9 Steps to Build an Accountable Primary Care Model

In April, Lumeris unveiled its Accountable Primary Care Model, also known as the Nine C's. The Nine C's are a framework for primary care physicians to guide them to deliver the triple aim of healthcare, plus one: physician satisfaction.

"The healthcare system is broken," says Tom Doerr, MD, director of innovation research at Lumeris. "That's the starting point [for the framework]. We formulated the Nine C's in an attempt to put a framework together that offers primary care physicians a way to transform their practices from volume-based to value-based delivery."

Here, Dr. Doerr shares more in-depth information on all nine parts of the Accountable Primary Care Model, how physicians can achieve success at each step of the transformation process and how the Nine C's can help physicians accomplish the "Triple Aim Plus One."

1. First contact. Serving as a patient's first contact point for acute and chronic illness care can lower the cost of healthcare significantly by lessening the chance of a major illness landing the patient in the hospital. Part of a primary care physician becoming a patient's first contact point is making the office accessible to patients.

There are several ways physicians can make their offices more accessible, according to Dr. Doerr. Physicians can provide email and telephone visits, stay open later and on weekends, and allow same-day appointments.

2. Comprehensive care. To offer more comprehensive care to patients, Dr. Doerr suggests spending more time with patients when they are in the office. "That enables physicians to do more throughout the appointment and anticipate any problems a patient might have in the future," he explains.

Another way to provide more comprehensive care is for primary care physicians to offer more services in-office as opposed to sending patients elsewhere. For example, Dr. Doerr, a practicing primary care physician specializing in geriatrics, trims the toenails of all of his diabetic patients. "When I do that, I can teach patients how important foot care is. It's a teaching opportunity," he says. Procedures like that can help build trust between provider and patient as well.

3. Continuous, longitudinal, person-centered care. This portion of the Accountable Primary Care Model involves different pieces. The longitudinal care portion refers to being a patient's first point of care over the course of many years. "Regardless of the illness, they come to me for an annual checkup," Dr. Doerr says. "I'm a first contact that's reliable for the patient."

Then, the person-centered care piece comes into play. Providing person-centered care involves discerning a patient's preference and priorities while engaging with the patient's family. Getting personally involved with patients and providing patient-centered care is rewarding not only for the patients but for the physician as well, Dr. Doerr says. "It's very meaningful work for me, and I derive satisfaction from the fact that I care for them. Relationships are transcending the fee-for-service, volume-based model of care."

4. Coordinated care. Providing coordinated care is an obstacle for many physicians striving to provide care in a value-based model. "We've got an epidemic of coordination issues," Dr. Doerr says. In order to provide truly coordinated care, everyone involved in a patient's wellbeing, from primary care physicians to nurses to specialists, need to know what their role is in the coordinated care model and who has the resources needed to fulfill that role. "There's more than one way to get it done, but you have to define the roles to make it happen successfully," Dr. Doerr says.

5. Credibility and trust. The first four C's in the model all help build to this one, since building relationships and staying with a patient throughout his or her care journey help build trust. "If you can help patients through the first four, that's a significant part of getting here," Dr. Doerr says. "If I am not credible to my patients then I am nothing more than a referral clerk."

Having credibility and trust with a patient are also important in a value-based model because patients who trust their physicians are more likely to listen to the physician's advice and follow a care plan, which typically lead to better health outcomes.

6. Collaborative learning. While care coordination takes place among care providers, collaborative learning can happen between payors and providers. The two groups have traditionally been enemies, but, according to Dr. Doerr, this care model can break down those walls. "The Advanced Primary Care Model transcends the relationships between payor and provider, and new value is created through communication."

Collaborative learning can involve sharing information to better manage the health of a population. For example, through collaborative learning and the sharing of information, providers can discover which patients are overdue for screenings, and payors can receive information on their customers. Additionally, the payor's facilities can trade tips, tricks and best practices to provide accountable care.

The trading of information among providers and between providers and payors can help physicians achieve the high-quality and low cost aspects of the "Triple Aim Plus One."

7. Cost-effectiveness. Providing cost-effective care is crucial to achieve cost savings, part of the triple aim. Cost-effective care is a hot-button issue in healthcare, but Dr. Doerr has some suggestions for primary care physicians making the accountable care transformation. "Most of the time, cost-effective care is based on the right diagnosis, the right care in the right place by the right provider at the right time," he says.

Further, primary care physicians can make a conscious, proactive effort to take healthcare cost information from payors — through collaborative learning — and translate that into making more cost-effective decisions with patients.

8. Capacity expansion. There are two main ways a primary care physician can expand his or her capacity, according to Dr. Doerr: team care and virtual visits through email or telephone.

For team-based care, physicians work with nurse practitioners, case managers and other physician extenders to care for patients. In this office model, participants are required to work at the top of their licensure.

9. Career satisfaction. While the main goals of the triple aim are related to patients, the "plus one" addition is all about physician satisfaction. Many primary care physicians are feeling the effects of burnout — family medicine and internal medicine are the third and fifth specialties with the most burned-out physicians, according a recent Medscape survey — and primary care physicians in the U.S. are paid about half as much as specialists, which combined lead to low career satisfaction.

Following the prior eight C's all contribute to improving career satisfaction among primary care physicians. Lengthening office visits allow physicians to create relationships with patients, which leads to satisfaction, according to Dr. Doerr. Additionally, providing value-based care aligns incentives around value, which can also boost satisfaction.

Overall, the Accountable Primary Care Model has been proven to help primary care physicians deliver accountable, value-driven care and achieve the Triple Aim Plus One of improved care quality and population health management, lower costs and improved physician satisfaction, according to Dr. Doerr.

More Articles on Accountable Care:

ACOs: The State of the Union
A 3-Phase Approach to Meet Healthcare Triple Aim: 13 Ethical Considerations & Recommendations

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