American Medical Student Association

Help Wanted?

Social support networks can meet patient needs doctors didn’t even know about. But you have to learn to ask.

by Avery Hurt Volume 58, Number 9

Physicians have always been mostly solo acts, despite the legions of nurses, lab techs and front desk staff, without whom doctors could not practice. And the typical medical clinic has often been less a part of the community than the names on the signs might suggest. The doctor sees the patient. The doctor treats the illness. The patient goes home. The doctor sees the next patient.

But as any patient or relative of a patient will tell you, illness is more complex than blood work and X-rays might suggest. In the real life of real patients, the business of health care does not start and stop in the consulting room. Figuring out how to pay for the medications, arranging transportation to doctors’ visits, getting home health care when needed, filling out forms for financial assistance and insurance reimbursement, getting answers to questions about all of the above—these things and more are an integral part of the health care process. Physicians who ignore these social issues are providing incomplete care. Yet dealing with all these details, in addition to diagnosing and treating illness, often seems beyond the capacity of the typical medical clinic.

Nuts and Bolts

“It is unusual for doctors to know what resources are available in the community,” explains Martha Pollack, a medical social worker and director of social services at the United Jewish Council of the East Side in New York. From the complexities of Medicare and Medicaid to less obvious things such as Meals on Wheels and home health care, physicians simply do not have time to educate themselves about these services, says Pollack.

In order to tackle these issues, the American Academy of Family Physicians (AAFP) calls for a new ap-proach to medical care, in which primary care is at the heart of the action. Their approach, the patient-centered medical home (PCMH), is getting plenty of attention, even in the White House. The program is intended to re-design primary care practices in order to serve patients in a more comprehensive way. “We are trying to move medicine from organ-specific to patient-specific to get away from the individual physician toward a care team,” says Dr. Terry McGeeney, president and CEO of TransforMed, an initiative of the AAFP designed to help physicians and their practices adopt the PCMH philosophy. Though the PCMH concept is still being studied and evaluated, the ideas that drive it are already being implemented in a variety of ways.

Pollack has spent years working with physicians to coordinate just this kind of care. “The most important thing for doctors is to look at the patient as a whole person: where they live, what kind of family support they have, what foods and medicines they can afford, and so on,” she explains.

“Medical practices need to do a better job connecting with community resources,” agrees McGeeney. That is where the team approach comes in. Physicians need to spend their time doing what they are trained to do and what they do best. Having a designated person in the office whose job is to coordinate with social workers and aid agencies can make a complex system much more manageable. Usually, says McGeeney, this person, often called a case manager, is one of the nursing staff. This nurse will work directly with social workers and outside aid agencies to make sure patients are getting the full range of services they need.

For example, patients are often unable to afford their medications. Pharmaceutical companies often have patient assistance programs (PAPs) that provide these meds free or at very low cost. However, applying for these programs can be complicated and requires the doctor to fill out and sign forms. The doctor has to carefully check the forms for accuracy, making sure the medication and dosage requested are correct, and so on. Often when the patient brings the forms to the doctor to be filled out and signed, the patient hasn’t completed his or her part correctly, says Dr. Rich Sagall, president of NeedyMeds.com, an online source of information about PAPs and other programs (see Resources below).

A case manager familiar with these programs can assist the patient in dealing with the paperwork and allow the doctor and the rest of the medical staff to do their jobs, while ensuring that the patient gets the needed help. The case manager reviews the paperwork and fills out the forms. The physician simply signs the application, knowing that a member of his staff has vetted the details. The system works similarly for a host of services like Medicare, Medicaid, the State Children’s Health Insurance Program, and home health care.

The health care team goes far beyond the medical office, reaching out into the community and including social workers, health care aides, benefits counselors and more, but the case manager in the office connects the physician to this larger web. “It takes more time and effort to implement,” Pollack admits, “but in the long run, it saves time.”

Many pilot programs are already testing various forms of something like the PCMH. However, one system already works very much this way and works exceedingly well. The Veterans Health Administration (VHA), with its system of community-based outpatient clinics (CBOCs) and on-staff social workers (both primary care and mental health) is considered by many to be a model of efficiency. VHA doctors are very much aware of the social needs of their patients and the options that exist for meeting these needs, says Amanda Hart, a primary care CBOC social worker with the Birmingham, Alabama, VHA.

However, even with knowledge of needs and programs, coordinating such a diverse team can be tricky. The key, Hart says, is electronic medical records. The VHA has electronic medical records and an encrypted e-mail system that keeps the entire health care team in the loop. “If I write a note about a patient, I can add as a signer anyone who needs to know, and that person will get the information immediately.” Hart is optimistic that electronic medical records will be a fact of life soon. “It will happen; we are in an electronic age,” she says. However, she is not so confident about getting more people involved in patient care. “Some for-profit systems are laying off social workers,” she points out.

But Does It Pay?

And that brings us to the money problem. A report by the AAFP (see Resources below) offers suggestions about how a private practice can be set up to implement these ideas and still make a profit, primarily by capitalizing on efficiencies and making better use of computerized records. However, most experts agree that under the current payment model, it will be very hard to practice this type of medicine. Yet many experts also insist that, difficult or not, this is what the future looks like.

Dr. Larry Green of the department of family medicine at the University of Colorado is helping design primary care residency programs that will prepare the next generation of family doctors to practice this kind of medicine. Green believes that over the past decade, a consensus has developed that all roads lead to PCMH. Nonetheless, Green admits that all these roads go through some kind of payment reform. “My own view is that there is no choice but to continue to move forward with a new model of primary care,” says Green, “but simul-taneously, we must be working on changes in payment methods. If you ask, Which comes first, the chicken or the egg? the answer is yes.”

Meanwhile, says Green, there are lots of workarounds. The change is already being made by what Green describes as “innovative people who refuse to be held back by obsolete structures.”

Resources

What’s Out There?

www.NeedyMeds.com  
Though it is primarily for finding help with the cost of medication, this site is almost a one-stop shop for information about various aid programs.
Eldercare
www.eldercare.gov  
Health Assistance Partnership by State
www.healthassistancepartnership.org/ship-locator  
Medicare
www.medicare.gov  
Veterans Health Administration
www.va.gov/health  
Children’s Health Insurance Program
www.cms.hhs.gov/home/chip.asp  
Meals on Wheels
www.mowaa.org

How Do We Make It Work?

The American Academy of Family Physicians (AAFP) offers suggestions on establishing practices in the model of the patient-centered medical home (PCMH).
www.aafp.org/online/en/home/publications/journals/fpm/preprint/kuzel.html  
TransformMed is an AAFP initiative designed to help physicians and their practices implement the PCMH philosophy.
www.transformed.com/resources.cfm  
TransforMed also supports the creation of pilot residency programs.
www.transformed.com/p4.cfm