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Achieving the Quadruple Aim:Practice Transformation, Provider Satisfaction and the Future of Primary Care
J. Nwando Olayiwola, MD, MPH, FAAFP
@DrNwandoAssociate Director, Center for Excellence in Primary Care
Assistant Professor, Department of Family & Community Medicine
University of California, San Francisco, San Francisco General Hospital
AACHC and WCN Region IX Leadership Conference
San Diego, CA – June 2015
Objectives
• Understand the literature of burnout in primary care
• Understand the core fundamentals of the “Quadruple Aim” in healthcare and various standards of Primary Care excellence
• Understand strategies to achieve the 4th aim and what the future of primary care could look like
My Recent Journal:
The Day I Had
“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 Generalist PhysicianSupply vs. Demand
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.”
What is Primary Care?
Primary care is the cornerstone of health care
that is effective and efficient and meets the
needs of patients, families, and communities.
Our primary care system currently has significant—
and perhaps unprecedented—opportunities to
emphasize quality improvement (QI) and practice
redesign in ways that could fundamentally improve
health care in the United States.
Source:
AHRQ, Improving Primary Care Practice
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/
Doc McStuffins—6 year old Disney character
who “fixes” toys and provides personal care to them
QUIZ
??
??
??
Why We Went into Primary Care
What We Found
Public
Health
Employers
Schools
Faith-Based
Organizations
Community
Centers
Home
Health Hospital
Pharmacy
Mental
Health
Patient-
Centered
Medical Home
Community Organizations
Connected
via Health IT
The Medical Neighborhood
Source:
Patient-Centered Primary Care Collaborative
$
Diagnostics
Skilled
Nursing
Facility
Specialty &
Subspecialty
$
Source:
Team STEPPS® - AHRQ and DoD
Workload of a PCP
The average primary care physician:
▫ 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
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
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 differentl
y
PCPs in the Safety Net are also faced with:
Complex patients—medically and psychosocially
Social determinants of health
Racial/ethnic minorities, vulnerable populations
Low literacy and limited English proficiency
Poorly coordinated care
Sources:
1. Gottlieb, Laura M. “Learning from Alma Ata: the medical home and comprehensive primary health care.” The Journal of the
American Board of Family Medicine 22.3 (2009): 242-246.
2. Hayashi, A. Seiji, Emily Selia, and Karen McDonnell. “Stress and provider retention in underserved communities.” Journal of Health
Care for the Ppoor and Underserved 20.3 (2009): 597-604.
3. Gottlieb, Laura, Megan Sandel, and Nancy E. Adler. “Collecting and applying data on social determinants of health in health care
settings.” JAMA Internal Medicine 173.11 (2013): 1017-1020.
4. TE King, Jr, Margaret B. Wheeler, A Fernandez, D Schillinger, A Bindman, K Grumbach, T Villela. Medical Management of
Vulnerable and Underserved Patients: Principles, Practice, and Populations. McGraw-Hill Medical Publishing Division, 2007.
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.
High Levels of Burnout
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. doi:10.1001/archinternmed.2012.3199.;
Graphic © Medscape Physician Lifestyle Report 2013
Why Are We So Burned Out?
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.
Graphic © Medscape Physician Lifestyle Report 2013
Burnout Matters!
Source:
West, Colin P., and Tait D. Shanafelt. “Physician well-being and professionalism.” Minnesota Medicine 90.8 (2007): 44-46.
The Perfect Storm
Patient-Centered Care
Patient
At Centerof the
Medical Home
Population
Health
Patient-
Centered
Care
Refocused
Medical Training
Patient &
Physician
Feedback
Advanced IT
Systems
Access to
Care
Team-Based
Healthcare
Delivery
Decision
Support Tools
Standards, Incentives & Standards
NCQA
AAAHC
Joint Comm
URAC
MUState
standards
Payer standards
Organizational standards
Evidence-based
standards
In This Context, a New Paradigm was Needed…
Triple Aim
Source:
Berwick, Donald M., Thomas W. Nolan, and John Whittington. “The triple aim: care, health, and cost.”
Health Affairs 27.3 (2008): 759-769;
Table 1. Ten Steps to Prevent Physician Burnout
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, Tait D. “Enhancing meaning in work: a prescription for preventing physician burnout and promoting
patient-centered care.” JAMA 302.12 (2009): 1338-1340.
And Still…
A Newer Paradigm is Necessary…
To Keep the Workforce
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 AimIn 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.”
Sources:
1. Bodenheimer, Thomas S., and Mark D. Smith. “Primary Care: Proposed Solutions To The Physician Shortage Without Training More
Physicians.” Health Affairs 32.11 (2013): 1881-1886.
2. Sinsky, Christine A., et al. “In search of joy in practice: a report of 23 high-functioning primary care practices.” The Annals of Family
Medicine 11.3 (2013): 272-278.
3. Willard, R., and T. Bodenheimer. “The building blocks of high-performing primary care: lessons from the field.” California Healthcare
Foundation (2012).
4. 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.
10 Building Blocks of High Performing Primary Care
Some Inspiration…
Think Differently!
Thinking Differently—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
Brief Case Study: My ExperienceCHC Locations in Connecticut
CHC Inc. Profile:• Founding Year: 1972
• Primary Care Hubs: 13 • No. of Service Locations: 218• Licensed SBHC locations: 24• Organization Staff: 600+
Innovations
• Integrated primary care disciplines• Fully integrated EHR• Patient portal and HIE• Extensive school-based care system• “Wherever You Are”Health Care• Level 3 PCMH-NCQA• Joint Commission PCMH• Centering Pregnancy model• Residency training for new nurse practitioners and post doc psychologists
Community Health Center, Inc.Patients who consider CHC their health care home: 130,000
Health care visits: 410,000 per year
Challenges
Multiple Sites (isolation)
Provider Turnover
Practice Transformation
Specialty Access
Patient Frustration
Table 1. Ten Steps to Prevent Physician Burnout
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, Tait D. “Enhancing meaning in work: a prescription for preventing physician burnout and promoting
patient-centered care.” JAMA 302.12 (2009): 1338-1340.
Missed Opportunities Dashboard
Sustained Reduction in MissedCancer Screening Opportunities
Additional Strategies
Accredited non-hospital, non-academic internal
CME program
Optimizing physician time
through Share the Care
Provider-specific questions on
employee satisfaction
Scholarly and quality
improvement opportunities
Mentoring and pipeline with medical
and nursing students, residents
Provider Turnover
Driving Change: Charting our Future
Sources:
1. Bodenheimer, Thomas S., and Mark D. Smith. “Primary Care: Proposed Solutions To The Physician Shortage Without Training More
Physicians.” Health Affairs 32.11 (2013): 1881-1886.
2. Sinsky, Christine A., et al. “In search of joy in practice: a report of 23 high-functioning primary care practices.” The Annals of Family
Medicine 11.3 (2013): 272-278.
3. Willard, R., and T. Bodenheimer. “The building blocks of high-performing primary care: lessons from the field.” California Healthcare
Foundation (2012).
4. 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.
10 Building Blocks of High Performing Primary Care
Template of the Future
Time Primary care physician
Medical assistant 1
RN Nurse Practitioner
Medical Assistant 2
8:00
8:15
8:30
9:00
9:15
9:30
10:00
Template of the Present
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Patient G
Patient H
Patient I
Patient J
Patient K
Patient L
Patient M
Patient N
Assist with
Patient A
Assist with
Patient B
Assist with
Patient C
Assist with
Patient D
Assist with
Patient E
Assist with
Patient F
Assist with
Patient G
Assist with
Patient H
Assist with
Patient I
Assist with
Patient J
Assist with
Patient K
Assist with
Patient L
Assist with
Patient M
Assist with
Patient N
Triage
Time Primary care physician
Medical assistant 1
RN Nurse Practitioner
Medical Assistant 2
8:00
8:10
8:30
9:00
9:30
10:00
10:30
Template of the Future
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Patient G
Patient H
Patient I
Patient J
Patient K
Patient L
Patient M
Patient N
Assist with
Patient A
Assist with
Patient B
Assist with
Patient C
Assist with
Patient D
Assist with
Patient E
Assist with
Patient F
Assist with
Patient G
Assist with
Patient H
Assist with
Patient I
Assist with
Patient J
Assist with
Patient K
Assist with
Patient L
Assist with
Patient M
Assist with
Patient N
Triage
E-visits
and
phone
visits
E-visits
and phone
visits
Complex patient
Complex patient
RN
Care
manage-
ment
Acute
Patients
Huddle
Panel
manage-
ment
Panel
manage-
mentBP
coaching
clinicHuddle with
RN, NP
Huddle with MD
Coordinate with
hospitalists and
specialists
30 patients are seen or contacted in the first 3 hours of the day
Template of the FutureTime Primary Care
Physician
Medical
Assistant 1
RN Nurse
Practitioner
Medical
Assistant 2
8:00–
8:10 Huddle
Huddle with RN, NP Huddle with MD
Complex patient
E-visits and phone
visits
Acutepatients
RN Care
manage-ment
Panel manage-
ment
E-visits and phone
visitsComplex patient
Coordinate with hospitalists and specialists
Care manage-
ment
Blood pressure
coaching clinicPanel
manage-ment
About 30 patients contacted/seen in 3 hours
8:10–
8:30
8:30–
9:00
9:00–
9:30
9:30–
10:00
10:00–
10:30
10:30–
11:00
Real Life Example from Iora Health
S.Rosari
o
J. Taylor-Landry
M. Joudy
W.Starch
N. Cibati
R. Kevato
ry
H. Caroll
9AM Huddle Huddle Huddle Huddle Huddle Huddle Huddle
10AM Hold Time Slot Hold Time Slot Hold Time Slot
11AM Hold Time Slot Hold Time Slot Hold Time Slot Hold Time Slot Hold Time Slot Hold Time Slot Hold Time Slot
12PM Michelle David David Hold Time Slot
1PM Gary Michael Michael Gary Hold Time Slot
2PM Movari Zahn NicholasZahn
NicholasMovari Larry
3PM Jenny GeorgeHold Time
SlotGeorge Jenny Martin
4PMGina
AndresPaul Daniel
DanielGina
AndresPaul
Daniel
Think Differently!
My Future Journal:
The Day I Want to Have
Thank You!
Contact:
Twitter: @DrNwando
(415) 206-2970 (O)