Besides the lack of available endocrinologists, there is a warped perception of who should care for the estimated 129 million Americans with at least one chronic disease, according to Peter Pronovost, MD, PhD.
“Across America, the thought is specialists deliver 90% of care for people with chronic disease, and our measure of success is how long of a wait time that specialist has,” said Dr. Pronovost, chief quality and clinical transformation officer at Cleveland-based University Hospitals.
“If it’s over three months or six months, they must be really, really good, because there’s demand,” he said, laughing. “But the mental model is still this archaic model that, ‘I only care for the people in front of me or who show up in my clinic rather than caring for a population.’ At our health system, we flipped that.”
Three years ago, the 21-hospital system worked with its specialists and primary care physicians to develop a model in which the latter provides 90% of the care, rather than the other way around.
The solution was a “beautiful dance” involving specialists, primary care physicians, nurses, social workers and pharmacists, Dr. Pronovost said.
Primary care physicians and specialists joined together to create checklists and protocols to manage chronic disease patients in short primary care visits. Specialists conduct short-term consults to confirm the diagnosis and treatment plan. And as a result, 90% of the patients are measured in primary care, and 10% are cared for by specialists.
For Medicare patients, about 60% of care is provided by specialists.
“There was this beautiful dance where they choreographed between what’s ideal and what’s feasible, and came up with something really beautiful for patients,” Dr. Pronovost said.
Despite the launch of powerfully effective drugs for virtually every chronic disease over the last five years, most patients are not on guideline-recommended therapy, studies show. To solve this, primary care and pharmacy have forged such a strong trust that there are automatic referrals to and dialogues with pharmacists, according to Dr. Pronovost.
University Hospitals first prototyped the new care coordination system among diabetics in its employee health plan population. The organization has since deployed it over the last two years for its ACO’s diabetes population.
Future rollouts are planned for chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, hypertension and other chronic diseases. These additional approaches have been prototyped and built, and the system is rolling them out in succession to avoid burdening primary care.
“[This is] reimagining what it means to care for chronic disease,” he said, adding that University Hospitals calls the care model a system of excellence “because it takes a system, and care must be proactive and relational rather than reactive and transactional.”
