Decoding Healthcare

Episode 2: Expanding the care team

  | October 20, 2017

Traditionally, physicians have been at the center of patient care. But population health depends on expanded care teams that include nurses, care coordinators, and even clinical pharmacists.

Rob Fields, M.D., medical director of the Mission Health ACO, talks about managing those teams — from encouraging doctors to embrace clinical standards of care to measuring the work of community partners.

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JOANNA WEISS: This is “Decoding Healthcare.” I’m Joanna Weiss.

KEVIN BAN: And I’m Kevin Ban.

JOANNA: And, Kevin, I don’t know if you’ve heard, but the universe is expanding.

KEVIN: Yes I’ve heard the universe is expanding. I’m not an expert here, but I’m a doctor and will have an opinion.

JOANNA: I’m sure you will. I am not an expert in the cosmos either, but I know this has been a year of big astronomic events, and I also know that we might need to consult the stars to figure out what is happening next in healthcare.

KEVIN: You’re referring to the solar eclipse, am I right about that?

JOANNA: Yes, that is something that happened.

KEVIN: Well, I’m not sure about the universe, but the one thing I can tell you is back here on Earth, new payment models are really driving change.

JOANNA: And that means that care teams, much like the universe, are going to expand.

KEVIN: I see what you did there. Now I got it.

JOANNA: I know. I’m going to keep going. We are getting to the point where we are looking at doctors not as individual burning stars but as members of constellations, and that isn’t always an easy adjustment.

ROB FIELDS: Some providers just have a hard time letting someone else manage—put in air quotes here – “their patients” instead of “our patients.”

KEVIN: That was Dr. Rob Fields. Rob is the medical director at Mission Health Partners ACO in Asheville, North Carolina, and he has spent a lot of time thinking about care delivery and building out teams.

JOANNA: I can imagine that is a really hard thing to do. As a doctor especially, you’ve got a certain mindset that you’ve been trained with, and now you’ve got to change it completely.

KEVIN: It’s very difficult. We spend a lot of time learning how to care for patients. We do that in a certain system, and then to change that is not our forte. That requires a lot of change management, and the truth is we’re often not that good at it.

JOANNA: So, we’re going to talk to Rob today about how to do that change management, how to build and manage care teams, how to get doctors to embrace clinical standards of care, how to measure the work of community groups that help with social determinants. So let’s dig right into your conversation.

KEVIN: Rob, help me understand exactly what you mean by “the art of medicine is behavior change.”

ROB: What we’re finding is that the knowledge and the internal algorithms that we go through to make clinical decisions more and more are being replicated in our artificial intelligence ways. So we can go online, for example, and  any consumer can get online and get base knowledge on how to manage heart failure or diabetes or high blood pressure. The knowledge is less of a secret than it used to be—that’s not really the art of it at all and the joy of medicine. The really important parts when I think about the art of medicine are the patient interactions, [and] how do we motivate behavior change in patients to self-manage their chronic illnesses and get to better outcomes? I think that is the challenge.

The art is less about the knowledge but more about … how do we transfer that knowledge to patients in a way that they can absorb and then do something with it? I mean how do we get patients to change their diet, to exercise, to do the things they need to do?

KEVIN: That’s really interesting. You’re actually seeing really the role of the physician changing significantly as a result of everything that is happening with technology and with data. What is the key role of a physician and her interaction with a patient?

ROB: I think simplistically you could say that it’s more of a coaching model. Maybe I would call it informed compassion. I mean what patients are looking for, and certainly in the primary care side more than anything else, is less of a technician; they assume quality in almost every instance, but what they don’t assume is that the person listening is actually going to be invested in them as a person and actually have compassion. And that’s a sad state, but that is exactly where I feel like we are most of the time. And we look at several studies evaluating patient experience [and] patient satisfaction in the healthcare industry, that comes up over and over again.

KEVIN: A lot of people talk about data and how it’s beginning to shape the way we care for patients. The criticism is that it’s just too much, we just have too much data and we’re trying to make medicine somehow a cookbook type of approach to caring for people, and that it’s really reducing people to numbers. How would you respond to that?

ROB: I disagree with that completely. I do agree that there is a lot of data and that … in the typical model of practicing medicine, it’s difficult to decipher what is relevant and what is not. I buy that, but I disagree with the concept that it’s turning into cookbook medicine. If someone, for example, has an A1C of 9 where they’re clearly out of control with their diabetes … there are plenty of published studies, there are standards of care that exist and can be readily found to help the provider in making a decision or recommendation as to what to do next. That’s not the difficult part. The difficult part is using not only the data but also the individual characteristics of the patient, their demographics. Where are they financially? Can they afford the medicines I’m about to prescribe them? It’s taking all those other elements in the context of the data to provide the best outcome.

KEVIN: What is the crux of the problem? What are we getting at here? It’s not the data; what is it?

ROB: On the provider side, it’s the inability to impact other things besides the medical pieces that actually make a difference. If you don’t have those other parts right, if you don’t know the patient well enough or their story well enough, you won’t be successful, period, and the patient won’t reach their goals.

KEVIN: What we’re really seeing, and this happens across many systems, is as people dive into the data and they begin to understand it, it leads to transformation of care, and roles really begin to change. So, what does that look like for you guys? How did the physicians initially react to the data? And then subsequently, as you have gotten deeper into value-based care, what type of change has happened?

ROB: One of the things that has changed is how we staff. In a very concrete operational way, what has been clear is that a lot of high-performing providers out there do a great job with the patients that are in the office and the patients they see every day. They are able to counsel them appropriately, get all their needed preventative measures done for the patients that they see, they have good outcomes, everything is great. But what many practices—even high-functioning practices—lack is really managing the population that is not in the office. How do you have line of sight on the people that you don’t see regularly? And you can get very busy and very absorbed, I think understandably, in the chronically ill patients that come to your office four, five, six, seven times a year, or more in some cases, because they are intensely sick. But how well do we do on the patients that we don’t see all the time or we see once a year or [who] somehow disappear and only show up once every year and a half, that sort of thing, often in crisis?

That’s where I think I’ve seen the biggest shift … doing more outreach from the practice to manage the greater population and not just the folks that they have line of sight on day to day.

KEVIN: How do you guys think about that now? I’m assuming that it’s not the doctor who is reaching out to these people. How do you guys achieve that?

ROB: You’re right—it’s not the provider. There is already too much … day-to-day work [in] the office to really add that on, but it is about changing your staffing model to be ready for value-based care. Sometimes that means adding an additional medical assistant or, if you have the resources, a clinical pharmacist or an LCSW. We’re seeing medical assistants now run registry reports on … blood cancer screening, colorectal screening, their diabetes follow-up, that sort of thing, and doing more outbound approaches.

And sometimes it may not even involve the provider at all, but it doesn’t mean [patients are] getting bad care. It’s been a little bit of a leap of faith. Providers often feel a great sense of ownership of their patients, and so if you’re talking to them about having protocols in place where the medical assistant can just go ahead and order the colorectal cancer screening or the breast cancer screening or have a clinical pharmacist do an outreach for somebody and really help them manage their diabetes independent of the provider, as long as they’re getting to the right outcome, that’s not bad care and it’s not a replacement at all of the provider; it’s really an extension of. And that is a philosophical shift that has been in some cases difficult, depending on where the provider is coming from.

KEVIN: The team can really work together, and ultimately what this does is it pushes the physician to the top of their license. I know everyone says that, but that’s what happens, and then you have other people who are doing the outreach and the engagement. In your experience, who are the best people to do that type of work?

ROB: We’ve had great success in a typical primary care practice and even in a specialty practice with high-functioning medical assistants. So you take an experienced medical assistant, and they can be wonderful, very high-functioning. We have also had incredible success with clinical pharmacy.

KEVIN: Tell me more about that. That’s a big deal, so let’s dive into that.

ROB: Traditionally pharmacists have been pigeonholed into specific roles. So, besides just being a dispensing pharmacist, we often, even in clinical pharmacy, will relegate those roles to anticoagulation and prior authorization. Talk about not using someone to the top of their license.

With a clinical pharmacist in place—a CPP, clinical pharmacist practitioner—they can use them almost like an advanced practitioner, like a nurse practitioner or a PA. One of the ways that we use them in the office, for instance, is—let’s say I see a patient who is perhaps new to insulin. Not only can [the CPP] provide education, but often I will depend on the clinical pharmacist to do follow-up phone calls and titration of the insulin to get [the patient] to goal. So you think of the standard model … at time zero I have started the insulin and I make a change, perhaps give a little bit of guidance on titration for the first few weeks, but then I’ll see them back a few weeks later—sometimes it can be a month or even in some cases three months later—and it’s hard to have real-time change during that process, in between visits. Whereas if you set a care plan and you have a clinical pharmacist follow up, you can have real-time titration of the medication, so by the time you see them they can be much closer to goal than they would have been otherwise with just incremental change, and you can do that with blood pressure, you can do that with diabetes, you can do that with heart failure.

KEVIN: Do you embed them into clinical practices?

ROB: Absolutely.

KEVIN: Tell me more about that, and even how the physicians perceived it upfront versus now.

ROB: It just takes some small wins, to get a patient to goal, for instance, or to identify a potential medication error or identify a situation where the provider didn’t know that they prescribed X but the patient was already taking Y, and the combination would have been disastrous. And when we get those small wins, that has really helped.

Financially, we are not fully in the value-based world. Most of our reimbursement comes fee-for-service, so I think paying for a clinical pharmacist has sometimes been an issue, but there are some great published models out there. Using clinical pharmacists to do your annual wellness exams, which in the value-based world is huge … if you can increase the utilization of the annual wellness visit and the completion of annual wellness visits, it helps in your attribution within the MSSP, for instance, as well as other value-based arrangements in the Medicare Advantage space. It allows for closure of gaps during the Medicare wellness visit, and it allows a fee structure that helps pay for the clinical pharmacist to do other work that is not readily reimbursed in the typical Medicare world.

So, it can be done, and again, in particular, in the value-based world it can be immensely valuable.

KEVIN: I’ve had several conversations about “if you could only do one thing, what would that thing be,” and I’ve heard a lot of people say, “I would focus on the annual wellness visit.”

ROB: From a value perspective, it’s worth everything we do to boost those numbers up. It’s better for patients. Providers in general do not like the wellness visit. It doesn’t fit right into the provider structure or culture, and the fact that it doesn’t actually include an exam … people have a hard time getting past that, and the patient honestly has a hard time with it. They come to see me, they expect me to at a minimum listen to their heart, lungs, and touch them and examine them, and they also will come to me with other problems that have nothing to do with their preventative visit. So, I think it actually works better to have a pharmacist do it, because it’s less distracting and it feels more natural.

KEVIN: Rob, when you think about the work that you’re doing, what are some of the more successful programs or the ones that show most promise?

ROB: Our entire care coordination model is based on social determinants, and I know that every ACO I talk to gives at a minimum lip service to the concept of social determinants. What we do differently is hold our care coordinators accountable for closing social determinants gaps, and our care coordination tool allows us to do that. If we do an assessment on a patient for whatever reason, based on the risk score or referral or a transitions call, we do an initial assessment for care coordination … along with their clinical needs and their clinical status, we assess their social determinants needs, so housing, transportation, finances, etc.

And then we have a network of community partners that are actually engaged in the tool. They log on to the tool just like a provider would or a nurse would, and when they receive that referral from the patient, they have line of sight into the care plan. When we talk about who is coordinating the care coordinators, we are starting to build that community network model for social determinants in the context of a health network, which I think is unique in the way that it’s been done so concretely. Operationally, not only do we run typical productivity reports on things like number of phone calls [and] number of touches to patients, we actually track closure of what we call pathways, the social determinants pathways.

It’s not really as a measure of how well the care coordinator is able to solve social determinants problems, but it’s how well we are doing as a community and where our gaps are and where we need to build resources so we can use it as a mode of advocacy. So I’m particularly proud of that.

KEVIN: That’s a great point, because a lot of times I think there is a reluctance even to ask the question, because you’re not sure what you’ll do with the answer, and that is a key element to this, right? Like if I’m going to ask you about your living situation or food insecurity, I have to feel like I can follow up on that. Otherwise it’s just sort of this hanging chad that I don’t know what to do with.

ROB: That’s right, and there is nothing more discouraging as a provider of any sort, whether you’re a physician or a nurse or anyone, where you’re drawing out potentially sensitive information from someone and then have nothing to do about it when you get to—I’ll say the bad answer. You get the answer that is often a tragic story or a desperate need, and … what do you do with it? We have developed a community network, and we target our assessment specifically to the agencies that are available to that patient. So, each agency has its own care coordinator. Often the housing agency is trying to solve a food insecurity problem or a transportation problem, which is not their expertise, but they’re left trying to deal with the whole person.

As we mature and grow that network—not just a network of providers but our network of agencies and our community—that would be a huge sign of success: we can facilitate the work of all the nonprofits to make them much more efficient than they are now.

We have several other programs I’m really proud of. We have a community paramedic program, which is not unique to us, of course.

KEVIN: A community paramedic program. Tell me more about what you’re doing.

ROB: Our care coordination team is primarily phone-based, so 95 percent of the outreach is really just over the phone. Frequently we need someone who is in the home assessing safety, doing a medication reconciliation, just being the eyes and ears on the ground, and we can dispatch a group of community paramedics. In their normal day job [they] are part of our regional transport services, so these are folks that are critical care-trained paramedics that transport folks from community hospitals, smaller regional hospitals, or critical access hospitals back to the tertiary care center, or from one ICU at one hospital to another. And they carve out part of their time to work with us to be dispatched. There is no charge to the patient. There is no billing involved. But we can send the paramedic to the home to do anything from a safety assessment to a clinical assessment, medication reconciliation, often just establishing a relationship.

We have a great story of a patient who was labeled as non-adherent and perhaps belligerent. He had fired home health. He had fired the local Council on Aging, had difficulty really engaging with the provider and showing up to the office. So we received a referral to go see this patient. The first three meetings with the patient occurred in the driveway in the community paramedic vehicle, because the patient refused to let him in the house.

KEVIN: Right, it was sort of a process of building trust somehow.

ROB: Absolutely, and after those three or four visits, the patient agreed to let the paramedic in the home, and it turns out that he was a hoarder. And he had no heat and no running water. He had a rain catchment system for water. So you can imagine a man with COPD and other health conditions in a home with no heat in the winter and no running water. It was not a good situation. But because there was that relationship built, he ultimately, and we’ll fast-forward, reengaged the community partners and got him to the right outcome and his home repaired and the house cleaned up. But it took that relationship. And it wasn’t specific to a paramedic, but it was specific to having someone that is willing to put in the time to build that relationship.

KEVIN: That is the type of hard work that really needs to happen, and I think anyone who gets involved in value-based care begins to understand that this is not about diagnosis and treatment; this is really about the social determinants, and that is a really powerful story.

Do you then get asked later by financial powers within your system, “Dr. Fields, can you help us understand what the ROI on this is?” That story is unbelievably powerful, but I think if you were asked to sort of generate an ROI—what does that look like? That feels like a totally different conversation.

ROB: Yeah, it’s challenging and it’s imperfect. We can look back at historical utilization … and cost savings, and so we could go back and look at historical ER visits and admissions, and then try to extrapolate from that, “Well, because we did this”—whatever “this” might be—and “the ER visits reduced by this amount, well that is because of us.” And it’s funny, if you talk to other ACOs that have achieved shared savings and you ask them, “Well what did you do?” most of them have no idea, because you don’t do one thing, you do seven things, and you hope that any one or some combination of those seven things actually adds up to a success story or multiple success stories. That’s closer to the truth that it’s really messy and to point to any one intervention is difficult.

JOANNA: Kevin, that was fascinating to me, partly because it acknowledged how much healthcare by necessity takes place outside of a doctor’s office.

KEVIN: Before we got into value-based care, I don’t think people had a deep appreciation for how much people’s lives get in the way of their care, and … these are the types of stories that begin to emerge as you get into value-based care. These are really complicated situations that are going to require out-of-the-box solutions, and as you start to get into value-based care, as you turn the payment model on its head, it’s these type of innovations you see.

JOANNA: On the other hand, so much of healthcare is still centered in the doctor’s office, and so much of this innovation has to be driven and supported by healthcare systems.

KEVIN: There is a certain amount of blocking and tackling. This is meat-and-potatoes work that needs to get done. What Rob is talking about is very innovative  …treatment schemes, but the truth is doing the basic stuff, like managing your network—something we’re about to talk about in our next upcoming episode—is fundamental.

JOANNA: Right, not just financially but because the information that you’re gathering from those patients needs to stay in network as well.

KEVIN: It’s better care and really the right thing to do for people.

JOANNA: “Decoding Healthcare” is a production of athenahealth.

KEVIN: Our producer is Nikki Zais. Our engineer and composer and jack of all trades is Mike Moschetto.

JOANNA: You can rate and review us on Apple Podcasts, Stitcher, and Google Play, or wherever you get your podcasts.

KEVIN: And you can follow us on Twitter @athenahealth. I’m @KevinBanMD.

JOANNA: And I’m @JoannaWeiss.

KEVIN: And for more stories about healthcare in America today, go to




Episode 2: Expanding the care team