Opinion | Getting It Right for 100% of Our Patients, 100% of the Time

Last week, I made the argument against 120% booking of primary care schedules. So now, how do we ensure that the plain old 100% gets done right?

If we can make sure all of our patients get there, for the right appointment at the right time, for just the right level of care that they need, then maybe we can fix our broken healthcare system. Once we fill up our schedules with “good” appointments — patients we’re sure are coming, which is good for patients and good for providers — then how do we make sure that everything that needs to happen, happens?

To make primary care work, we really need a truly patient-centered medical care model, with care that extends both before each appointment and then after it. Before our patients arrive, we need to make sure they are enrolled in the electronic medical record’s online portal, that their insurance information is up to date, that they have filled out all of their online forms, completed all of the appropriate screening questionnaires, and all of the rest of the things that need to happen before their arrival in our office.

If for some reason they can’t enroll in the portal, such as lacking a home computer or a cell phone, or they have a data plan on their cell phone that limits their online minutes, or if there’s no broadband in their neighborhood, then we need an institutional and corporate investment in making sure they can get all of these things, to be able to truly provide equitable healthcare.

Someone from our team also needs to find out what’s happened to them in the interim since they were here with us last. And if there are outside records that need to be collected, or forms that will be needed for the appointment, or any other specific agenda this patient might have such as a preoperative visit or school form that needs completing, then we need to make sure it gets done.

On arrival in the office, we need to make a good-faith effort to make sure that everything is correct in their charts, that we’re providing the right care to the right patient, that we have all of their emergency contact information, and that we’ve successfully enrolled them in the patient portal (and they know how to use it). We also should do our best to flesh out their agenda and what issues they want to address, let them know what agenda items we might have, see what forms they have with them today, what healthcare maintenance items they’re willing to take care of in the office today or get set up, what refills and referrals they need, and so much more.

As the visit wraps up, we need to make sure they’ve gotten all their questions answered, have access to all the education they need about their medical conditions and medications, and that they’re going to get timely follow-up appointments: with us, with the specialists we’ve referred them to, or for whatever procedures we’ve ordered for them, such as mammograms and colonoscopies.

Then we need even more resources to help carry on the healthcare after the patient leaves. Someone needs to check to make sure they’ve filled their prescriptions at the pharmacy; that they know how to take them and are taking them correctly; that they are not experiencing any significant side effects; that they are proceeding with dose escalations; that they have started that exercise and diet plan we discussed; and that they’re getting connected to all the resources they need in their community. We need navigators to make sure they get to all of their follow-up appointments — either back with us or with specialists — and that there is someone available to drive them home from their colonoscopy next week.

We need interim telehealth visits to check on their progress, with mental health team members checking on the response to new antidepressants or anti-anxiety medications. And we need telehealth visits with nurses to check on progress with patients’ home monitoring of their diabetes or hypertension, to check on any side effects, and to help with medication dose escalations.

Those of us who are practicing primary care in resource-limited settings can envision this sort of a system — a balanced, fully staffed practice that gives all of our patients exactly what they need, and lets each of us practice up to our medical licenses. If we build this, medical students and residents might once again choose careers in primary care. Right now there is no reason not to love a career in primary care — except for the chaos, the burnout, the crazy low pay.

There is endless data out there showing that having a solid connection to a primary care practice improves the health and longevity of patients, but only if the system works well and is fully resourced. Additionally, numerous studies show a looming massive deficit in people choosing primary care as we move forward, and it’s only going to get worse if things don’t get better on the ground.

So, bring us up to 100%, make sure everyone’s coming, then commit to helping us give them everything they need — 100% of the time.

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