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Why a Team Approach is Better for Senior Patients and Their Physicians

Sponsored by Humana Inc.


Tina Shenouda, MD, MBA, is a family practice physician and Chief Medical Officer of Partners in Primary Care, a subsidiary of Humana. In this role, she is responsible for the delivery of medical care for Partners’ network of 56 senior-focused primary care centers across seven states, with nine more centers scheduled to open by the end of March 2021.

I come from a family of physicians. Both of my parents, my brother, multiple extended relatives and myself have devoted our careers to practicing medicine. At 86 years old, my father still sees patients. We were drawn to the profession by the connections and long-term relationships a physician develops with patients and their families and the satisfaction in working together to help them achieve better health.

That type of direct patient care is at the heart of family practice medicine, which is why it was my specialty of choice, and that of my colleagues. But for many primary care physicians, the reality of practicing medicine is quite different from what attracted us initially. Administrative burdens, the demands of managing a practice and a fee-for-service payment system all impinge on the time we can spend with our patients, often making it difficult to cultivate the strong bonds essential to providing good care. In fact, a Deloitte survey found that the greatest source of dissatisfaction among PCPs is having less time for each of their patients.

Part of the problem is a lack of adequate staff and resources to address both office-related work and the complexities of patient care, including social determinants of health, that stretch physicians beyond our capacities. According to studies of time demands on physicians, primary care doctors need 18 hours a day to fulfill all their responsibilities.  

A combination of these and financial factors has resulted in a decline in the number of primary care physicians practicing in the U.S. Since 2011, fewer medical students are choosing to go into primary care, and who can blame them? A recent Medscape survey found that only 62% of internal medicine doctors would opt to go into the same specialty again. These dwindling numbers are particularly discouraging at a time when aging baby boomers are increasing the demand for primary care physicians, with a shortage of up to 55,000 PCPs expected in about a decade. This is especially concerning for underserved communities which currently have little access to PCPs.

PCPs Need a Care Team

It’s clear that a new model of primary care medicine is needed. There is no way that PCPs can adequately meet all the demands on their time, especially when treating an aging population with complex medical needs. Fortunately, there is an approach that works. The support of a care team has allowed me and a growing number of PCPs to focus our time and energy on direct patient care the way we intended when we began our careers.

I am a practicing physician and the chief medical officer for Partners in Primary Care, a network of 56 senior-focused primary care centers across seven states, with nine more centers scheduled to open by the end of March 2021. Partners in Primary Care accepts patients covered by any Medicare Advantage plan and those eligible for both Medicare and Medicaid (dual eligible). The team approach is critical to providing comprehensive care to our older patients. With the additional staff and expertise of a care team, our physicians spend much more time with patients than most – on average 45 minutes per visit, compared to the industry standard of around 17 minutes. Patients also benefit from access within the same facility to mental health practitioners and social workers who help address their social service needs.

While a care team can be effective for treating any patient population, it’s particularly beneficial when caring for seniors. With 85% of seniors suffering  from at least one chronic disease and accounting for nearly 40% of all adult hospitalization, many older patients require a great deal of medical support. Physician visits alone are often not enough to properly manage and monitor their conditions. That’s where our Care Coaches step in for additional support. Working closely with patients on a regular basis, these RNs support patients in adhering to their treatment plan, educate them about their conditions, assist them following their hospitalizations and coordinate between all the various practitioners and specialists providing care. Our Care Coaches meet with patients in person or virtually 20 or more times each year, a level of individualized care that would be impossible for a physician to accomplish.

Adding SDOH and Mental Health to a Treatment Plan

As physicians, we’ve experienced first-hand the limits of treating a patient’s medical condition when there are social and environmental factors negatively affecting their health. It’s no surprise to us that clinical care accounts for only 20% of health outcomes, while 80% are the result of social determinants of health (SDOH).

Addressing SDOH is particularly critical when caring for seniors. Many older Americans live in a precarious financial state that directly impacts their health. Almost one in four are food insecure; homelessness among seniors has been on the rise and is expected to triple within the next decade. Many older adults also have limited access to transportation, preventing them from securing essential goods or getting necessary medical care, as well as increasing their sense of isolation.

While physicians recognize that these factors have detrimental effects on patient health, few have the time or resources to address them. A study published in JAMA Network Open revealed that only 16% of physician practices screen for key social needs, which is understandable given the limitations most physicians face in trying to resolve non-medical issues single-handedly.

Having a social worker as part of a care team who can both identify those gaps and work with patients to resolve them can make a major difference in the health of our patients. For instance, one of our high-risk patients was regularly cancelling appointments. In speaking with him, our social worker learned that the patient could not afford his co-pays or his medication. The good news is, the social worker was able to connect him with affordable housing, SNAP food benefits, and reduced utility bills to save him approximately $600 a month – almost the entire amount of his original rent payment and more than enough to cover his co-pays and medications.

The mental health of our patients is also inextricably tied to their physical health. While one in four older adults experiences some mental health disorder, few seek help from mental health professionals.  A behavioral health specialist caring for the patient alongside their primary care physician reduces barriers to receiving psychological counseling and treatment. During the pandemic, when social isolation and loneliness have become even more acute for many older people, having these services easily available to patients at one facility or virtually is more critical than ever.

Improving Coordination of Care and Outcomes

Each day our care team meets for a morning huddle to review the files and discuss the patients they will be seeing that day and what specific issues will need to be addressed. Having an in-house pharmacist, social worker and behavioral specialist allows us to work closely together on a patient’s treatment plan. In addition to ensuring that care is well coordinated among team members, RNs who closely monitor the patient’s status also stay in close communication with other specialists and hospital staff who have been treating them.
Underpinning this care team model is a value-based payment system that promotes a high-touch, holistic approach to patient care that benefits both our patients and physicians and leads to better outcomes. Data from our South Carolina centers shows that, in 2019, 30-day hospital readmission rates for our patients were almost 60% lower than those of the general Medicare population. Our rate of hospital admissions was 186 per 1,000, significantly lower than the national rate for this age group, which ranges from 233 per 1,000 (65-84 years old) to 456 per 1,000 (age 85+).

It’s clear such a change in the way we deliver care to seniors was needed. Care teams allow primary care physicians to get back to the work they were trained to do – spending their time caring for their patients.  

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