Written by: SA Kushinka

Diabetes and hypertension are lifelong diseases that are notoriously hard for many patients to manage. This July, as program team members for Kaiser Permanente’s PHASE program, we participated in a site visit at the Sonoma County Indian Health Project (SCIHP), which has developed an innovative — and unusually effective — approach to managing these diseases. Not only are patients empowered to take charge of their health, many have been able to stem or even reverse the effects of these diseases.

Thanks to our hosts, we were able to hear firsthand from both the care team and patients who had participated in the PHASE clinic and achieved remarkable health results. What we learned from that inspiring visit were some of the elements that went into the program’s success:

The SCIHP PHASE innovation consists of a patient-centric group visit – with a twist. SCIHP joined the PHASE project as a sub-grantee of the Redwood Community Health Coalition in 2017. It has had a robust diabetes management program in place for many years, given that American Indian/Alaskan Native people are nearly 2.5 times as likely to be diagnosed with diabetes as Non-Hispanic Whites. SCIHP wanted to try a new approach: Rather than the traditional group visit – many patients with one provider – one patient has an appointment with a team of care providers.

Patients are prepared for the group visit during their initial consult with PHASE. When a patient is first referred to PHASE, the team strives to understand each patient’s needs in a non-judgmental way, unhindered by time constraints of the typical office visit.  As the medical assistant prepares the patients for their visit, taking vitals and conducting screenings, she’ll often tell them a success story for inspiration and to dispel any initial skepticism. She provides a handout describing the team assembled for the visit.  At the top of the list of team members is “You!” — i.e., the patient.

The 30-to-60 minute “one stop shop” encounter is designed to support and empower the patient. We walked through the clinic following the patient flow into the exam room to imagine the visit from the patient’s perspective. He or she would meet a  multidisciplinary team that includes a clinical pharmacist, registered dietician, nurse educator,  medical provider, medical assistant, and a clinical scribe to document the visit. Each team member plays a clear, valued, and respected role in supporting the patient.

The driving principle of the visit is empowerment and education: pharmaceutical, dietary, and medical. The clinical pharmacist will begin by listening and learning about how the patient is experiencing symptoms of the disease by asking open ended questions to elicit their engagement. Together they identify one small goal that the team can help them achieve.  He or she not only explains what each medication does and why it helps, but tries to simplify and, in many cases, eliminate many of the medications the patient is taking. The team’s use of newer diabetes medications has been a game-changer for many patients — helping them to lose weight and reduce or even eliminate their need to use insulin. These medications have helped simplify medication regimen and have aided in medication compliance, as well as lowering A1Cs. The dietician sits nearby and does a “quick and dirty nutrition triage.”  The patient is encouraged to schedule a nutritional consultation, and 75 percent of them do. The billing provider, SCIHP’s CMO, will stop in to conduct a physical exam. At the end of the visit, a specially-trained RN health educator reviews the patient’s understanding of education provided and facilitates goal-setting with the patient.  Together, the team and the patient develop a plan of action and care.  And because there is a medical exam as part of the visit, SCIHP is able to bill this visit at their PPS rate. For some insurances, visits by a clinical pharmacist alone are also billable.

An RN patient educator serves as the point person, so the patient knows who to call for follow-up questions. As the care team moves to see the next patient, the team’s RN Patient Educator enters the room prepared to reinforce the plan  (which has been documented in the EHR by the team’s scribe), provide health coaching, set SMART goals, help the patient strategize and visualize how they can make the plan work in everyday life, and provide any education needed for changes in medication. She also ensures the patient knows they have a direct contact for any questions.

A dramatic change 

The SCIHP team was clear that the patient controls the visit, and the patients that spoke with us during our site visit were an inspiration. Talking about their journey, they spoke knowledgeably about their disease, pointing to statistics and metrics from their glucometer readings.  They described in detail the carbohydrate content in various foods and how to control cravings — understanding which foods to avoid or embrace, but also when and how to eat these foods. We heard how their symptoms disappeared over time and of significant improvements in energy level. Tellingly, one of the patients referred to the group visit as PHASE “classes.”

The patients also mused on the dramatic change in their relationship to the healthcare system: “How come no one ever talked to me about my disease for twenty  years?” one asked. Said another: “With my other provider, I was always made to feel that it was all my fault…’Just take these medications’ was the extent of my education.”

It’s a moving and powerful thing to see real patient empowerment — and to know these individuals have the chance to live long and healthy lives. As SCIHP’s clinical pharmacist told us, “We used to call this the Kleenex Clinic because there is a lot of emotional release when patients realize they don’t have to suffer, that they have control over their disease.  We’re here for them.”



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