In an era of chief patient experience officers and other quality improvement administrators, two doctors say a primary care physician deserves a spot in the hospital's C-suite.
Writing in the July/August 2017 Annals of Family Medicine, Noemi Doohan, MD, PhD, and Jennifer DeVoe, MD, DPhil, explored what Robert M. Wachter, MD, FACP, has called the Achilles heel of hospital medicine: discontinuity.
They proposed a potential solution: Hospitals could appoint a physician with experience in both hospital medicine and primary care as a chief primary care medical officer (CPCMO). The CPCMO would lead improvements in care transitions, working 0.25 full-time equivalent (FTE) in a continuity clinic, 0.25 FTE as a hospitalist, and 0.50 FTE on administration, according to the paper.
Dr. Doohan, a hospitalist and future director of the developing family medicine residency program at Adventist Health Ukiah Valley in California, recently spoke with ACP Hospitalist about the concept.
Q: How did you come up with this idea of the CPCMO?
A: I came up with the idea with my coauthor, Dr. DeVoe, who's the chair of the family medicine department at Oregon Health & Science University. It's an idea we've been developing over the last several years, this idea of the CPCMO, both from a theoretical perspective in the first paper we wrote [“The Future of Family Medicine Version 2.0: Reflections from Pisacano Scholars,” Journal of the American Board of Family Medicine, February 2014] and then with Dr. DeVoe's own experiences with the gaps in medical care when her father was hospitalized and dying. She couldn't get in touch with the primary care doctor for her father [“Dad's Last Week,” Annals of Family Medicine, May 2016]. . . . The primary care system should not end at the hospital door; the primary care system should be everywhere the patient goes, and that's what we hope to ensure with the CPCMO.
Q: Has your concept evolved over time or remained consistent?
A: I think it's evolved in that we feel even more strongly that it's important. In writing this paper, we had a concept of a CPCMO, but we hadn't fleshed it out and said specifically what the CPCMO would do. For us, the process of writing this paper was a process of really thinking specifically what we would define this role to be, including that in this paper we specify FTEs.
Q: Who would be the ideal CPCMO?
A: We're saying it should be a primary care doctor, so it could be an internist who also has a primary care practice or a family doctor. And what we are saying is that this doctor should have a primary care practice as well as a hospitalist practice. They should be practicing in both worlds, inpatient as well as outpatient, so that they continue to have an understanding of the evolving systems in both spaces.
Q: Would you expect the role to be attractive to physicians?
A: There are definitely doctors in this country that want to practice in that way. They want to both have ongoing primary care relationships with their panel of patients, as well as take care of those patients in the hospital. . . . It does come down to how you compensate the doctors for their time, but it's definitely attractive to primary care doctors who do believe it is important to provide continuity for their patients in the hospital. I don't think that there's a lot of them, but I think that there's enough of such primary care doctors to step into CPCMO roles. I am one of those doctors.
Q: How would this system build on hospitals' existing efforts to improve care continuity?
A: I use hot-spotting, the approach made famous by [family physician] Jeffrey Brenner, MD, as an example. One of the things that's being done with hot-spotting programs is you get an intensive outpatient case management team to really focus on the individuals in this high-cost, high-need population and try and see: What are some of the social needs that aren't being met that, if they're met, they would be better served so these patients would not be coming to the ED unnecessarily? Maybe it's transportation, for example, or maybe it's access to a primary doctor. We're addressing the problems of the complex-care patients with outpatient case management teams that are doing a really good job, but it's not necessarily changing the systems of the primary care office and the hospital to better meet the needs of those patients. We need the primary care doctors who can really make changes in the hospital system and the primary care office-based systems, based on the fact that they understand those systems.
Q: How might a CPCMO affect the way hospitalists practice?
A: Let's take the example in the paper of the patient who is homeless with schizophrenia and uncontrolled congestive heart failure who had eight ED visits in the last month. She has multiple handoffs to different hospitalist teams and critical details about the patient were lost, including that she already has a primary care doctor that knows about her but wasn't contacted. What we have now with hospital-based hot-spotting systems is that we often have intensive outpatient case management teams that would be called in for this patient, but what a CPCMO could do for a patient like this is actually restructure the way that the hospitalist team responds when a high-need, high-cost patient comes on to the service and make changes within the hospitalist service. For example, perhaps they could make a special high-cost, high-need hospitalist consultant so that when this type of patient comes in, they have doctors who are more experienced maybe with addiction medicine or psychiatric care that this hospitalist consult team would be the one to respond.
Q: How might the CPCMO's responsibilities vary from hospital to hospital?
A: I think that any of us who work as hospitalists really understand that there's a culture at every hospital. The CPCMO would have to be responsive to the community they're in, in terms of understanding the needs in that community and how the gaps in continuity can be addressed best for that community. It will be different, depending on the unique community where that hospital is based and the primary care system around that hospital, so it's going to need to have a leader who understands that local medical ecosystem. It's really important to point out that our idea is to build the connections between the hospital and the outpatient setting, so in my example of the high-cost, high-need patient, it's not good enough to try and work on the systems problems within the hospital that contribute to this patient repeatedly coming into the ED. We also have to simultaneously work on the systems problem in the primary care clinic, where maybe that patient can't get an appointment, and when they go into the primary care clinic, maybe they don't have the services to take care of a woman who's schizophrenic. We have to simultaneously work on the systems challenges in the hospital, as well as in the primary care setting, that contribute to discontinuity.
Q: What would be the potential challenges of creating an administrative position like this?
A: I think that the challenge is in, first of all, elevating the role of primary care doctors within the hospital culture so [that] the importance of primary care physician leadership in the hospital for continuity is recognized. I think that it's fairly common these days to not have the primary care physician voice being at the table at leadership decisions in hospitals, so I would say the first challenge is to recognize how important the primary care physician's leadership is in hospital decision making and also to recognize how complex the outpatient world in primary care is, and that that complexity is something that you need expertise at the table to represent. The second problem, I think, is that any time in a hospital world you propose a new role, a new C-suite role, a new chief role, there's a lot of questioning about whether that's redundant and if you really need it. So making the argument that, of the many new chiefs, why should we add a new primary care chief? The other challenge is that we're arguing that this role should be a doctor who has experience in both the inpatient and outpatient world that's current, and that duality is harder to find in this day and age, where you generally don't have doctors practicing in both worlds, which is what we believe contributes to the fragmentation that we see.
Q: Have any hospitals adopted this concept?
A: When Dr. DeVoe and I wrote the paper, we got people responding to us saying, “You know what? I just happened to get a job that doesn't have the title CPCMO, but in fact, that's what I'm doing in my new hospital role.” So we are seeing that there are health care systems across the country that are recognizing this importance of having a primary care doctor in a leadership role at the hospital who can represent expertise regarding that full scope of care across the continuum of care for patients. So there are hospital systems that are creating this role. We were very excited to hear that. For us, the best scenario would be that this role would be created in hospital systems and that we would start seeing it tested and studied. That would be a dream job for me if my hospital would create such a role.