Addressing Whole-Patient Care
About this Challenge:
Regardless of patients’ roles in their own healthcare, there will always be questions about how doctors should approach medical problems — by focusing more on the symptoms and disease, or on the patient who has them?
Most doctors specialize due to a variety of pressures and incentives from economic and technological to social, professional and educational. The number of medical specialists (and specialties) continues to grow while the number of primary care physicians continues to shrink.
In the process, the goal of fitting all these specialties together for effective whole-patient care becomes ever more elusive. How can we treat the whole patient rather than the disease?
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Dr. Jack K. Der-Sarkissian is a board-certified family practice physician at Kaiser Permanente Los Angeles Medical Center.
A firm believer in the philosophy of total health, Dr. Der-Sarkissian partners with his patients to provide whole-patient care that emphasizes prevention, healthy eating, daily exercise and work-life balance.
An active member of the medical community, he is Assistant Chief and Quality Lead of Family Medicine at Kaiser Permanente Los Angeles Medical Center, an Elected Member of the Board of Directors at Southern California Permanente Medical Group, Medical Director of the OPTIONS Pre-Bariatric Surgery Program at Kaiser Permanente Los Angeles Medical Center, and is the Regional Lead for Adult Weight Management of Southern California Kaiser Permanente.
Dr. Der-Sarkissian attended medical school at the University of Southern California and completed his residency in Family Practice at Kaiser Permanente Los Angeles.
His interest in total patient care and addressing many of the most pressing medical concerns of the day, has led him to pen numerous articles in peer-reviewed publications concerning obesity.
Driven by an innate desire to make a difference in people’s lives, Dr. Der-Sarkissian was drawn to family practice as a means of addressing the total health of the communities he serves.
I became a family medicine physician because I firmly believe that doctors are able to make a real difference in people’s lives. That difference begins with honest communication and an authentic relationship with patients. In my experiences, patients have better health outcomes when we discuss options and they are active participants in the discussion around their care decisions. Together, we are able to address direct concerns, but also uncover other issues that might be impacting their health.
Susan E. Hernandez, M.P.A. is a fourth-year Ph.D. student and research assistant in Health Services at the University of Washington. Ms. Hernandez’s research interests include organizational approaches to improving quality in primary care settings, adoption of medical home practices in minority-serving institutions, and reducing racial/ethnic disparities. Her dissertation will test whether a national patient-centered medical home intervention exhibits differential effects on racial/ethnic groups in clinical quality; and healthcare utilization and cost.
Before beginning her doctoral work, Ms. Hernandez previously worked as a program associate for the Program on Health Care Disparities at The Commonwealth Fund. Here, she collaborated with the assistant vice president to develop grants, write publications, and analyze Fund-sponsored surveys.
Currently, Ms. Hernandez is working on a Commonwealth Fund-supported project studying how five organizations selected for their diversity in culture, organizational structure, delivery system integration, and market environment respond to patient-centered innovations being implemented throughout Washington State. She is also working on a Robert Wood Johnson Foundation-funded project evaluating eight payment reform efforts designed to promote high-value health care outcomes through leveraging existing market knowledge, partnerships and resources across the United States.
She earned her M.P.A. in Health Policy and Management from the Robert F. Wagner Graduate School of Public Service at New York University in 2008. She also earned her Bachelor of Arts in Healthcare Policy from City College of New York in 2003.
My interest in healthcare stems from several deeply personal experiences. Most recently, serving as my grandmother’s advocate and translator I am reminded that at the end of the day a patient is a person. I balance this perspective with my study of health service and my experience in philanthropy. Together they inform my interdisciplinary approach to researching ways to improve healthcare delivery. I use a combination of both qualitative and quantitative methods to cull out emergent themes about our healthcare system. I also aim to frame my research in a way that is both accessible and actionable for policymakers and organizational leaders.
Marci Nielsen, Ph.D., M.P.H., is the Executive Director of the Patient-Centered Primary Care Collaborative, a large coalition of provider/clinicians, purchaser/payers, and consumer stakeholders who have joined together to advance an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH). She previously served as Vice Chancellor for Public Affairs and Associate Professor within the Department of Health Policy and Management at the University of Kansas School of Medicine, served on the Board of Directors of the Health Care Foundation of Greater Kansas City, TransforMED LLC (a wholly owned, non-profit subsidiary of the American Academy of Family Physicians), and the MidAmerica Coalition on Health Care, and has been a committee member on the Institute of Medicine’s Leading Health Indicators for Healthy People 2020 and Living Well with Chronic Illness: A Call for Public Health Action.
Marci was the first Executive Director (2006-2009) and Board Chair (2005) to oversee Kansas’ health care agency, the Kansas Health Policy Authority (KHPA), Kansas Medicaid, the State Childrens Health Insurance Program, and the State Employee Health Program. She worked as a legislative assistant to U.S. Senator Bob Kerrey (D-Nebraska), and was the health lobbyist and assistant director of legislation at the AFL-CIO. She has an undergraduate degree in biology and psychology from Briar Cliff College, an M.P.H from the George Washington University, and a PH.D in Health Policy and Management from Johns Hopkins School of Public Health. Early in her career she served as a Peace Corps volunteer working for Thailand’s Ministry of Public Health, and also served for six years in the U.S. Army Reserves.
I believe that addressing the care of the whole person requires creativity, compassion, and humility – and the talents of a team of healers working seamlessly together with a patient and their family and/or loved ones. I lead a national movement aimed at promoting patient-centered primary care that considers considers it paramount to address the needs of the whole person.
Although a definition of whole person care is more than just the sum of its parts, my definition begins with:
"Whole" = Recognizes all aspects of what makes us human; our mind, body, and spirit.
"Person" = Underscores the need for each of us to be considered as a valued individual with our dreams, wishes, and fears.
"Care" = A word of many meanings, "care" includes the services provided to us (from healers, our families, our caregivers, etc.), the manner in which it is provided (with respect and expertise) as well as the demonstration of compassion and concern.
Dr. Diane E. Meier is director of the Center to Advance Palliative Care (CAPC), a national organization devoted to increasing the number and quality of palliative care programs in the U.S. Under her leadership the number of palliative care programs in U.S. hospitals has more than tripled in the last 10 years. She is also vice-chair for public policy and professor of geriatrics and palliative medicine; and Gaisman Professor of Medical Ethics at the Mount Sinai School of Medicine in New York City. In 2009-2010, she was a health and aging policy fellow in Washington, DC. She is currently principal investigator of an NIH-NCI-funded five-year multisite study on the outcomes of hospital palliative care services in cancer patients.
Dr. Meier was recognized in 2010 by HealthLeaders as one of 20 Americans who make health care better. She received a MacArthur Foundation “genius award” fellowship in 2008, among many other awards.
Dr. Meier has over 200 publications in major peer-reviewed medical journals, including the New England Journal of Medicine and the Journal of the American Medical Association. She authored Palliative Care: Transforming the Care of Serious Illness and edited the first textbook on geriatric palliative care.
I am a doctor who works in palliative care and geriatric medicine. Years of clinical work, teaching, and research in academic medicine convinced me that medicine was on the wrong track – more focused on the disease or the organ than the human being and their family and their community. I have worked for 15 years to rekindle the originating impulses of the healing professions to remind us all that “the secret of the care of the patient is in caring for the patient.”
Blair Sadler is a senior fellow at the Institute for Healthcare Improvement, and a member of the faculty at the UCSD School of Medicine and Rady School of Management. He served as President and CEO of the Rady Children’s Hospital in San Diego for 26 years, leading it to become the first U.S. pediatric hospital to win the Ernest A. Codman Award for its work in developing clinical pathways. He speaks to healthcare Boards and leadership teams about their role in patient safety and quality as well as managing adverse events.
Previously, he served as a law clerk for the Superior Court of Pennsylvania, medical-legal specialist for the National Institutes of Health, on the faculty at Yale University (and Co-Director of the Yale PA program), as a senior officer at the Robert Wood Johnson Foundation, and senior executive at the Scripps Clinic and Research Foundation.
Today, evidence-based design is central to Sadler’s work in many arenas: as an international consultant on safer, low-stress hospitals; as a Center for Health Design board member; and as a founder of the Center’s Pebble program (a collaborative effort to identify, support and disseminate the work of pioneering organizations worldwide).
As the President and CEO of Rady Childrens Hospital in San Diego for 26 years (1980 to 2006), I was heavily involved in helping to create a culture of collaboration among disciplines on behalf of the pediatric patients we served. When over half of our in-patients were less than four years old, we knew that it was essential to treat whole families, as well as whole patients. As a Senior Fellow at the Institute for Healthcare Improvement over the past six years, I have been very impressed with their efforts to make health care truly patient-centered. We must overcome natural tendencies to think and work in specialty silos and create policies and practices that always put the patient in the center of everything we do.
Douglas Thompson serves as the ACO director for developing and implementing a strategic business plan for Cambridge Health Alliance’s (CHA) transformation into an ACO. Mr. Thompson provides leadership of the development and implementation of all global payment contracts between payers and the CHA, including Medicare and Medicaid. Under his tenure, CHA has become a national model for the development of safety net delivery system ACOs.
Previously, Mr. Thompson was vice president of finance at Network Health, a health plan serving more than 170,000 members. During his tenure, the health plan went from a projected $20M loss to a $21M gain.
Prior to Network Health, Mr. Thompson served as chief financial officer for the Commonwealth of Massachusetts, Office of Medicaid. In this capacity, he developed and oversaw a $9 billion budget and drove cost control to a historically low increase without reducing eligibility or services. Mr. Thompson also championed an effort to develop medical homes across Massachusetts, Primary Care Clinician (PCC) Plan and multiple payers.
Mr. Thompson earned a Bachelor of Arts in Philosophical and Sociological Thought in Medicine from Boston University and a Master in Public Policy from the John F. Kennedy School of Government at Harvard University.
As a senior executive responsible for transformation of a safety net healthcare and public health delivery system for a predominantly low-income population, I am acutely aware of the opportunities and challenges inherent in addressing whole-patient care. My current experience is complemented by experience as CFO for both a Medicaid managed care organization and for a state Medicaid agency. Throughout my career I have also addressed this issue asa senior consultant to Medicaid agencies and large behavioral health management companies. Finally, I have seen how our current healthcare system delivers whole patient care through personal experience of caring for a loved one with serious medical issues.
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18 Comments
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sergio pillon: 1) Patient care ins't on the top of doctor's priorities
2) We learn DISEASES and not PATIENTS
3) Healthcare systems are disease oriented
4-5-6-7-8-9) Chapter VI: Of New Princedoms Which a Prince Acquires With His Own Arms and by Merit (By Niccolo Machiavelli, 1513 a.c.)
And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. For he who innovates will have for his enemies all those who are well off under the existing order of things, and only lukewarm supporters in those who might be better off under the new. This lukewarm temper arises partly from the fear of adversaries who have the laws on their side, and partly from the incredulity of mankind, who will never admit the merit of anything new, until they have seen it proved by the event. The result, however, is that whenever the enemies of change make an attack, they do so with all the zeal of partisans, while the others defend themselves so feebly as to endanger both themselves and their cause.
But to get a clearer understanding of this part of our subject, we must look whether these innovators can stand alone, or whether they depend for aid upon others; in other words, whether to carry out their ends they must resort to entreaty, or can prevail by force. In the former case they always fare badly and bring nothing to a successful issue; but when they depend upon their own resources and can employ force, they seldom fail. Hence it comes that all armed Prophets have been victorious, and all unarmed Prophets have been destroyed.
10) You know better than me how in YOUR organizzation these factors are interacting..., those are the result of a complex, Darwinistic evolution. Very hard to change -
sergio pillon: 1) Patient care ins't on the top of doctor's priorities
2) We learn DISEASES and not PATIENTS
3) Healthcare systems are disease oriented
4-5-6-7-8-9) Chapter VI: Of New Princedoms Which a Prince Acquires With His Own Arms and by Merit (By Niccolo Machiavelli, 1513 a.c.)
And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. For he who innovates will have for his enemies all those who are well off under the existing order of things, and only lukewarm supporters in those who might be better off under the new. This lukewarm temper arises partly from the fear of adversaries who have the laws on their side, and partly from the incredulity of mankind, who will never admit the merit of anything new, until they have seen it proved by the event. The result, however, is that whenever the enemies of change make an attack, they do so with all the zeal of partisans, while the others defend themselves so feebly as to endanger both themselves and their cause.
But to get a clearer understanding of this part of our subject, we must look whether these innovators can stand alone, or whether they depend for aid upon others; in other words, whether to carry out their ends they must resort to entreaty, or can prevail by force. In the former case they always fare badly and bring nothing to a successful issue; but when they depend upon their own resources and can employ force, they seldom fail. Hence it comes that all armed Prophets have been victorious, and all unarmed Prophets have been destroyed.
10) You know better than me how in YOUR organizzation these factors are interacting..., those are the result of a complex, Darwinistic evolution. Very hard to change -
Hayman Buwaneswaran Buwan: why “whole patient care” is a complex and difficult problem for the medical establishment, for patients and for society? --> because it maybe the 'opening of that pandora's box of issues' which may prolong a clinic visit, be beyond the scope of care of that clinician, require further intervention, patient is not ready to discuss due to fear or non-concern, society frowning upon the issue, fear of financial/insurance/career repercussions, etc.
This is a big topic. The silence and lack of attention to the whole person may be another factor contributing to rise in 'chronic' issues.
It's a system problem as noted before by Dr. Meier. -
Hayman Buwaneswaran Buwan: why “whole patient care” is a complex and difficult problem for the medical establishment, for patients and for society? --> because it maybe the 'opening of that pandora's box of issues' which may prolong a clinic visit, be beyond the scope of care of that clinician, require further intervention, patient is not ready to discuss due to fear or non-concern, society frowning upon the issue, fear of financial/insurance/career repercussions, etc.
This is a big topic. The silence and lack of attention to the whole person may be another factor contributing to rise in 'chronic' issues. -
Nancy Hanrahan: Whole person care is real--it is not logical to refer to someone as not "whole". Whole person care is reality as there is never anything but a person who seeks and receives healthcare. Silos are created by the infrastructures that house the health care providers and the process follows the infrastructures which are fractured, frustrating to navigate, and do not communicate with other parts of the health system. The latter process causes unnecessary harm to patients and higher costs. This situation causes even the best organized person to feel frustrated and not 'cared' for. Drivers of change will be through economic sanctions, in my opinion. if quality of care is connected with reimbursement, we would see the system change rapidly. Case in point: Medicare restricting payment for 30 day readmission. There is great potential for change from the Affordable Care Act--specifically, matching quality with financing. We may have reached the tipping point where the paradigm will shift. Hopefully. -
Nancy Hanrahan: Whole person care is real--it is not logical to refer to someone as not "whole". Whole person care is reality as there is never anything but a person who seeks and receives healthcare. Silos are created by the infrastructures that house the health care providers and the process follows the infrastructures which are fractured, frustrating to navigate, and do not communicate with other parts of the health system. The latter process causes unnecessary harm to patients and higher costs. This situation causes even the best organized person to feel frustrated and not 'cared' for. Drivers of change will be through economic sanctions, in my opinion. if quality of care is connected with reimbursement, we would see the system change rapidly. Case in point: Medicare restricting payment for 30 day readmission. There is great potential for change from the Affordable Care Act--specifically, matching quality with financing. We may have reached the tipping point where the paradigm will shift. Hopefully.
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TEDMED Moderator: Would we get more whole-patient care if we had more primary care physicians? Their numbers are continuing to shrink, unfortunately. The Affordable Care Act includes provisions for federal incentives to boost the number of primary care doctors but effects are not expected to be felt for years. What can be done today and tomorrow?
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Bruce Ramshaw: I think the transition to Whole Patient care will require a transformation in how we deliver care. The study of complex adaptive systems science allows us to understand how a care system designed for the patient might look. I gave a TEDx talk about this topic at aTEDxChange event earlier this year. I'm not sure I gave ten factors, but this would be my best answer to the question and a description of our attempt to transform our care system to address the Whole patient:
https://www.youtube.com/watch?v=QPeLIbh0BAw -
Bruce Ramshaw: I think the transition to Whole Patient care will require a transformation in how we deliver care. The study of complex adaptive systems science allows us to understand how a care system designed for the patient might look. I gave a TEDx talk about this topic at aTEDxChange event earlier this year. I'm not sure I gave ten factors, but this would be my best answer to the question and a description of our attempt to transform our care system to address the Whole patient:
https://www.youtube.com/watch?v=QPeLIbh0BAw -
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Question 1
What are the top 10 contributing factors why “whole patient care” is a complex and difficult problem for the medical establishment, for patients and for society…and how do these factors interact with each other?Factors include: lack of a universally accessible health care system, significant heterogeneity of the population, wide disparities in health literacy, language barriers, cultural barriers, lack of diversity among health care providers, a growing aging population, higher patient expectations, obesity epidemic, financial incentives that reward specialty care, wide differences in approaches to delivery by different states, porousness of borders, challenges researchers face when testing new discoveries, and the broad diversity that exits within the nation's already diverse population groups.
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1 Comment
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Bruce Ramshaw: I think the transition to Whole Patient care will require a transformation in how we deliver care. The study of complex adaptive systems science allows us to understand how a care system designed for the patient might look. I gave a TEDx talk about this topic at aTEDxChange event earlier this year. I'm not sure I gave ten factors, but this would be my best answer to the question and a description of our attempt to transform our care system to address the Whole patient:
https://www.youtube.com/watch?v=QPeLIbh0BAw
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Casey Lankow: The CareProfiler system allows healthcare organizations to strengthen the relationships between care recipients and caregivers. By asking the care recipient questions about how they want to be cared for and comparing those results against personality profiles of direct care staff, the organizations can see which staff are most compatible for each patient as well as what areas other staff might need to keep in mind when caring for a specific patient. |
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TEDMED Moderator: What the Challenge Team discuss Whole-Patient Care in an online live event. |
Live Event
Members of the Great Challenge Team, Addressing Whole Patient Care gathered on Google + Hangout to discuss the topic in a virtual roundtable event.
View the Live Event recast and then continue the discussion on Twitter using #GreatChallenges!
MODERATOR: This discussion is being moderated by John Nosta, Executive Vice President, Sr. Strategist at Ogilvy CommonHealth Worldwide who is a well-established advocate of digital innovation in health. |
Participants:
Jack Der-Sarkissian, MD, Susan E. Hernandez, MPA, Marci Nielsen, PhD, MPH, Diane Meier, MD, Blair Sadler, JD, Douglas Thompson, MPP
Meet the Team