Last week I spoke of a goal for care delivery in Alabama that I believe is achievable.  This goal is not Alabama specific although given some of our health markers I suspect we have more “opportunities” than most. This goal was long on vision but short on specifics. Today I want to offer nine specific challenges to us all (targeted to consumers because we are all health care consumers) that I believe will help push the health care delivery system in Alabama towards that goal. If we as patients and/or a provider demand care in this manner, it will happen (maybe).

1) If quality care exists in your community, use it

This is the most important point of them all. We all know that people choose a physician based on affability, availability, and ability is assumed. Unfortunately in rural America ability is not assumed. The phenomena of bypass is a testament to this fact. Patients need to be educated regarding certification by accrediting bodies and the implication regarding “ability. This means the JC for hospitals and NCQA for ambulatory sites.  Physicians need to demand transparency. Post practice data and encourage others to make practice data available. Hospitals are now making hospital data available  Patients need to be educated to be vocal if demands are not met and most importantly, not to just vote with their feet

2) Demand improved  primary care (and be willing to pay for it)

Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. The academic work can be found here and a resource can be found here.

3) Seek out and use “Medical Homes” for health care

The American Academy of Family Physicians has been working for the past 5 years on creating a type of primary care practice for the future. They refer to their model as the Patient Centered Medical Home (PCMH) and more information can be found here. Family physicians have been called America’s best kept secret. The majority of them are changing over their practices to Patient Centered Medical Homes.  In a PCMH quality care is documented, measured and improved. The patient experience is enjoyable and patients are encouraged to communicate and self-manage problems. Technology is used to improve the care experience. The care experience is continuously improved. There will be a certification process that will probably be through NCQA.

4) Find physicians who have conquered the digital divide

Without electronic health records, it is almost impossible to accomplish chronic disease management. With an electronic health record, however, a VA in rural West Virginia showed a significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol).  There are now Health Information Exchanges being developed that will facilitate E-prescribing, receipt of structured lab results, and sharing patient care summaries across unaffiliated organizations. In addition, congress has directed the development of Regional Extension Centers to help physicians “get connected.” Alabama’s Center is Al-Rec. These centers are charged with providing education and outreach to providers, assist with vendor selection and purchasing for electronic health records, and provide workflow design consultation. In addition, these centers are tasked with promoting interoperability.

5) Find a doctor comfortable with telehealth/telemedicine

Telemedicine is effective but expensive, We have very  good evidence for improved outcomes in toxicology (Poison Control) where Every $1 spent on manning phones saves more than $7 in avoided health care charges. We also have evidence for ophthalmology, orthopedics and fracture care,  telemetry, stroke treatment, and dermatology. Unfortunately, the expense is difficult for many practicing physicians to cope with but if patients were to demand remote access there are effective solutions.

6) Demand a focus on quality

Rural hospitals that use established guidelines, such as the American Heart Association’s  GWTG-CAD performance measurements,  mortality is same as in urban settings. The performance measures mentioned above include recommendations such as early aspirin use, smoking cessation counseling, and use of certain drugs at discharge that are very easy to follow. Better systems, not more expensive equipment, save lives and are easily achievable in rural America.

7) Demand provides in your community to collaborate, collaborate, collaborate

If there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration. Only 19% of critical access hospitals  report  a collaborative relationship with CHCs. Barriers include a lack of knowledge about the other and competition for patients. In communities where this collaboration happens, there are improved primary and preventive health services, improved Inpatient care, better 24 hour emergency care and  better access to specialty care.

8 ) Encourage mental health and primary care to work together

Primary care is already used 50% of the time for those seeking care for mental illness. Persons with mental illness are more likely to make a visit to their primary care doctor to receive care than they are to go purposefully to a mental health professional.  Primary care doctors do have a lack of recognition of mental health issues based on billing data but this may be an artifact of the billing system. Although there is currently a lack of integration of general medical and mental health services, there is a groing trend for physicians in private practice as well as rural health clinics to offer mental health services on site. This needs to be encouraged.

9) Work to build a healthy community

Health care delivery can only go so far. A healthy community is needed to move a community to being full on chronically ill individuals to one full of individuals who are chronically well.