Focus on Primary Care

What if we thought of primary care clinics as important research labs?

Academic medical centers are exceptional at developing cutting–edge technology, treatments and cures. but what about putting some of that brainpower toward creating new health care delivery models?

Algorithm No. 1

  • Disrupt Things

    Disrupt your traditional model of business and create a protected, sheltered entity where you can run things completely differently.

  • Think— Like a — Patient

    Remember: It's not about what the faculty and staff want. It's about what the patient wants.

  • Force Collaboration

    Create truly integrated care teams, and then bring them together physically. No offices, no closed doors.

The Idea

THE IDEA: REVOLUTIONIZE THE WAY WE DELIVER PRIMARY CARE

Ten years ago, our primary care clinics were failing. We were running them separately from the rest of the health care system—and losing $20 million per year.

The loss was so deep and devastating that it was actually threatening the bond rating of the University. "We were a toxic asset," says Michael Magill, M.D., chair of the Department of Family and Preventive Medicine. "People were mad, scared and very worried about our group." That turned out to be the perfect environment for real innovation. With mounting financial and administrative headaches, the community clinics were restructured as a separate entity under the wing of University of Utah Hospitals and Clinics, while integrating all of their functional areas, from scheduling to marketing to billing, in a way that was needed to survive the crisis. And that's when the real experimentation began.

Taking a cue from innovation luminary Clayton Christensen and his theory of "Disruptive Innovation," the restructured clinics untethered themselves from organizational bureaucracy. This allowed them to rapidly create new models of management and patient care and envision all-new care delivery systems.

Michael K. Magill, M.D., Chair of the Department of Family & Preventative Medicine
"In a constrained payment world, we need to think of primary care as part of our institutional strategy and as a way to survive."

— Michael K. Magill, M.D. Chair of the Department of Family and Preventive Medicine and Director of Research for University of Utah Health Care's Community Clinics

Primary Care 3.0. For the past eight years, that's exactly what Michael Magill, M.D., has been trying to create through a transformative new care delivery model called Care by Design. Magill has received three federal grants totaling $4.5 million to redesign what many consider a failing health care delivery system. "As an academic medical center we have amazing potential to help accelerate change around processes and care delivery," says Magill.

"We were a toxic asset. People were mad, scared and very worried about our group."

And so our community clinics became a powerful health services research lab, complete with wild ideas, new experiments, disappointing detours, unexpected discoveries and, ultimately, a new understanding of how to move forward. In the end, the guiding principles all came down to a single question: What does the patient want? By honestly exploring this question—and staying consistently focused on finding the answers—breakthroughs began to emerge. "We knew what changes had to be made, and we made them," says Robin M. Lloyd, M.P.A., executive director of University of Utah Health Care's Community Clinics. "We didn't ask permission."

Today, University of Utah Community Clinics have become a national model for patient-centered medical homes, a new approach that provides patients with a home base to coordinate all of their health care. The financial losses have been turned into profits, patient satisfaction scores have risen dramatically, and hospital administrators now come from all over the country to learn about our model and connect the dots at their own organizations.

"We're creating the kind of care that keeps people well and keeps costs down," says Magill. With health care costs rising faster than the national inflation rate and health care reform just around the corner, there's never been a better time for efficient, affordable and integrated primary care. "Primary care saves money by cutting the incidence of major health problems like heart disease or diabetes later in life," says Paul Grundy, M.D., adjunct professor in the Department of Family and Preventive Medicine. As the global director of health care transformation at IBM, Grundy is a major employer advocate for shifting health care delivery to patient-centered, primary care-based systems. IBM spends $2 billion a year for employee health care, and Grundy feels that far too much of that money flows to specialists for procedures instead of primary care doctors for prevention. "That's why we need a back-to-the-future approach to the family doctor, enabled by advanced information technology and innovative health services."

Robin M. Lloyd, M.P.A., Executive Director of University Health Care’s Community Clinics
"In order to innovate, you have to have a burning platform. And then you need to ask: How hot is the platform? How high are the flames?"

— Robin M. Lloyd, M.P.A. Executive Director of University of Utah Health Care's Community Clinics

When Robin Lloyd, M.P.A., looked at the University's community clinics, which were losing $20 million a year, he knew the fire was red hot. "We used Lean design practices to break down and examine every little process, eliminate waste and do things more efficiently. Most importantly, we asked, ‘What does the patient want?’ We started redesigning and were never satisfied," says Lloyd. Over the past several years, he and his team have hosted more than 300 physicians and administrators from 55 health systems across the country who came to learn more about the Utah model.

That is precisely what our newest community clinic, the South Jordan Health Center, aims to deliver.

We've designed the South Jordan Health Center to model a different kind of health care system–one that delivers better care at a lower cost; one that provides integrated, continuing care rather than just managing single episodes; one that's smarter, simpler and altogether better for the patients we serve.

"In truth, the current health care system isn't a system at all," says Grundy. "It's antiquated. It doesn't link diagnosis, drug discovery, health care deliverers or insurers. And it's expensive. Every year, personal health care expenses push more than 100 million people worldwide below the poverty line. Our current health care processes are simply not smart enough to be sustainable."

"In truth, the current health care system isn't a system at all. It's antiquated … and it's expensive."

But here's the challenge: The clinical arm of a typical academic medical center, such as University of Utah Health Care, generates 94 percent of its revenues from specialty care and only 3 percent from primary care. (The other 3 percent comes from emergency services.) So how could we afford not to focus on specialty care? For Paul Grundy, the answer will soon become obvious: If the value proposition you offer to employers and patients isn't competitive, quite simply, they'll take their business elsewhere.

"Our addiction to high-margin business is toxic, dangerous and wasteful," says Grundy. "I don't want to see five different specialists working independently on my employee with no one looking at the big picture. It's unethical and immoral to manage an episode of care only and not coordinate care for a patient."

So how will we get to the future?

Grundy, Lloyd, Magill and other health care visionaries firmly believe that the transformation of American medicine will revolve around patient-centered, community-based medical home clinics. "Someday, we're going to quit building ICUs and start building more South Jordans," says Lloyd. "This model is going to save the system." Grundy agrees. "Over the next couple of years, there will be winners and there will be losers. And though it may not be easy to see now, I believe we will see new leaders emerge who win not by surviving the storm, but by changing the game." In the meantime, we're continuing our research in our community clinic "labs."

Richard Orlandi, M.D., Professor of Surgery
"We just need to expand our perception of who we are and what we do."

— Richard Orlandi, M.D. Professor of Surgery and Executive Medical Director, South Jordan Health Center

Otolaryngologist Richard Orlandi, M.D., professor in the Department of Surgery, is exactly the kind of subspecialist you wouldn't expect to find anywhere near a community clinic. He's the only fellowship-trained nasal and sinus specialist in the Intermountain West, author of more than 70 articles and book chapters, reviewer for all of the major journals in his field—you get the picture. So what is he doing at a community clinic like South Jordan? He's trying to shift the mindset of department chairs and physician colleagues that an academic medical center shouldn't just be where patients go to receive end-of-the-line care. He believes it should also include a cadre of first-contact general specialists–cardiologists, neurologists, dermatologists, oncologists–who practice out in the community. "Why make the patient leave our system between primary and tertiary care? Why not provide the full spectrum of care so we can take care of patients in the most coordinated way?"

Susan A. Terry, M.D., Executive Medical Director of University of Utah Health Care’s Community Clinics
"There were so many lost opportunities in the traditional model of care.
At South Jordan, we're bringing them back."

— Susan A. Terry, M.D. Executive Medical Director of University of Utah Health Care's Community Clinics

Over the last 15 years, Susan Terry, M.D., has seen the transition from a one-on-one, physician-patient relationship to a collaborative team approach, which she believes is the model for the future. "It's not reasonable to expect physicians to do everything we’ve done in the past," says Terry, especially as access to health care increases. "We've created a state–of–the–art team model for patient care that gives nurses, pharmacists, dieticians, medical assistants and others new opportunities to help maintain and improve the health of patients."

The Implimentation

The Implementation: South Jordan Health Center

  • The front stage

    The Front Stage

    Never abandon the patient

    From the moment the patient is greeted at the front door, systems are designed to shepherd the patient through her visit and eliminate waiting. Self-check-in kiosks streamline the admittance process and electronically notify providers that the patient has arrived. A guest relations specialist walks the patient directly to an exam room, where a medical assistant meets the patient. Seating in waiting rooms is minimal since the goal is to never leave them waiting. On average, patients are in and out of the clinic in just 30 minutes, instead of the nationwide average of 1½ hours.

  • The Front Stage

    Never abandon the patient

    From the moment the patient is greeted at the front door, systems are designed to shepherd the patient through her visit and eliminate waiting. Self-check-in kiosks streamline the admittance process and electronically notify providers that the patient has arrived. A guest relations specialist walks the patient directly to an exam room, where a medical assistant meets the patient. Seating in waiting rooms is minimal since the goal is to never leave them waiting. On average, patients are in and out of the clinic in just 30 minutes, instead of the nationwide average of 1½ hours.

  • The Front Stage

    Design uniformly for efficiency

    Every exam room is designed exactly the same, so providers know where things are. Simple design features such as the ability to stock cabinets from the back stage keep staff from interrupting patient care. Details like having printers in the exam room keep doctors in the room with the patient instead of sifting through a stack of documents at a shared printer.

  • The Front Stage

    Take a cue from Disney

    The architecture reduces patient anxiety by creating a calming front stage for patients and an efficient working back stage for providers. Patient-facing spaces are quiet and softly lit — more like a boutique hotel than a busy clinic. Patients never see syringes or EKG machines, and they don’t hear phones ringing or devices beeping. The back stage is designed to foster collaboration between medical team members.

  • The Back Stage

    make patient care a team sport

    “Physicians in cubicles? It was heresy when we told our doctors they wouldn’t have an office,” says Lloyd. “But a marvelous transition occurred. They loved hearing what nurses and medical assistants were saying to patients.” At the nurses’ station, all sight lines are unobstructed, so that everyone can easily and naturally collaborate with one another in a common space.

  • The Back Stage

    Quiet things down

    A centralized call center schedules across all 10 of our community clinics and is the hub for passing along messages from patient to provider, which eliminates phones from ringing in patient care areas. Patients can typically get appointments to see their doctors on the same day they request them, as long as they call by 10:30 a.m.

  • The Back Stage

    Encourage everyone to practice at the top of their license

    Medical assistants stay with the patient the entire visit and are trained to do a variety of tasks that free up physicians to practice at the top of their license. Using the electronic health record, they enter the medical history and vitals. They are cross-trained to draw blood, give injections, perform EKGs or take X-rays if authorized by the physician. At the end of the appointment, they print out the post-visit summary and answer any questions.

  • The Back Stage

    Integrate primary, specialty and emergency care

    Having everything in the same building streamlines care for patients and improves communication between providers. Co-locating primary and specialty care makes financial sense too. South Jordan provides patients with convenient access to Huntsman Cancer Institute, Moran Eye Center, 15 specialties, pharmacy, physical therapy, radiology and same-day surgery. The Emergency Department is open 24/7, and trauma patients can be transferred to University Hospital in 16 minutes

  • The Back Stage

    Integrate primary, specialty and emergency care

    Having everything in the same building streamlines care for patients and improves communication between providers. Co-locating primary and specialty care makes financial sense too. South Jordan provides patients with convenient access to Huntsman Cancer Institute, Moran Eye Center, 15 specialties, pharmacy, physical therapy, radiology and same-day surgery. The Emergency Department is open 24/7, and trauma patients can be transferred to University Hospital in 16 minutes