"The medical home is a good idea, but we’re not quite getting it right yet," he said.
There are lots of reasons why primary care isn’t there yet, Dr. Brenner said. Most offices haven’t built the right kind of clinical care teams, they lack the data systems, and physicians don’t have training in this area. Primary care physicians could take lessons from their colleagues in addiction and behavioral health on how to coordinate care for these patients, he said.
"We talk about the bio-psycho-social model, but I don’t know that we have all the components and the team and the training to fully pull it off yet," Dr. Brenner said.
The coalition has been working with local primary care physicians to try to get there, embedding nurses in their offices and helping them to create protocols for the adjustment and management of medications for blood pressure, cholesterol, and diabetes.
The idea is to create standardized protocols for common clinical scenarios and then delegate as much of the work as possible to nurses and other providers, freeing up physicians to take on the complex cases. Dr. Brenner said that in an ideal primary care practice, RNs would handle the well-child visits, the sore throats, and the simple medication adjustments.
"We need to industrialize primary care so that it becomes highly reliable, it becomes protocolized, standardized, and delegated so that we can stand out on a limb and customize and individualize for the sickest and most challenging patients," Dr. Brenner said.
And he wants to see nurses and project managers given the chance to run clinical care teams.
The Camden coalition uses licensed practical nurses, RNs, and community health workers. The coalition also relies heavily on Americorps volunteers, typically 22-year-told college graduates who are taking a year off before going to graduate school to be nurses, doctors, or public health workers. Many of the tasks that physicians stay late to do – or those that often fall through the cracks – can be delegated to these other providers, he said.
"It’s time we got out of the way and let our nurse colleagues get into the game," Dr. Brenner said. "I think their training is much better suited, frankly, for running teams, for working collaboratively, and for really improving quality and reducing costs."
Working harder doesn’t work
Instead of handing off less complex patients to clinical team members, most primary care physicians try to do it all, Dr. Brenner said. They stay in the room longer, make extra phone calls, and stay late at the office for a family conference. But this is "ad hoc work" that physicians do when they can find the time or the energy. It’s not something that they can do for every patient, he said.
"We’ve got to turn all that special sauce, all that ad hoc work into standardized, protocolized, structured work that always happens for everyone," Dr. Brenner said. "The only way we’re going to do that is to delegate and delegate and delegate."
Dr. Brenner said that he knows firsthand what’s like to try to do it all – that was his approach in his own practice. He had a completely paperless office and open-access scheduling, but he tried to make everything work by simply working harder. Ultimately, declining reimbursement from payers made it impossible to keep the doors open.
"I was trying as hard as I could but honestly I wasn’t doing all the things that I said. I wasn’t delegating, I wasn’t building a high-reliability team," he said. "I was trying to just work harder personally."
As the Affordable Care Act pushes new models for care coordination, including accountable care organizations, Dr. Brenner said he sees primary care physicians playing a major role. But they will need to delegate and to get more training to be successful, he said.
"I’ve been very fortunate. I’ve been at the right place at the right time," he said. "I think there are lots of other family docs who have the same skill sets and could do the same kind of work."
mschneider@frontlinemedcom.com
On Twitter @MaryEllenNY