The Special Care Center reinvented the idea of a primary-care clinic in almost every way. The union’s and the hospital’s health funds agreed to switch from paying the doctors for every individual office visit and treatment to paying a flat monthly fee for each patient. That cut the huge expense that most clinics incur from billing paperwork. The patients were given unlimited access to the clinic without charges—no co-payments, no insurance bills. This, Fernandopulle explained, would force doctors on staff to focus on service, in order to retain their patients and the fees they would bring.
The payment scheme also allowed him to design the clinic around the things that sick, expensive patients most need and value, rather than the ones that pay the best. He adopted an open-access scheduling system to guarantee same-day appointments for the acutely ill. He customized an electronic information system that tracks whether patients are meeting their goals. And he staffed the clinic with people who would help them do it. One nurse practitioner, for instance, was responsible for trying to get every smoker to quit.
I got a glimpse of how unusual the clinic is when I sat in on the staff meeting it holds each morning to review the medical issues of the patients on the appointment books. There was, for starters, the very existence of the meeting. I had never seen this kind of daily huddle at a doctor’s office, with clinicians popping open their laptops and pulling up their patient lists together. Then there was the particular mixture of people who squeezed around the conference table. As in many primary-care offices, the staff had two physicians and two nurse practitioners. But a full-time social worker and the front-desk receptionist joined in for the patient review, too. And, outnumbering them all, there were eight full-time “health coaches.”
Fernandopulle created the position. Each health coach works with patients—in person, by phone, by e-mail—to help them manage their health. Fernandopulle got the idea from the promotoras, community health workers, whom he had seen on a medical mission in the Dominican Republic. The coaches work with the doctors but see their patients far more frequently than the doctors do, at least once every two weeks. Their most important attribute, Fernandopulle explained, is a knack for connecting with sick people, and understanding their difficulties. Most of the coaches come from their patients’ communities and speak their languages. Many have experience with chronic illness in their own families. (One was himself a patient in the clinic.) Few had clinical experience. I asked each of the coaches what he or she had done before working in the Special Care Center. One worked the register at a Dunkin’ Donuts. Another was a Sears retail manager. A third was an administrative assistant at a casino.
“We recruit for attitude and train for skill,” Fernandopulle said. “We don’t recruit from health care. This kind of care requires a very different mind-set from usual care. For example, what is the answer for a patient who walks up to the front desk with a question? The answer is ‘Yes.’ ‘Can I see a doctor?’ ‘Yes.’ ‘Can I get help making my ultrasound appointment?’ ‘Yes.’ Health care trains people to say no to patients.” He told me that he’d had to replace half of the clinic’s initial hires—including a doctor—because they didn’t grasp the focus on patient service.
by Atul Gawande, New Yorker | Read more:
Photograph by Phillip Toledano
