Marc Harrison, MD: You're listening to Intermountain Healthcare's podcast channel.

Anne Pendo: Well, welcome to our podcast today from Intermountain Healthcare. My name is Anne Pendo, and I’m a practicing internist and medical director for experience of care and clinical integration. And I am excited today for our podcast. We have Dr. Marc Harrison, the CEO of Intermountain Healthcare, Chad Spain and Nick Duncan, family medicine docs at the Cottonwood Family Medicine Clinic. And Kirsten Hanson, the care manager. And today we are going to be talking about what we are calling reimagine primary care. And Marc, hopefully you can start us off with how this even came to be.

Marc Harrison, MD: So thanks, Anne. I love the idea of really working to keep people well, and to keep them in the least restrictive, least expensive environment possible. Keep them in their communities and use resources that make sense economically as well as socially. And over the years I've been exposed to some of the ideas around some of these, "disruptive or innovative clinic models" that use team based care to achieve these goals. And of course, as we move along our journey towards population health and value, understanding how to take the best care of the people who trust their lives to us is always at the front of my mind. And we began to have a conversation internally about whether in a population health and value environment, whether a very traditional volume based fee for service kind of model made the most sense to achieve the outcomes in safety, and quality, and experience, and keeping people in those less restrictive environments. To that end, we then sort of asked ourselves, should we do this ourselves? Do we have the discipline to actually change our model and do this experiment? Or do we need to bring in one of these new startup companies to do it? I was assured that we would have the discipline to not crush a new endeavor like this. And I also was assured that we had pioneers here. People who really were willing to try new things and to innovate. And it looks like we were right on both fronts. And I'm absolutely thrilled, and very honored to be with some of these pioneers here today. So that's the background, Anne. Does that make sense to you?

Anne Pendo: You know what, it does. And I appreciate that introduction. As we started this journey of reimagining primary care, one of the questions was, who would be interested in doing this? And as we met with groups of physicians, it became clear that there were a number of physicians that said, sign me up, I want to think about practicing care differently. And we've got two docs here today who were part of that. And I'll start with you, Chad. If you could share a little bit about what that was like for you. What made you say yes. Raise your hand. I want to think about this. The way I provide care to my patients differently.

Chad Spain: Absolutely. We had a clinic meeting, where at the end of the meeting it was proposed that this model may take place. And we were asked just as providers whether or not anyone would be interested in doing this. Initially based off of more of a geriatric model. And there wasn't a whole lot of interest initially, but to me it sounded like an opportunity. I know with the geriatric patients that I see now, and the time that I spend with them, that I enjoy the time with them, and I oftentimes will get longer visits with them and can take care of them a little bit better because of that time that I have. So it sounded like opportunity, sounded like something I would be interested in, and then after kind of saying, yeah, I want to jump into this and listening to this model where we do get more time with patients. We get more support staff around us to help with this. It was something that I think we all dream of coming out of medical school, and certainly residency, and something that we want to do. So it sounded like a great opportunity.

Marc Harrison, MD: So Chad, how long have you been out of training?

Chad Spain: So I've been out five years now.

Marc Harrison, MD: So out long enough to be very experienced, and probably at the top of your game clinically, but not so long that you're maybe stuck in a rut.

Chad Spain: I think as far as the rut part goes, coming out of residency, and seeing what practice looked like, it was quite frustrating, honestly, in the primary care setting at least. We were encouraged, or at least the model was set up, where we see as many patients as we can, and you don't get time to get to know your patients. There are times when you wish you had more time, and that you can take better care of them. So that was honestly pretty frustrating to me. And something where I wish I could say no, I wasn't in a rut. But no, there have been times when I have been quite frustrated by primary care because of those things.

Marc Harrison, MD: So we'll get back to whether this new model is making things better or worse in just a second. Nick, I was wondering, can you actually talk a little bit about how this reimagined model is different from your standard primary care, see as many patients as you can today kind of office? What makes it different?

Nick Duncan: I was actually reflecting on this last couple of days, and one of the phrases that kind of came to mind was, we're focusing more on the patient instead of the problems. I feel like it gives us a chance to really, like Chad said, get to know the patients better, have more time with the patients when they're here, and then have more of a team behind us so that we can focus more on taking care of the patients instead of dealing with a lot of the things that we were having to take care of, that didn't necessarily need a physician to do. Like inputting information. And I feel like this is really moving in the right direction of freeing us up to provide better patient care, and more patient centered care, than just kind of fee for service. Deal with the problems in front of us. And then move on to the next step.

Marc Harrison, MD: Can you tell us a little bit about who's on the team?

Nick Duncan: So, the two of us in our clinic have joined and we both have a medical assistant that we've been working with. We also have a care manager, Kirsten who's been with us before, but now a little bit more focused with us, and a little bit more freed up to help us triage things a little bit better. Again, when we need somebody with clinical experience, we can rely on her to help triage things and get us in line with what needs to be done first. And then we also have care guides that have been added to our team. Each of us, we have a one to one care guide, they're integrated so we don't necessarily have one assigned.

Marc Harrison, MD: For those of us who are the uninitiated, or like an ICU doctor like me, what's a care guide?

Nick Duncan: So a care guide is someone who is part of the team who helps us communicate better with patients. Someone who helps get patients where they need to go. Helps us make sure and communicate to patients when they need to update some of their preventive things. Stuff like that. So Kirsten, what's it like to be part of this team? You have to put up with these guys, I mean, sorry about that.

Kirsten Hanson: They are pretty tough. But I've worked with and worked with them for the last three years as a care manager in this clinic. And then was, as care management has kind of been changing, we've kind of changed our role a little bit. And I was always interested in the clinical nurse aspect, and being the only RN in a clinic setting, you see some issues with being able to triage patients appropriately, and take care of them in the clinic without having the RN. So I was always interested in that piece of it. So when they approached me about helping to be the care manager for this project, and having some flexibility to do some clinical RN duties, I was very excited about that.

Marc Harrison, MD: So are you getting stretched? Are you using your skills in a way that you haven't been able to before?

Kirsten Hanson: Yeah, I mean, my background is in the hospital. And I have worked in the clinic setting for the last five years, and I really feel like each clinic can really benefit from having an RN embedded in the clinic. Because they're able to take a lot of the patient needs and address them without them even going to the physician. So I think that it's very helpful to have that. But as far as your question being stretched, I feel like I am using my brain a lot more than I was.

Marc Harrison, MD: That's got to be fun.

Kirsten Hanson: Yeah.

Marc Harrison, MD: Gotta love that, right?

Kirsten Hanson: Exactly. Sure, sure.

Marc Harrison, MD: So Anne, tell me how many patients are part of a panel for a reimagined primary care practice?

Anne Pendo: So our goal for this new way of thinking about primary care would be about 700 to 800 patients in a panel. And when I was in practice, and had a full panel, I had about 2,000. So you can see there's a big difference between the traditional way of practicing, and thinking about this in a different way.

Marc Harrison, MD: So Chad, somebody could be listening to this podcast and say, well, surely these guys are impoverished at this point, right? So, they're getting to spend more time with their patients. They get to sort of pace their day. They've got a smaller panel. Have you guys been treated fairly economically as we've set this up?

Chad Spain: Yes, I believe so. We did have an amendment to our contract where we are no longer working fee for service. And we are paid off of salary. So it takes such a big load of stress off, not only for the days when patients don't show up, or if you need to take a day of vacation, it's not going to harm you for doing that. And so, it's much more comforting from that standpoint.

Marc Harrison, MD: And I guess all you really have to worry about, and it's a big deal, but what you have to worry about is keep your people well, right?

Chad Spain: Exactly.

Marc Harrison, MD: And so you could comfortably send them, for instance, to Connect Care. Suggest that, hey, this sounds like something we can take care of over the phone, or over a telehealth visit. And not worry about whether it hurts your take home pay for your family.

Chad Spain: That's exactly right. And the whole goal, the whole premise behind this is to keep people well, keep them out of the hospital. And so, whether it's keeping time open during the day where we can fit people in if they call, and we're worried about them, or doing your Connect Care visit with them, which we don't have that capability yet. But it's coming, and coming very soon. And so, that will be very nice. That absolutely is a big part.

Nick: That will be very nice. That absolutely is a big plus.

Marc Harrison, MD: Like my daughter, who takes pictures of her tonsils and sends them to me, she would fit right in to this kind of thing.

Nick: Sure.

Marc Harrison, MD: Yeah, absolutely. Nick, are you guys getting to see anybody at home? I mean is that part of this model? I guess it sounds very flexible.

Nick: Yeah, so the versatility is one of the things I really like about it, and from the get go that was one of the things that I thought about. I actually have had an experience where we had a patient, a patient's spouse call in. Sounded fairly urgent. The picture that was painted was a little bit unclear. There was communication with a specialist as well about what to do, and the initial thought was, you know, send the patient to the ER. My first thought was, "Why can't I just go visit the patient?"

Marc Harrison, MD: Nice.

Nick: "It doesn't sound like it's ..."

Marc Harrison, MD: Sounds like Marcus Welby. It sounds like, you know, old fashioned medicine. It's awesome, right?

Nick: Yeah. I haven't done a home visit since residency, so it was kind of exciting to think I have the flexibility now to do that.

Marc Harrison, MD: How did it go?

Nick: You know, it was really satisfying, I think, to think that I could do something that we don't normally do, and see how much it helps a family, and not just a patient, but the family feel at ease. I went with my MA to the house. She took vital signs. We literally sat down, evaluated the patient, talked with his spouse, were able to kind of answer any questions, try to come up with somewhat of a road map for how to move forward, and we were able to keep him out of the ER. I mean this is someone who didn't need to be in the ER, had a progressive neurological condition, and had some fluctuations going on.

Marc Harrison, MD: That's really an amazing story. Is that an isolated story, or does this, Kirsten does this kind of stuff happen all the time, where we're able to work as a team and use our brains and skills to keep people out of restrictive and expensive, and scary environments?

Kirsten: Absolutely, we have some good success stories already with a few patients that we've seen in the clinic since we started this. One in particular I can talk about, I guess, is one of our patients came in for, she had COPD, was on oxygen, and she was just doing poorly on her regular oxygen. Had saturations in the 70s, so right there, past state, or previous state, we would have likely sent her to the ER immediately.

Marc Harrison, MD: Sure, why not, right?

Kirsten: There's no question in my mind, but because we were sort of focusing on the prevention, and trying to take better care of this patient in the moment, we were able to do an EKG, send her for chest x-ray, able to monitor her during that time period while we were getting labs and things like that. We ended up diagnosing her with heart failure, and kept her out of the ER, and were able to, I was able to call her the next day, and then she came in the next day and had a very frequent follow up with her, to make sure she was doing okay.

Marc Harrison, MD: That's really a powerful story, because I think we all know that, particularly when frail people end up in the ED, they're going to get admitted one way or the other, right?

Kirsten: Yes

Marc Harrison, MD: Then they're going to be in the hospital, if they don't get a nosocomial infection or if they don't fall down, or if they don't get delirious, they may very well end up in a post-acute facility detrained, and for some of these folks that can be the end of their life, can't it?

Kirsten: Yes

Marc Harrison, MD: You very well may have saved a life by keeping that person out of the hospital. That's pretty, that's a very impressive story.

Nick: I think Kirsten underplays her role in this, just to pump up, no seriously, the care manager position. She contacted this patient every day, sometimes twice a day to make sure she was doing well. She was able to get the heart failure physician, the on call physician, on the phone to talk to me directly, to make sure that we were going down the right path in keeping this person out of the hospital, and undoubtedly played a big role out of keeping this patient out of the hospital, which likely would have been an extended stay.

Marc Harrison, MD: One of the sad facts of medicine right now, healthcare right now, is about half of doctors have significant symptoms of burn out. Did I get that right, Anne? You're the expert on this.

Anne: That's correct.

Marc Harrison, MD: Lots of nurses too, and I'm sitting here thinking, "I want to join your team." I'm a pediatrician, but I'd actually be happy to go see some older people. This sounds like fun. Is this changing your lives professionally in a good way? In addition to the patient outcomes, how does it feel to be a caregiver in one of these re-imagined clinics?

Nick: I honestly feel like this gives me hope for the future of primary care. I mean kind of like Chad talked about his own experience, going into this, staring down an entire career ahead of me of fee for service just didn't seem like the best fit, and when this was brought up, and I had talked to Dave Hendrickson about this, it seemed, I was a little bit skeptical at first, and wanted some more details, but once we started going down that road, I feel like it's really opened up my opportunity as a physician to practice the way that I want to practice. We've still got a long ways to go, and a lot of things to fix and change, but right now I feel like I have more of a sense of hope about where primary care is heading because of this program.

Marc Harrison, MD: That really does my heart good. I have a, Mary Carol and I have a boy who's in, a man who's in medical school right now. He's a third year student, and when I watch his enthusiasm for what he's doing, he loves taking care of patients, and he loves being part of a team. I want him to maintain that joy in medicine for the length of his career. I would agree with you that some of these models that we've had historically, particularly this churning fee for service approach, can just grind you into the dust, and so thank you. That resonates, that, when you say staring down that long career, I don't want him to have to experience that. I want him to love what he does.

Marc Harrison, MD: We actually have Dave Hendrickson here, and you want to talk a bit about ... You sort of took a risk on helping to administering and leading this project, and you've done an enormous amount of heavy lifting. You want to talk a little bit about what motivated you to do this, Dave?

Dave Hendrickson: Well I think, as an administrator, as you're out talking with teams and physicians, you hear lots of the concerns or comments, like Chad and Nick are stating here, and you want to do something about it. You kind of feel like you're constrained or handcuffed a little bit in what you can actually do, and so as we evaluated some of these other companies out there, and looked at what we could do here, it just seemed like an exciting opportunity to say, "Hey, we can actually flip the system on it's head and do some really cool things that we could not otherwise do, and so the opportunity to participate, and work with such great folks, like the folks you're talking to today seemed like an opportunity too good to pass, even though we don't have all the answers, and I think at times it can be frustrating or discouraging. We know we're working through some tough stuff, and eventually that will lay the ground work for others who are able to do this work, and hopefully be able to take care of patients in this way.

Marc Harrison, MD: How fast do you think we should propagate this, Dave?

Dave Hendrickson: Well, I think that's a double edged sword. Certainly you can see some of the initial good stories and good impacts, which I think are uplifting for many folks. I do think though we want to be smart about this, and we want to actually ensure that we have a best practice, and we have things that we know that work, that we work out some of these kinks before we roll it out across the rest of the system. That's what I think we have to refine and do over the next year or so, as we work through this with these eight providers that are doing this work, and these teams, is figure out what really does work, and what can we share, and what can we spread, and then slowly roll that out as quickly as we can.

Marc Harrison, MD: I think I just got told to cool my jets, but that wouldn't be the first time that's happened, but I appreciate what you're saying. This is a big change, and let's be thoughtful about it, but I also, I would lean into this. We know that, around the country, this model is popping up in innovative settings, and quite frankly in much more cost effective settings than our beautiful clinics that we work in. If we're going to be competitive, so that we can serve more effectively, we're going to have to keep making change. I don't see any way around it, but I'm heartened by this.

Marc Harrison, MD: Kirsten, can you talk a little bit about what additional duties you think non-physician providers can take on in this context, and whether there are other teammates who you think should be incorporated into the team, like maybe pharmacy for instance? Do you have some thoughts on that for us?

Kirsten: Ah, sure. I already talked about the clinical RN. I feel like that's kind of integral to making this work, and that's not just because I am one. I think that they can take a lot off the plates of the physicians in the group.

Dave Hendrickson: I support that comment.

Kirsten: Things that they don't even have to deal with, can be dealt with over the phone. It doesn't need to be a message in their box. In addition, I feel like a pharmacist can be super helpful as well. We just had a pharmacist start in our clinic, so she'll have, she'll be involved somewhat at this point, but I think that she can be very helpful as well. In addition, I think the care guides, as we get them up and trained, are going to be very helpful for some of the non-clinical things that we need help with, transportation, scheduling appointments, pre-visit planning, and making sure that the physicians can capture every, all the HCC codes and make sure that they can close all the gaps in care.

Marc Harrison, MD: I really like what you're saying there. First of all, around the pharmacy side, I would imagine that over time things like medication for hypertension, some of the diabetes management, anti-coagulation, a couple other classes of pharmacotherapy, I think will probably will be very well, maybe even better managed by the pharmacist then by others.

Marc Harrison, MD: I was wondering if maybe you guys could talk a little bit about how you see this model supporting end of life care, so that people die in the environment that they want to die in, as opposed to, you know we hear regularly that people end up in a much more medicalized environment than they wish. Can you guys talk a little bit? Does this support that?

Chad Spain: Absolutely it does and I believe that having access for patients to come in not only with illness, but if they have questions about their care that we can spend time with them and not just tell them what to do from a medical standpoint, but in giving them options in what they can have happen with their care. So absolutely it should play a role. But Nick, I think with your, if you want to follow up on your home visit, I think that's a perfect Segway right into that.

Nick Duncan: Yeah, as part of our home visit, really I spent essentially an hour talking about the roadmaps that we had available, whether home health right now, whether hospice and really kind of teaching patients and family members what the definitions of those are, what that means. Because I feel like there's a lack of education in what end of life care means and what hospice means versus palliative care.

Nick Duncan: And in that example, I had the chance to really educate and help people understand that we're not giving up on people. We're changing the goals of care. We're helping people have more dignity and choice when it comes to end of life care and realize that quality of life means something and not just, just because we can do more care doesn't mean it's the best thing in that scenario.

Nick Duncan: And this has really allowed me to have more conversations with other patients as well. Not just this one setting, but have the time to educate them about what this all means.

Marc Harrison, MD: Isn't that why people went into medicine in the first place? I think a lot of us, right? The ability to have those kind of conversations.

Nick Duncan: Exactly it. Absolutely.

Marc Harrison, MD: So, and I'm going to ask you to think about something for a second. I'm going to ask you to give me advice about this program in just a second. So why don't you mull that over?

Marc Harrison, MD: I was wondering if you guys could maybe say a couple words to your fellow clinicians, nurses, physicians, and others about who you think will like this model and who you think won't do well in it. Because this is not the only way to practice medicine. So maybe some advice or some guidance to the folks who are out there who are listening. So Kirsten, do you want to go first or looks like ...

Kirsten Hanson: I guess I would say that flexibility is key here and especially when we're changing how medicine is typically practiced. I think we have to be flexible and know that there are some roadblocks to that because there are. This isn't the only way to practice medicine. But I do think that this can be of benefit to the patient and it's very patient centered.

Marc Harrison, MD: And fun for the practitioner, sounds like too.

Kirsten Hanson: Oh yeah. Definitely.

Chad Spain: They say change is always hard, but I don't think in this setting of healthcare that we can be afraid of it. If we want healthcare to change, we need to be willing to make change ourselves, and I think this is a great opportunity to do it.

Chad Spain: If any practitioner has ever felt like they've been burned out or that they don't have enough time for patients or that they're frustrated at the end of the day, I can't say that this job right now is perfect, but I certainly see hope as Nick said, whereas before I don't know that that was the case.

Marc Harrison, MD: Nothing's perfect, but my wife or so she tells me, right.

Marc Harrison, MD: But this sounds like it's really pretty good and it's meeting your needs.

Chad Spain: It is. Yeah, it really is.

Marc Harrison, MD: So what do you say to your colleagues, Nick?

Nick Duncan: So, Ann talked about something at the very beginning. She used the term growth mindset and we have really had to focus on that because there have been some, you know, definite setbacks and frustrations and I think having the end in sight that we're going to improve healthcare and this is a change that in my opinion is for the betterment of patient care. I think that has helped us work through those challenges and again, realize try not to get stuck in the moment. But think what this can do for patient care.

Nick Duncan: And I think this is the way that primary care can serve patients better, allows us as primary care physicians who know the patient better to treat them in most settings, and to try to keep them out of the hospital.

Nick Duncan: We can do so much prevention and I think people who are really dedicated to that I think will do well in this.

Marc Harrison, MD: The other thing that makes a ton of sense to me., I'm sitting here and thinking some of the lack of alignment that has existed between some of our advanced practice clinicians and some of our physicians around RVU's and billing that just goes away. Boom, right? All of a sudden everyone's just playing on the same team, trying to do the right thing for patients. And that's how success is defined. That would be really liberating, I would imagine.

Anne: The other thing that's been unique in this setting is thinking about a team and teaming. And that's a different, it requires a growth mindset to be part of the team. So I'm working with Kirsten, my care manager, and she's got a role. And I trust that role and that the tasks that you do, you will do well. You will come to me, the physician, when or the APC when you've got a question or need support. But if you tell me, I've talked to a patient, I put them on your schedule. My answer is, thank you very much. I'm not going to go back and review what you've done.

Anne: And that I think is a shift for physicians is being able to really trust that each member on the team is doing their work. We're all working together with a common purpose. And so if someone's really in a fixed mindset or he really wants to control all of the parts of the work, this is probably not something that's going to work well for them.

Marc Harrison, MD: That makes a lot of sense. Well, I can't imagine that that lone wolf approach is going to be very successful in 2018 and beyond, regardless of ... Because increasingly healthcare is totally a team sport and patients/consumers have very different expectations and pretty hard to meet all of that all by yourself. You know, some people may want to try.

Marc Harrison, MD: So, Ann I'll tell you what, why don't you give me some advice, you've done it before, I always appreciate it.

Anne: Yes, I have.

Marc Harrison, MD: And then why don't you sort of wrap things up, you know, given your role as a leader in this arena.

Anne: So, the advice I'm going to give to you and thank you for listening, is I believe that primary care is the foundation of the work that we do as a health system. And the focus that we've had on re-imagined primary care in these last six months has been inspiring and heartening and engaging.

Anne: So let's do more of this and let's keep doing the work that we're doing. Keep asking the questions. One of the things that I observe in this whole process is that it's a do something, try it, get feedback, modify it and do it again. And that is a new way of thinking about how we work. So I'm going to challenge other areas to start thinking about approaching change in that same way.

Marc Harrison, MD: And I don't want to be about the money really, but it is something that I think will be on people's minds. You'll be able to assure the clinicians who are interested that we'll do the right thing economically for them, right?

Anne: Yeah, so I think as well, you know, a piece of this care, of providing this care is different in that we're being educated about what does an ED visit cost? What does a hospitalization cost? Really being mindful of that. So if our goal as a system is to be more affordable, not only are we compensating for doing the right things, but we should be able to lower costs for those in our community, and that's really our goal, right?

Marc Harrison, MD: Highest quality at lowest cost.

Anne: Yeah.

Marc Harrison, MD: And what we know right now is based on polling data that, on survey data that the biggest fear that Americans have is what happens if somebody gets sick. And we also know that the average American can't handle a $400 or $500 unexpected expense. That's a really tough place to be.

Marc Harrison, MD: So I think we have an obligation as a health system, and I think that's a transition we're making from a health care system to a health system to address both quality, reliability and cost.

Marc Harrison, MD: And I'm entirely optimistic about Intermountain's positioning to be the absolute gold standard and leader in this regard. And I'm particularly optimistic after meeting Kirsten, Chad and Nick, right? That I think we're in really, really good hands, don't you?

Anne: I do, I do. And I am going to say thank you to you because really this work started with a question asked by you and really giving us the freedom to investigate it, figure out what we should do and then the support to go forward and do it.

Marc Harrison, MD: Thank you. That means a lot.

Anne: We are looking forward to having you all back to let us know how things are going with re-imagined primary care. We've got an upcoming podcast with Josh Romney who's been integral in this process of helping us use our EMR iCentra more effectively, so we'll be looking forward to sharing that in the future. And thank you to Nick Duncan, Chad Spain, Kirsten Hanson, and especially thank you to Dr. Marc Harrison. Goodnight.