Navy Consultant’s Report
08/30/2017

Navy Consultant’s Report

Andrew  McDermott, MD
Medical Officer
Naval Hospital Jacksonville
andrew.j.mcdermott@gmail.com

“Fine FPs, this quarter I am turning over the Specialty Leader section to LCDR McDermott to discuss the ongoing implementation of Value Based Care.”
Tim Mott, MD, FAAFP
Naval Hospital, Pensacola, FL
tfmott@yahoo.com

“Raise your hand if you’re happy with the way we do medicine?” The room, previously filled with talk, was awkwardly silent and the air void of hands.

“Why do we do the same thing, get the same results, and have the same frustrations?” This was my introduction to value-based care, by a guest lecturer and pioneer in the field.

The following three months witnessed an orchestrated chaos, proving to be a beautiful marriage of business analytics, care pathways, and outcome metrics that matter to both providers and patients. I was lucky enough to be a member of the development team for diabetic care and was surprised to find the disease was more involved than monitoring hemoglobin A1c. Speaking with several patients who were members of the team, it became apparent the struggle was not from poor understanding of the disease, but was about the “why” we are struggling. The “why” ultimately dictates the value-based care infrastructure.

While each Integrated Practice Unit, or IPU, is different, the Diabetes IPU developed a core team of five providers: physician, pharmacist, dietitian, behavioral health specialist, and nurse educator. A care navigator (a hospital corpsman in the Navy Medicine model) serves as a liaison and coordinator of care. Our core team intimately develops the care pathways and meets regularly for treatment boards to discuss complicated patients and form more integrated treatment approaches. In addition, each patient meets with every member of the core team, generally in a round-robin setting.

How is value-based care different? The heart lies in the focus: prioritizing what’s important to patients, in their words. Patient-reported outcomes anchor this approach, and measures of success rely heavily on patients’ responses. For the Diabetes IPU, we periodically ask patients to rate the statement: “I find it hard to do all of the things I have to do for my diabetes” on a 0 to 10 scale. Our hope is that with time, patients’ ratings improve, showing that they feel more in control of their diabetes. This same approach is true for each IPU, and asking questions best represents the patients’ perceptions of their care.

By relying on patient-reported outcomes, I  connect  with  patients  in a much different manner. Each story resonates and I’m permitted to peek into individuals’ lives and see how their disease impacts them. Most of my time is spent listening, and this provides insight into forming individualized care plan
that patients feel intimately involved in constructing. It’s an empowering process both for patients and providers.

Value-based care represents a renaissance in how we provide care, and it’s rooted in simplicity. Patients have said that providers don’t listen enough. Providers claim we don’t have enough time to listen. The architecture of value-based care provides a framework for enabling an authentic, patient-focused experience that respects the individuality of each patient and helps providers understand each patient’s story. Patients are not algorithmic, and their care shouldn’t be either.

As our pilot at Naval Hospital Jacksonville expands, we’ve incorporated a Family Medicine Residency Program. Following an initial patient visit, LT John Koch (a third year resident), stared at the ground perplexed. I asked him why.

“This is not at all what I thought it would be. All we did was ask questions about why she was having a tough time with her diabetes. This is not what I went to medical school for,” LT Koch replied.

I smiled.

“Now we know why she’s struggling.

Her story clued us in as to why she hasn’t been taking her medicine. We were able to offer a different care plan to her, one that she was part of making. We found out the why, and now we can use our tools to better mesh with her individual story. I would argue this is exactly what you went to medical school for.”

He laughed, “Well, when you put it that way…”

I don’t claim value-based care provides all of the answers our community so desperately seeks for a more sustainable system. I’m certain the value-based care methodology has transformed my approach to the patient. It has taught me (again) to prioritize patients and their stories, since those stories form the foundation of the physician-patient connection. Maybe (just maybe), patients’ individual stories will better guide us to choose the right tools from our toolbox, as LT Koch learned. Maybe downstream, traditionally-defined patient outcomes will also improve. We’re already starting to see this with A1c scores. At the heart of this reformation needs to be a realization of our commitment: to help patients and value them as individuals.

DISCLAIMER

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

COPYRIGHT  STATEMENT

I am a military service member. This work was prepared as part of my official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the

U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.