CFI Selective: Innovating Outpatient Primary Care

Illustration of person's head reflecting on ideas

John Roger Alden Shepherd, Mayo Medical Student (Class of 2015), participated in a one-week selective with Mayo Clinic’s Center for Innovation, learning from the Community Health Transformation platform. Here is his reflection detailing his observations and learning in Mayo Clinic’s Center for Innovation.

My selective with the Mayo Clinic Center for Innovation (CFI) was a FANTASTIC experience! This week allowed me the opportunity to step back from the traditional medical school environment and look at healthcare from different perspectives. Working with Allison Verdoorn & Dr. Marc Matthews, with the Community Health Team at the Mayo Family Kasson Clinic. I was challenged to think critically to evaluate the deficiencies of the current practice of medicine and then think innovatively about how to better meet the needs and improve the health of the patient in the outpatient setting. One focus of CFI is trying to address how to better manage longstanding chronic diseases? One big idea---empower the patient to be in control of their own care. For the first two days, I observed the patient’s primary care experience and interaction with staff in the Kasson Clinic. There, CFI has created a way for patients to develop, write-down, and keep the goals of their visit and determine what is most important to their life in living with their disease such as being able to stay or become more active, live longer, limit cost of medications, improve blood pressure or lab values etc. This not only lets the patient drive the conversation but also allows the provider to focus on how they can help the patient achieve their goals.  Many would agree that the best way to manage chronic disease is to prevent it in the first place.  Therefore, the Kasson Clinic has made a community garden visible right outside its front door. This is such a cool idea for many reasons. Imagine: a patient and their doctor who can now have the diet conversation outside in the garden instead of the exam room. Instead of continually telling someone to diet, eat healthier foods, lose weight, exercise, reduce the A1C or fasting glucose levels etc., this garden provides a different means to change patient perception and motivation through example.

This and other community wellness ideas are a translatable way of empowering patients to take charge of something they can control in their life and hopefully see results that others have done which they can do and emulate it. All of these ideas are being designed at the home base of CFI on Gonda 16 where teams are working on how to completely revolutionize primary care. What about ideas such as cooking classes? How about support group possibilities for management of chronic diseases which would allow the patient to challenge their neighbor to set and strive to reach their goals collectively together instead of just thinking about it in a doctor’s office? How can we use technology to gain insight into pathophysiological conditions? The social determinants of health are greatly overlooked in the setting of disease. You can learn a lot about a person simply by visiting their home. CFI tackles this predicament and more by asking questions like, how do you deal with a difficult patient who is not improving and not taking their medications or the provider’s recommendations? Or perhaps the patient may only be able to exercise at night after work, but because their neighborhood is dangerous due to gangs he/she does not want to go out and risk walking around the block? Finding solutions to the management of disease must include asking about the factors that contributed to the disease.  Perhaps we could use technology to visit the home of patient. What about a timeline such as that Facebook uses to help the patient think of the factors in their life which may have contributed to times of being in a good or declined state of health?

Patient empowerment illustration

Other challenging questions the CFI is trying to address is how can empowerment of the patient be researched and hypotheses tested? How can we provide access to community resources before the risk factors of a patient’s life escalate into disease? How do we create value providing the highest level of care while also reducing the cost? I began my time with CFI working on randomly selected patients assessing the number of visits, who provided care, and the cost of that care received within the last year. Working through the visits, there were many individuals sent to the physician where, rather than seeing their primary care provider, the needs of patient could possibly have been met by another provider such as a CNP, RN, or over the telephone. We hypothesized that excessive testing or procedures could have been reduced or avoided had a less expensive and invasive approach – such as simply changing the patient’s diet – been tried first. This may help achieve the same or possibly better outcome, such as in one case which a 69 year old could have avoided an unnecessary appendectomy and extensive celiac testing which resulted in no explanation or diagnosis or relief of her symptoms until almost 1 year later when she tried a reduction of fatty foods in her diet!

The next point I take away from this week is that there are many examples that the team approach to medicine has proven to be essential and is increasingly associated with greater health outcomes. A radical new way of thinking about this is to develop methods of empowering the patient to have a stronger and more consistent relationship with select members of the healthcare team made up of possibly a doctor, resident, RN, CNP, LPN. This is individualizing medicine to create a personalized care team to better manage and have continuity of care for the patient. Can we create an app to utilize social media techniques to allow the patient to make their own comments and updates on factors they feel are affecting their health condition instead of an internal electronic medical record that has no direct patient input about their goals, questions & concerns, etc. all of which can then receive feedback and be better addressed from the healthcare team? Studies are starting to test if patients calling or video-conferencing in have a decision made as to who on the team could best meet their needs.  Could this lead to reductions in billable expenses by focusing the energy and expertise of the one member of the team who is qualified to provide the level of required service?  In medical school, we are engulfed into a culture based on the longstanding traditions of medicine that in stepping back and challenging the central dogma is perhaps indirectly limiting the care we can provide to our patients. In many practices, more doctor to doctor consultation about a difficult diagnosis is done instead of having that same discussion with the full care team-what happens if we challenge this idea and then add incentive for both the practice and patients? If the community and the actual provider directly share the burden of being financially responsible for care received perhaps better outcomes can be achieved. This pay for value idea is soon to be tested at the Kasson Clinic. How can we present this idea to both small and large businesses or corporations and use evidenced based research methods to determine if greater value and reduction in costs can be achieved? If we can prevent escalation of disease and complications, which lead to emergency depart visits, infections, hospitalizations, long and continued follow-up, what the patient will save and their improved health will be a result. Can better communication with specialty consultation in cases where the patient must be in the hospital allow for better management of the patient by the primary care team especially once the patient is back home? The CFI provides a very unique environment that allows for creative thinking to answer these questions involving brainstorming, multidisciplinary discussion, research and implementation. This is inspiring and slowly changing how we think about healthcare.

Comment bubble with quote about improving health

My short time with the CFI has allowed me to challenge the central dogma of healthcare and longstanding clinical practice approach. It is clear that when patients’ needs are not met greater costs, worse outcomes, and decreased satisfaction follow which cycles into progression of greater health problems, diseases, complications and drives up cost. If we can revolutionize the way in which a primary care practice interacts with its community and be a visible example of ways to live healthier, hopefully we can stop the cycle earlier and better manage or prevent the severity of some diseases. We can shift our current practice of disease management to preventative and individualized medicine. I feel very fortunate to have had this opportunity to think about the social determinants of health and what the future role I want to have as a physician within the a healthcare team. The complexity of the United States healthcare system will not be changed rapidly. Unique places such as the Kasson Clinic allow for testing in a small scale before bringing it back to the large Mayo Clinic practice. The CFI has so many brilliant thinkers who help each individual unlock their creative potential and meeting David Kelly of IDEO is an inspiration example of someone who shares their wisdom with the world. To be successfully creative and innovative you must continually personalize, analyze, define, synthesize, continue to ask new questions and develop ideas then continue the cycle. This selective has been an amazing experience and I hope to continue to be involved in the innovative work the phenomenal CFI team is generating.

Illustrations by Samantha Dempsey, RISD Student + Maharam STEAM fellow.