Primary School

Launched in October 2010 with a $30 million gift from an anonymous donor, the HMS Center for Primary Care is taking on the challenge of transforming primary care medicine, improving the training of the field’s practitioners and leaders, and supporting the development of innovative systems in health care delivery. The Center represents a vibrant community of students, faculty, allied health professionals, and staff at its affiliated clinical sites.

In this interview, Russell Phillips, the Center’s director and the William Applebaum Professor of Medicine at Beth Israel Deaconess Medical Center, and Andrew Ellner ’04, Center codirector and an HMS instructor in medicine at Brigham and Women’s Hospital, talk about primary care, family medicine, and the overall goals of the Center.

Q: What role do you and others at the Center hope HMS will have in shaping the future of primary care?
Phillips: We would like the School to take a leadership role in the coming transformation of health care. To help make that happen, the Center will focus on leading a redesign of both primary care practice and education at HMS.

Q: Creating effective teams seems to be essential to the redesign of primary care. Why is the team approach so critical?
Ellner: One big driver is the need to make the work of primary care doctors more sustainable and more joyful. Primary care has been a hard specialty to practice, with an increasing number of expectations of what could or should be done for patients within the primary care setting. Innovations in the way care was delivered grew out of a need to find new ways to meet these increasing demands. One area of innovation focused on changing the delivery of care so that it wasn’t so dependent on the individual physician, but instead involved a team. This has influenced thinking about teams of providers working with individual patients, and about looking across populations of patients to be more efficient or effective in the way a clinic or a practice serves a group of people.

Q: I understand the Center also is interested in growing the family medicine presence at HMS. Why?
Phillips: From my perspective as an internist, family medicine has placed greater focus on the whole person, on improving communication skills, and on changing health behaviors. And because family medicine physicians take care of the whole family, they have perspectives on adults of all ages and on children, on family and community dynamics, and on the relationship between families and health. It’s an approach that fosters a different skill set from internal medicine or pediatrics and brings a valuable perspective to the primary care workforce.

Q: HMS has not traditionally offered opportunities in family medicine to its students. Do you anticipate this will change?
Phillips: I do think this will change. We are talking to leaders at our affiliated teaching hospitals and soliciting their interest in creating a training program in family medicine. It’s our hope that one or more of the affiliates will be interested in creating an academic department or division at their hospital, with the possibility of starting an academic department in family medicine at HMS eventually. We have a new $2 million gift from an anonymous donor and anticipate putting out a request for applications to leverage that gift to create a family medicine training program.

Q: Are the changes to health care being introduced by the Affordable Care Act helping to drive this interest?
Phillips: Interest in incorporating primary care and family medicine into the School’s curriculum had been growing before these changes, but the requirements of the Affordable Care Act have definitely helped. Most of our academic medical centers are now part of accountable care organizations. Under the new payment models for ACOs, a network’s success will depend on its ability to manage the health of large populations of patients, so a network’s primary care base will be an important strategic element for its success and survival. Our affiliates are focused on the question of who their primary care doctors will be in the future. They’re also interested in learning how to manage a primary care practice to keep patients healthy and to avoid unnecessary spending.

This transformation in health care really is a complex challenge. It’s long been thought, for instance, that if you addressed a patient’s primary illness, you would prevent readmissions. But it turns out that someone who is admitted to the hospital for one thing has an increased risk of being admitted for a lot of other problems. So it’s not just that you need to treat the heart failure a person is admitted with, you also need to treat the general chronic illness and deal with the patient’s social system.

Q: On a day-to-day basis, how will hospitals need to change the way they function?
Phillips: Under the old fee-for-service model, if a patient was repeatedly admitted to the hospital, the hospital would collect fees over and over again. With accountable care, the hospital might get a set fee per year for each patient. This change will provide a strong financial incentive to keep patients healthy and out of the hospital.

Let me give you an example of this sort of situation. I was making rounds recently as a visiting professor. We saw a patient with diabetes that was so out of control that he was admitted. He was also homeless and had a drug addiction.

That patient was going to go back to the streets, and without question, was going to be readmitted. That sequence of events would not be the result of the hospital staff’s inability to provide medical care—the diabetes could be managed, the addiction could be managed—but under the old fee-for-service system, there were not the resources to help this patient break that cycle, to prevent him from coming back to the hospital, acutely ill and in need of rescue care to save his life.

Ellner: Someone like that patient might be hospitalized 30 or 40 times a year. If you consider the cost of those hospitalizations, it’s certainly less expensive to have the patient served by a primary care team that includes a social worker, a pharmacist who reviews the medicines regularly, and a nurse care manager who helps manage and coordinate care. The new payment models will make that kind of coordinated care possible.

That’s better for everyone. It’s better for the patient, who gets help to stay healthy. It’s better for society because it’s bringing costs down. It’s also a completely different experience for the physicians involved in the care; they suddenly experience what it’s like to be part of a team of caregivers. I’ve seen that transition in my clinic in the past two or three years, and it is such a dramatic change. As a provider, working alone, you can feel helpless and terrified when caring for patients who have so many challenges in their lives. Now, my patients with multiple chronic illnesses and complex social constraints have a team that includes a nurse care manager involved in their care. And every member of the team communicates with other members by email, keeping all of us involved and informed.

Q: That’s an interesting example of using technology to solve a problem. And it’s not some radical new high-tech advancement. It’s just email.
Phillips: Sometimes we just need to find ways to get simple tools into the right hands. For example, we conducted a heart-failure readmission prevention program, and we found that what helped most was giving the patients bathroom scales so that they could monitor their weight at home. We just went out and bought them scales.

Q: But is it enough for patients to just have access to tools so they can collect data and monitor their own health?
Phillips: Not at all. As part of the team care approach, patients can be empowered to monitor their own health, and they can receive the support they need to sustain their efforts. Take the homeless patient with diabetes we mentioned. In an ideal situation, if I saw that patient in my practice, we would have a care manager assess the patient’s needs before he left the hospital, probably bring in a social worker or a community resource specialist to assist the patient with temporary housing or other social safety net supports, and ensure that a substance abuse counselor talked with the patient as well. For high-cost, repeat-visit patients, the solution isn’t always more visits to the doctor and more tests. It may be something as simple and straightforward as installing an air conditioner in the house of a patient with asthma so that she has better air quality. Or buying a patient a scale.

Q: Such a complete transformation of the way health care is paid for and medicine is practiced would seem to present a daunting challenge.
Ellner: It does, but one of the exciting things for us as a faculty is to see that the challenge will be tackled by the talented, motivated students who are electing primary care medicine. These students are interested in fixing health care, and in understanding how to make complex systems work better. It’s probably the most inspiring part of our job to not just work with such students, and to remove barriers so that they take the lead on creating solutions, but also to learn from them.

It’s also exciting to know that we’re not only working with the School and the affiliate hospitals, but also with the broad resources of the University. In the first cohort of our Agents of Change project, we have a new group of medical students working in teams with folks from Harvard’s graduate schools for business, education, and public health to propose innovative solutions to problems that have been identified by the professionals in community health centers in Boston.

Phillips: That’s one part of a larger program that the Center is launching to foster innovation and to develop new approaches to how care is provided, including technologies and processes that support population management and better care coordination, and tools to help patients participate in their own care.

The Center has had great success with its Innovation Fellows program, which creates protected time for primary care faculty at the affiliate hospitals to promote care delivery innovations and cross-disciplinary collaborations, and to serve as mentors.

We don’t know what health care will look like in the coming years, but it’s clear that primary care team work and collaboration will be a central part of any change. It’s exciting to see HMS students and our colleagues laying the foundation for that transformation.

Jake Miller is a science writer in the HMS Office of Communications and External Relations.