Value-Based Care in Action: Mr. Roberts’ Journey to Health
By Tyler Jung, M.D., Chief Medical Officer of Greater Good Health
I have practiced in and been part of the value-based care world for nearly three decades. I’ve seen and led value-based care efforts in virtually every kind of system, large and small, local and national, primary care and multispecialty, younger and older populations, and under every conceivable contracting architecture. While purposeful hiring of people, development of processes, deployment of useful data and technology are the backbone of success, I believe it is critical that efforts around value-based care do one thing well – demonstrably change the health trajectory of the patients we are serving.
My good friend, Rushika Fernandopulle, who I worked with for five years at Iora Health, would often say, “If we don’t actually change the health of our patients, we’re just wasting time.” I think he’s right. You might think changing health is what healthcare is all about because that is what all the care, consultations, tests, labs, procedures, medications, and beyond are supposed to do, right? In some instances, of course, but let’s be real. For many incredibly dedicated healthcare clinicians, the realities of transactional fee-for-service that lead to never-ending workloads often produce non-integrated and non-coordinated care. It’s hard to dramatically change a patient’s health in 15–20 minutes. Doing it alone is harder still.
Tapping into our patients is one way to change health
Recently, I had the pleasure of meeting a patient, let’s call him Mr. Roberts, who was in his late sixties. Mr. Roberts had diabetes and hypertension, was overweight, and literally rolled into his first visit in a wheelchair. He informed us that we were his fourth primary care clinician in just a couple of years. A story like this isn’t uncommon. As a provider of senior-based primary care and with the goal of changing health, we built our care team around supporting patients like Mr. Roberts. While the make-up of the care team is not elaborate — it consists of a nurse practitioner, medical assistant and a front office coordinator — their purpose is significant. Right away, the care team jumped into action and started talking to him about his health, asking questions, listening intently, and supporting him. Our team spent an hour with Mr. Roberts and created a plan. They read the plan back to him at the end of the visit and focused on an initial goal to get his blood pressure and diabetes under control. In a surprise to Mr. Roberts, the care team called him three days later to check in, asking if he was following the plan. We noted that we would call back in a few days and check in again. He said that we didn’t need to keep calling, but we did.
When he returned to the clinic a few weeks later, Mr. Roberts was surprised that we greeted him by name and remembered small details about him. He told us he had never experienced care like this before. We explained that we cared about him and wanted to be sure he knew that we were his partner on his health journey. This must have resonated with him. Slowly but surely, he felt empowered to take charge of his health and over the course of six months Mr. Roberts was a new person. He no longer needed a wheelchair and began walking one mile, then two, and finally up to five miles every other day. A feat like that would have seemed impossible for him previously. In addition to his improved mobility, his diabetes is under control, and we’ve reduced his blood pressure medicines.
More than medicine: What really made the difference
When I spoke to Mr. Roberts, he said that because his health team was so invested in him, he felt that he would pay it back by investing in himself. This was a watershed moment for me. I love our clinicians and believe they are the best in the world. Yet, I’m positive that our clinician’s prescriptions and recommendations for blood pressure, diabetes, diet and exercise were no different than what he received from his three previous clinicians. The real difference was tapping into Mr. Roberts himself and empowering him with support. Of course, not all patients are Mr. Roberts, but many are. Changing the health of patients might take more medications, tests, procedures, or frankly, less of them. Perhaps changing health is about having conversations with our patients and tapping into their motivations.
Expect more from your primary healthcare provider
When people ask me what VBC means, my answer is less about some unfulfilling quality cost ratio, but instead, more about changing health. Health, particularly for patients with chronic conditions, has a way of being inevitable. It’s incredibly hard to change health in most circumstances, not because clinicians are not trying, but because most systems are not designed to promote the kind of time needed to empower patients, discuss goals and expectations, coordinate efforts with other clinicians, and have a common care plan. Within the complexities of healthcare, it has been said that primary care is a logical place to drive value-based care. I would argue that not all primary care is positioned to drive value-based care. Primary care that is purposefully set up to change health is where I believe we will find the path to value-based care.
About Greater Good Health Greater Good Health is a premier partner for risk-bearing organizations in managing total cost of care. The company is enabling and expanding access to value-based primary care through its innovative suite of clinical solutions and its own primary care clinics for seniors in underserved communities. Greater Good Health’s proven Nurse Practitioner-led model reduces unnecessary costs, improves clinical outcomes and delivers a best-in-class patient experience.
For more information, visit www.greatergoodhealth.com.