PCP Clinical Innovation Network Call: Iora Health

On Wednesday night, the Primary Care Progress community gathered for a call with Dr. Neil Patel and Dr. Andrew Schutzbank who are on the cutting edge of primary care delivery redesign at Iora Health. The team at Iora has created a new model of primary care that allows doctors to spend more time with patients, deliver more preventive and wellness care, and adopt innovative features that better meet the needs of patients. The model changes payment, staffing, processes, IT systems, and culture in order to dramatically improve the experience and quality of care for everyone while reducing overall healthcare costs. (Learn more about the call here.)

Some fantastic issues were raised in the Q&A after their discussion. There were a few in particular that I would have loved to hear the perspective of others involved in innovative models as well, or even trainees just interested in what innovative models should look like.

• Brian Blank asked whether the high involvement of health coaches in building relationships with patients made doctors unsatisfied or feel like they were just prescription machines. It seems that the doctors at Iora are very satisfied, and that patients build strong relationships with both health coaches and the doctors - they're not mutually exclusive, but synergistic. I wonder - what are the experiences at other innovative clinics
• A nurse practitioner student asked how NPs fit into the Iora model. It seems that only MDs are personal primary care providers, but NPs have been hired for things like triaging and a smoking cessation program. The decision was to have MDs only has the primary care providers for marketing reasons.  I wonder - how do other innovative models work with the different health professions?  How can we promote successful models like Iora without turning away underrepresented health professions?
• Dave Gellis asked what trainees can do to to build skills to work in models like Iora Health. The response was to visit and work with clinics that are innovating themselves, perhaps doing rotations there. I wonder - how can we promote innovative clinics as sites for rotations, or increase access to trainees?

Do you have any thoughts to these questions? Were there any other questions asked on the call that intrigued you? Did you have anything you wanted to ask but didn't have a chance to? Andrew Schutbank is on call to answer any questions about Iora!

Would anyone agree or disagree that the Iora Health clinic has remodeled primary care to resemble an inpatient medical team?

At one point in the conversation, Andrew Schutzbank spent some time talking about the workflow at Iora Health in contrast to a traditional primary care practice.  In a traditional practice, everything is very linear.  The patient arrives, checks in at the front desk and is roomed by a nurse or medical assistant.  Then the doctor sees the patient, the patient leaves, and the doctor does her dictation, billing, and moves on to the next patient. 

At Iora, the team huddles in the morning; then when a patient arrives, they spend some time with their health coach first, then the doctor comes to formulate a plan, then the health coach works one-on-one with the patient afterward to finalize the plan, and if there are any problems, the doctor comes back to the room to help work it out.  This creates a very fluid environment where the provider finds himself or herself floating between several rooms at once, tailoring the amount of time they spend with each patient to their degree of need, and delegating responsibilities to other members of the team.

What strikes me is that this sounds like recreating primary care in the image of *an inpatient team*.  The team rounds first, then the physician spends time on each patient throughout the day according to need, and delegates a lot of responsibility to house staff (if it's a teaching team) and/or nurses.  Is this just the nature of "team care" that it will resemble inpatient medicine more?  What do others think?

I think you raise a good point--that team care is baked into the model of inpatient medicine, whereas it is seen as an innovation in outpatient care delivery. Must have something to do historically with the educational model of the inpatient ward team as being the unit of care delivery versus the solo doc. I'd argue though that the need for "teamness" is if anything even more pronounced in primary care these days than in the inpatient realm. I think what Iora and others are doing are designing processes that truly engage the team. The huddle as a mechanism to get the team on the same page and identify the patients' needs and the potential contributions of each of the team members is really key.

There are a lot of other enablers of good teams that we pay attention to variably in medicine, both on the outpatient and inpatient side (where a lot of the "teams" are really just groups of people who happen to work together on the same patient). I hope to that end Iora does more than recreate our at times barely functional inpatient teams!

Interesting points Christopher--
Our attempt was to create a fairly linear experience for the patient, and in doing so realized we needed to be flexible with our work flow.  There is a good deal of controlled chaos in the practice, but that is a design decision and tailored to each population of patients.  I appreciate your comparison to an inpatient team, as many of our patients are (were) equally likely to be inpatient or outpatient on a given week.  But I think the "teamness" and not the "inpatientness" is the apt comparison. A major area that we continue to focus on is the population management, or more concretely: "Taking care of the patient that is not in front of you."  That is the true purpose of the team, the tasking system and the huddle--to minimize the distracting effects of needing to get everything done for the patient who happens to be in front of you, regardless of complexity, urgency or triage.  On a larger sense, I hope the stark division between inpatient and outpatient care begins to fade away as the inpatient setting, like the group room, the home visit, or the exam room, becomes another specialized place that we can care for our patients.