-based, cross-sectional survey of 4500+ primary
care personnel from 588 VA clinics participating in PACT
• Team ratios approx 3:1: Nurse Care manager, admin clerk, clinical associate
• Dependent variable- burnout
• Independent variables -measures of team-based care:
– Team functioning
– Time spent in huddles
– Team staffing
– Delegation of clinical responsibilities
– Working to top of competency
– Collective self-efficacy
Findings• 39% of staff reported burnout (PCPs,
nurses, clinical associates, clerks)
• Lower burnout associated with: participatory decision-making, fully staffed PACT (even after adjusting for clinic workload and proportion of PCP panels over capacity)
• Higher burnout associated with: PACT team assignment, working “below” license, stressful, fast working environment
• Not just about assigning teams, but getting team composition and staffing right
Source: Helfrich, Christian D., et al. "Elements of Team-Based Care in a Patient-Centered Medical Home Are Associated with Lower Burnout Among VA Primary Care Employees." Journal of General Internal Medicine (2014): 1-8.
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Staffing Ratios
Considerations
Consider value added for increased
intensity of service
Other human resources costly but can increase
production
Higher clinician:non-clinician ratios
decrease burnout and improve
efficiency
Source: Helfrich, Christian D., et al. "Elements of Team-Based Care in a Patient-Centered Medical Home Are Associated with Lower Burnout Among VA Primary Care Employees." Journal of General Internal Medicine (2014): 1-8.
Estimates of Staffing Infrastructure
2.68 FTE:1 physician
Insufficient to meet PCMH standards
Current4.25 FTE:1 physician
Incremental cost $4.68 pmpm
Ideal
• Analytical model developed:• Targeted interviews with
administrators of PCMH practices through convenience sampling
• Literature reviews
• Staffing implications of Joint Principles of PCMH
• Analysis of current staffing estimates from MGMA
• Staffing compensation by geographic location
• Staff with specific expertise needed to carry out PCMH functions
• New functionalities needed for fully operational PCMH
• Incremental staffing estimates:• Receptionists
• Nurse care managers, NPs
• Non-clinical pharmacists
• Social workers
• Nutritionists
• Health coach MAs
• Clinical Data Specialists
59% Increase
Source: Patel, M. S., Arron, M. J., Sinsky, T. A., Green, E. H., Baker, D. W., Bowen, J. L., & Day, S. (2013). Estimating the staffing infrastructure for a patient-centered medical home. The American journal of managed care, 19(6), 509-516.
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TEAM CULTURE AND TEAM ROLES
Building Block 4: Team-Based Care
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Why does team-based care matter?
Align roles to meet population needs
Build capacity to make timely access possible
Non-clinician team-members contribute to continuous healing relationship
Foundation for the Template of the future
Building Block 4: Team-Based Care
Teamwork…
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Reframing the Discourse Since the Threats Have Not Changed
Historical Approach: Demand-Supply Gap
New Approach:Demand-Capacity Gap
Team Roles
New Models
9 Elements of High Performing Team CareStable team structure
Colocation
Culture shift: Share the Care
Defined roles with training and skills checks
Standing orders/protocols
Defined workflows and mapping
Staffing ratios adequate to facilitate new roles
Ground rules
Communication: meetings, huddles, daily flow
Source: Ghorob and Bodenheimer. Building Teams in Primary Care: A Practical Guide. 2015. Fam Syst Health
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Team-Based Care: Stable Teamlets
Patientpanel
1 team, 3 teamlets
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
Other team members: nurse, behavioral health professional, social worker, pharmacist, complex care manager, health coach, panel
managers
Study Design & Methods
Setting: 19 San Francisco primary care safety net clinics
Data collection: Annual PCP & staff survey (2012–2014)
Survey measures:
• Maslach Burnout Inventory (MBI) 16-item General Survey
• One-item measure of team structure
• One-item measure of PCP satisfaction with team model
• Seven-item measure of team culture developed by study team
• 12-item measure of panel management capability
Data analysis: T-tests, chi square, GEE modeling to account for clustering at clinic level
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Teamlet (n=42)(works with same clinical assistant)
Team (n=161) (works with group of clinical assistants)
No teams (n=22) (works with different clinical assistant)
Source: System Transformation Evaluation. Center for Excellence in Primary Care. 2012.
Not satisfied, 10%
Neutral, 12%
Satisfied, 79%
Not satisfied, 34%
Neutral, 26%
Satisfied, 40% Not
satisfied, 59%
Neutral, 32%
Satisfied, 9%
Results: Provider satisfaction
Provider satisfaction with team model, by team model (n=235 PCPs)
Source: System Transformation Evaluation. Center for Excellence in Primary Care. 2012.
63%
49%
44%
37%
26% 26%29%
26%
21%
0%
10%
20%
30%
40%
50%
60%
70%
Immunizations (p<.01) Cancer screenings (p<.05) Diabetes care (p=.06)
Teamlet (n=39-40) Team (n=149-161) No team (n=19-21)
% PCPs confident that panel management can and will be done, by team model (n=207-222 providers)
Results: Panel management capability
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0.00
1.00
2.00
3.00
4.00
5.00
6.00
No Team Team Teamlet
Exh
au
sti
on
Mean
Sco
re
Team Structure
Low Team Culture
High Team Culture
Interaction between team structure and team culture on clinician burnout
Among clinicians reporting low team culture, team structure appeared to have little impact on burnout. Among clinicians reporting high team culture, stable teamlets were associated with lower burnout (p = .002). 231 clinicians from SFDPH and UCSF primary care practices, Maslach Burnout scale.
Source: Willard-Grace, R., Hessler, D., Rogers, E., Dubé, K., Bodenheimer, T., & Grumbach, K. (2014). Team structure and culture are associated with lower burnout in primary care. The Journal of the American Board of Family Medicine,27(2), 229-238.
Key Findings
• Teamlets associated with greater PCP satisfaction
• Teamlets associated with higher PCP confidence that staff can take on new roles (like panel management)
• Greater team culture associated with lower emotional exhaustion and cynicism
• Tighter team structure was associated with lower PCP exhaustion when team culture was also high
• Greater panel management capability associated with lower cynicism when team culture was low
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Closing the Demand-Capacity Gap: Share the Care
Clinicians
Non-clinician
team members
Patients Technology
Source: Bodenheimer and Smith, Health Affairs. 2013; 32:1881-86
MAs as panel managers Health coaches
ScribesNurses
PharmacistsBehavioral healthStanding orders
Peer health coachesSelf care
TelehealtheReferrals
Phone visitseVisits
Group visitsAlternative scheduling
All team members know their patients
Redefining roles of the care team
Empowered to share responsibility for their panel
Success stories are about all team members
Pay-for-performance and recognition systems reward
the team
Share the Care™: Culture Shift From “I” to “We”
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Team-Based Care, the Quadruple Aim and the Building Block Crosswalk
Source: Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: care of the patient requires care of the provider.The Annals of Family Medicine, 12(6), 573-576.
Implement team documentation: associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier
Use pre-visit planning and pre-appointment laboratory testing: reduces time wasted on the review and follow-up of laboratory results
Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders
Standardize and synchronize workflows for prescription refills: can save physicians 5 hours per week while providing better care
Co-locate teams: increases efficiency and can save 30 minutes of physician time per day
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Adult Primary Care: Capacity vs. Demand
Demand for care=Capacity to provide care
Thinking Differently
Sharing the care adds capacityPatient self-care reduces demand
Share the care
Self care
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Teams Are Like ChessNot enough to just have the chess pieces….
Must know what every piece does AND how to play together
PCMH and PCMN offer patient-centric solutions to delivering health care
Advanced primary care systems should focus on well being of staff- both through measurement and strategy
Building Blocks offer a useful framework to achieve PCMH quality and move towards Quadruple Aim
Primary care transformation can be attained, measured and spread
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Thank You!
J. Nwando Olayiwola, MD MPH, FAAFP
Director, Center for Excellence in Primary Care
Associate Professor, Department of Family and Community Medicine
University of California, San Francisco
http://cepc.ucsf.edu
Twitter: @DrNwando
Twitter: @UCSFCEPC
+1-415-206-2970 (O)