Patient Engagement – Iora Health’s Innovative Model Builds Deep Relationships with Patients
By Joel Lazar, MD, MPH
When Mary first presented to our primary care practice, she was burdened by chronic illnesses and felt jaded by her unsuccessful attempts to manager them. She frankly acknowledged her lack of trust in conventional healthcare, and even her loss of faith in her own abilities. Weighing close to 300 pounds, living with poorly controlled diabetes (despite large requirements of insulin spread across multiple daily injections), feeling dehumanized in prior clinical settings, and judging herself negatively in the context of perceived past failures, Mary had little confidence that her new care team could support the personal changes she so deeply desired. But our primary care practice, Dartmouth Health Connect, was established by Iora Health in 2012 on the core conviction that personal health transformation is indeed possible–though achieving it depends on a healthcare delivery model that is also fundamentally transformed.
The present U.S. healthcare system is profoundly challenged in meeting both the illness an the wellness needs of individuals and communities. “Fixing” this system requires more than peripheral adjustments; rather, clinical care in general and primary care in particular–the centerpiece of any effective system–must be rebuilt from the ground up, with robust and empowering relationship as their foundation. The vision of Iora Health is to restore humanity to healthcare, and our ambitious mission is to transform healthcare itself and the lives it serves through a high-impact, relationship-centered care model.
An invitation to transcend traditional barriers
As she subsequently shared with us, Mary appreciated our invitation to partner with her in a respectful, collaborative, and creative manner. She perceived our willingness–our intent–to remove system barriers that have traditionally stood between patients and their engaged empowerment.
The first barrier to fall was financial. Transformation of care begins with reshaping the business model that supports it. Fee-for-service payment runs counter tot he goals of wellness-focused primary care, so we have fully removed fee-for-service from our new model.
The majority of our patients are employees (or family members of employees) or Dartmouth College; as a self-insured organization and the the second-largest employer in the region, the college bears ultimate responsibility for its staff’s healthcare costs. We have formed a value-driven partnership with Dartmouth, providing capitated primary care to all eligible employees and dependents. The college pays us a straight per-member-per-month fee; in exchange, we provide full primary care to all members with no billing to our patients. We see individuals at whatever frequency is appropriate for them–once per year or 50 times per year–to ensure our care is of the highest quality and as accessible and engaging as possible.
Patients encounter no financial paperwork, no copays, and no charge at all for any service we provide within or primary care practice. This altered payment structure shifts our clinical interactions from transactional to relational, and our patients enthusiastically embrace the change. They understand that the removal of financial barriers is an invitation to deeper engagement.
This model also is highly valued by our care team. Altered payment does not, in itself, solve healthcare’s perennial problems, but it gives us and our patients the space to creatively address those problems. We can shift our attention away from the traditional fee-for-service “needs of the visit” (“What must I do to bill most aggressively for Mary’s care?”) and instead toward the relationship-focused needs of the patient (“What can I do, in the office or in groups, or by phone or video, or during walking visits or home visits, to meet Mary’s specific needs?”). Imagine the possibilities!
Health coaches and expanded relationships
Out of all our creative solutions, embedded health coaches are the most essential. Like ever new patient at Dartmouth Health Connect, Mary was assigned a personal health coach at her first visit. Coach Lisa is not an external consultant but an integrated member of our care team, hired for her core empathic skills and charged specifically with eliciting Mary’s personal wellness goals: to lose weight, to get off her insulin, and to feel better about herself. In partnering with Mary over time to gradually achieve these goals, Lisa used motivational interviewing and shared decision-making techniques, combined these with content knowledge in specific health domains, and performed her job with deep compassion and interpersonal sensitivity.
With Lisa’s prompting, Mary identified some early, achievable behavior targets. These involved small changes in the carbohydrate content of her diet and a commitment to brief walks during lunch hour. She checked in frequently with Lisa, sometimes via 1:1 meetings in person and other times by phone or email. Occasionally, they would meet for a midday walk on campus. In addition, Mary, Lisa, and I (as Mary’s clinician) would collaboratively discuss therapeutic adjustments during interval meetings. Over time, Mary grew increasingly motivated to monitor and record her blood sugars throughout the day and to adjust her insulin dosings based on increasingly bold modifications of diet and activity. These safely supported “experiments” have impressively enhanced Mary’s trust in her own capacities. In addition, the varied meetings provide opportunity for broader exploration of Mary’s values, care priorities, and emotional responses to her evolving states of illness and wellness.
Patients at Dartmouth Health Connect experience an expanded care team where they feel deeply understood and fundamentally respected by their doctors and coaches. Patients feel known here and are embraced–figuratively and literally–as who they are. Walk through our practice and you’ll witness warm handshakes evolving spontaneously into hugs. You’ll hear team members cheering aloud with patients when goals are achieved or even approximated.
Other building blocks of engagement
Daily morning huddles are another design feature that our new model permits–and depends upon. Our team meets for a full 30 minutes each morning, with leadership of the session rotated among staff members. In addition to honoring small victories, we review in detail our “worry list” of patients. Who has been hospitalized or seen in the local emergency department? Who is struggling with acute family stressors and will benefit from new forms of support? Who needs a phone call or video check-in, and by whom?
Recognizing the potential health burdens of isolation and the power of positive affiliations to support wellness-oriented behaviors, we also run regular patient groups (to which families and friends are invited) on diverse themes centered around realization of self-care goals. Groups may focus on weight management, yoga, mindfulness meditation, advance directive planning, or other themes. Patients now feel comfortable not only participating in, but also leading a number of these groups.
In addition, we sponsor a quarterly “Patient Advisory Group,” comprised of representative practice members whom we convene over dinner to advise us regarding community needs and new opportunities for practice innovation.
We’re especially heartened to hear participants express their sense of co-ownership in our shared work, which applies not only to improvement of patients’ personal health but also to optimization of our service model.
Rewarding outcomes
We’ve endeavored to quantify the early results of our shared initiative. Across the practice, clinical measures of chronic disease management have improved and reports of patient satisfaction are gratifyingly high. Patients’ costly emergency room visits and hospital admissions have meanwhile trended downward, much to the happiness of not only the patients, but also Dartmouth College.
But the individual success stories remain the most heartwarming reflection of our shared efforts. I’ll never forget the day when Mary lost her 100th pound! (Yes, her weight is now well below 200 pounds!) She looks and feels great. The warm glow in her eyes is contagious to passerby. Her blood sugar levels have come down dramatically, as have her insulin requirements of greater than 100 insulin units per day, Mary has weaned herself down to a mere two units and is confident she’ll soon be insulin-free.
Mary’s improved self-confidence is, for me, the most compelling dimension of her transformation. She is lit up, alive, in a manner she hasn’t experienced in years. And this newly manifested engagement–this deeply embodied empowerment–will enable further accomplishments she’s yet to imagine.
These stories of patients’ success are gifts given back to their care partners; they inspire us to engage even more greatly, creating a virtuous cycle. The patient journey toward health transformation are shared by us all as continuous and mutual reinforcement.
Joel Lazar serves as medical director of Dartmouth Health Connect, a primary care practice in Hanover, New Hampshire, and is also a member of the Clinical Leadership Council of Iora Health, the practice’s parent company. Lazar received his bachelor’s and medical degrees from the University of Pennsylvania, and completed his residency in family medicine at Thomas Jefferson University Hospital in Philadelphia. He also earned a master’s degree in public health from The Dartmouth Institute for Health Policy and Clinical Practice. Prior to his work with Iora Health, Lazar served in clinical and leadership roles first with the Indian Health Service in Shiprock, New Mexico, and then in the Department of Community and Family Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. He may be contacted at joel.lazar@dartmouthhealthconnect.com.