The New Model of Primary Care at BMC

Melanie Cole (Host): No matter which type of primary care you chose, you have a medical home at BMC. This means you become part of a primary care team which provides a new, expanded type of care. My guests today are Dr. Jason Worcester. He's the medical director and general internal medicine and Dr. Christine Pace, she's a general internal medicine physician, both at Boston Medical Center. Welcome to the show doctors. So, Dr. Worcester, I'd like to start with you. What is a patient-centered medical home and how does that benefit patients? What really is it?

Dr. Jason Worcester (Guest): So, a patient-centered medical home is an all-encompassing patient driven health care model. It's a model that enables our patient to get a variety of services from a multiple of team members, but at the same time, allow patients to feel like they are an individual patient and part of the team.

Melanie: So, Dr. Pace, how does this medical home coordinate the health care needs helping people to stay well, or preventive check-ups, visits to specialists, admissions, kind of give us a rundown on what that means?

Dr. Christine Pace (Guest): The big part of it is a more team-based approach to care. We know that patients with chronic diseases typically need multiple touches from their care team, not just one visit with one physician every few months, for example. So, for a patient with diabetes in our practice, they might see their regular primary care doctor for a check on their blood pressure, how their diabetes is going, what preventative services they might need for wellness, and the doctor might say, you know, I would like you to see my nurse practitioner colleague in two weeks for a check on that blood pressure and to see how your sugars are on this new medication regimen. They might see the nurse practitioner in a couple of weeks for some extra coaching and further medication adjustment, and if they’re still struggling, a pharmacist or a diabetes nurse educator might become involved, also. So, it's really providing patients with more wrap-around support and from team members who are really experienced and expert with coaching patients around behavior change, which we know the doctors are not always as experienced with.

Melanie: So, Dr. Worcester, I'm going to go to you on this same topic about behavioral health and lifestyle modification. How are you integrating that into the primary care setting?

Dr. Worcester: So, in terms of behavioral health integration, the traditional model for behavioral health and psychiatric care has been generally siloed from primary care practices. What we've done at Boston Medical Center is enable our social workers and psychiatrists to actually work side-by-side our physicians and nurse practitioners in our practice. This has enabled patients to actually see a behavioral health specialist within our practice. This has allowed patients to feel that they don't have to go elsewhere for this really important care. In terms of motivational and behavioral health change, we're really utilizing our entire team to enable patients to make lifestyle changes. The traditional model of just having one physician talk to the patient and instructing them how to change their life, we found is -- although it sometimes can be helpful -- is not generally not too successful so what we're doing is getting all our team members involved whether it be nursing, clinical pharmacists, or behavioral health specialists or medical assistants, all working on the patient's behalf to help them make lifestyle changes.

Melanie: Dr. Worcester, what does that team look like? You mentioned a few practitioners and healthcare providers. When we are talking about other kinds of lifestyle modifications like exercise, nutrition, if a diabetic is not sure what they can or cannot eat, how is that model all encompassed into this?

Dr. Worcester: Well, what could happen if you take our, say, a typical diabetic whose blood sugars maybe are not well-controlled or the patient's struggling trying to control their blood sugars, we'll have them see the physician who will be the primary caregiver for that patient, but at the same time, they will also may see one of our certified diabetic educators who, in our practice, is a registered nurse who will see the patient, review their medications, review their lifestyle, really get into details about what are the reasons and the barriers that the patient may not be achieving control of their diabetes. During the same day, may also see one of our clinical pharmacists who can review in-depth the medications that they're on and make fine-tune changes to really improve their diabetes control. You know, at the same time when they're walking into the clinic, they'll be greeted by one of our medical assistants and the medical student may ask how they are doing as well, so really trying to have the patient being exposed to multiple different team members to really get, you know, a continuous feedback of how they are doing.

Melanie: And Dr. Pace, you’ve both mentioned pharmacists being involved which is interesting and not that usual and especially with the geriatric population, and they're on so many medications. They don't know what each medication does. How is this pharmacist involved with the geriatric patients and their families trying to get it so that they adhere to the medications and understand which ones are for what?

Dr. Pace: So, we have a really phenomenal team of pharmacists, so we have PharmDs, so they are both with doctoral level degrees in pharmacy as well as pharm techs, and they offer sort of a spectrum of care around pharmaceutical services. So, the PharmDs that Jason mentioned can really get involved with medication adjustments and then they can also, for example, meet with someone who has tons of medication, what we would consider polypharmacy, to help collaborate with the PCP in peeling back some of those medications, deciding what's really not essential and perhaps causing harm in that situation. So, the PharmDs think about the regimen and work with the PCP to make it as appropriate and really as short a list as possible. Our pharm techs are also incredibly helpful and the big focus for them is supporting patients around medication adherence. So, they can do things like work with the pharmacy itself to have blister packs sent to the homes so that the patient doesn't have to go to the pharmacy to pick them up and so that they are packaged in a way to maximize their ability to take the medication.

Dr. Worcester: And I will add that this all takes time to arrange medication, review adherence, arrange blister packs. This takes a lot of time, and this all can't all be accomplished in a single visit with a single physician. It really takes time above and beyond that and the medical home model that we've implemented at Boston Medical Center has allowed us to give patients the time they need for this really detailed comprehensive health care, especially in the geriatric population because as you mentioned, Melanie, they are so -- they are so complicated.

Melanie: And Dr. Worcester, how is primary care changed in the last decade? What have you seen as some big, really positive changes and where do you see it going in the future?

Dr. Worcester: Well, I think the things that haven't changed, I think maybe to start there is that I think patients still feel that they are identifying with their physician. I think that's one of the -- this is why we went into primary care, we wanted to feel like we're taking care of patients so, that, I think hasn't changed. I think the team approach is the new -- is something has definitely changed. If we go back 10 years ago all the care was essentially being driven by a single physician, and I think, being that the team approach expand, I think, has been a major change, and it makes it more exciting because we're able to hopefully get more done for patients, and patients are actually hopefully getting better care and feeling better about themselves, I think, because, I think we realize that physicians need to let go of some things sometimes, and I think that's been a positive aspect over the last 10 years.

Melanie: Dr. Pace, some people don't think they necessarily need a primary care doctor -- that they just go when they're sick. What would you like to tell them about that?

Dr. Pace: So, I think, I guess I have two thoughts on it. I certainly do think that someone who's, you know, 25 and generally healthy -- there's actually mixed data on whether they actually need a physical exam every year, but putting even the physical exam aside, it can be incredibly valuable to have a relationship with a primary care provider for those times when you are sick. It's incredibly challenging to go in when you are sick and meet with somebody who doesn't know your baseline, know you, your values, your usual level of activity, things like that. So, just having someone who you're establishing a relationship with, just in case, is really important. As you get older, 30, 40 on up, where there’re actual aspects of preventative care that you need to meet with the doctor about or a nurse practitioner provider. So, you know, I think especially 40 onward, you certainly need to have somebody who's your point person for working on general wellness, and I think most of us, you know, even starting in our 20's have a few chronic conditions that are at play for us, whether it's anxiety or just struggling with stress or whether it's thinking about your family planning, things like that -- almost everybody has some issue related to that that they need a primary care provider's support around.

Melanie: And Dr. Worcester, the American Academy of Pediatrics has been recommending a medical home for quite a while now, and is pediatrics a part of this? People don't typically think of primary care providers or family medicine now being involved with pediatrics as well, so speak about how pediatrics comes into this picture.

Dr. Worcester: Well, for us, at Boston Medical Center, we're an adult practice, but what we've done is collaborate with our pediatric and adolescent clinics here at Boston Medical Center to continue that primary care relationship because as we know, as kids and adolescents get older, they need to be transitioned to a new physician and that's many times difficult for some patients because they've been -- many times -- being followed by the same doctor for 18 years and then having to transition to a new doc -- to a new practice -- can be distressing to some. So, I think collaborating with our other primary care specialists, I think has been a nice way to bridge that gap for patients so that they actually get established with a new primary care physician.

Melanie: So, Dr. Pace, wrap it up for us with your idea of this primary care model, what you want listeners to know about it at Boston Medical Center and what you really want them to hear about being involved in their own healthcare and being their own best health advocate?

Dr. Pace: I think medical care has changed -- the landscape has changed in terms of what the illnesses that folks are experiencing so we know that chronic diseases like diabetes, obesity, etc., are a huge part of our patient's experience. The medical system that was designed for us hundreds of years ago was really oriented towards very episodic care, and we know that that’s not appropriate management of chronic diseases, so I think that's one thing that the medical home – holistic, longitudinal, comprehensive care helps patients manage complex chronic disease -- is really important. There's really no other way to appropriately care for our patients.

I think, number two, we know a lot more about wellness, and we have many more services available to help patients with preventive health care. So cancer screenings, there's multiple ways that we support patients with cancer screenings throughout the life cycle. The wellness alone, I think, it could be hours and hours and hours just to make sure that someone's received all the preventive healthcare services they need so that's another reason why this team-based approach is really important. Ultimately, your primary care provider is still your primary care provider; that's your point person, but they're sort of the quarterbacks of a team approach to helping you stay well.

Melanie: And, Dr. Worcester, kind of reiterate the information for listeners about your team, and what you want them to know about getting involved in the medical home.

Dr. Worcester: I think it's important to realize that coming into a medical home as the patient may be a different experience for you. You're going to see providers other than your primary care physician, but also, at the same time, to realize that they are there to help you and that your primary care physician can't do it all, and they are really relying on that team approach, and I think once you recognize that and understand that the entire team is trying to take care of you, I think there is strength in numbers and strength in a team, and I think overall you're going to be in better hands, and I think you'll probably have a better experience as well as hopefully a healthier life.

Melanie: Thank you both so much for being with us today. It's great information. You're listening to Boston Med Talks with Boston Medical Center and for more information on primary care at Boston Medical Center, you can go to bmc.org. That's bmc.org. This is Melanie Cole; thanks so much for listening.