Delivering Results: Whole-Person Primary Care in Action

On September 9, 2024, the Primary Care Collaborative (PCC) hosted a discussion with health leaders to learn about the business case for taking a whole-person health approach to primary care—one that is comprehensive and addresses aspects such as lifestyle change.

The webinar was part of PCC’s multi-year initiative to reimagine primary care that treats the whole person inclusive of their physical, behavioral, spiritual, and social wellbeing—sponsored to Ardmore Institute of Health and HealingWorks Foundation.

This included showcasing examples where this model delivers an ROI, including for a county-wide public school system based in Indiana, for employees of a safety net hospital in Queens, NYC, and other examples across the country.

MediSys Health Network’s Dr. Alan Roth, Vital Incite’s Mary Delaney, and Midland Quality Alliance’s Dr. Padmaja Patel spoke as PCC’s Ann Greiner moderated the conversation.

Panelists began by providing a top-level overview of how they implemented a whole health approach to primary care, the financing that supports such a model and the results they have been able to achieve for patients and the overall system.

Dr. Roth explained how his team transitioned to a proactive care model by risk-stratifying patients and implementing high-value visits. This approach led to reduced costs, improved quality of care, and better outcomes, achieving the quintuple aim by enhancing patient and physician satisfaction while lowering health care costs and utilization.

Delaney discussed her work with commercial health plans, highlighting a success story from Carmel Clay Schools in Indiana. Starting in 2012, the school system implemented a near-site clinic and used data-driven approaches to identify and address employees' health needs.

With a focus on building trust and understanding what matters to individuals, they expanded their resources, including mental health therapists, a dietitian, and a wellness coordinator. By reducing plan spending, they reinvested in these services, leading to significant health improvements, including a drop in type 2 diabetes and $6.5 million in savings in 2023.

Dr. Patel highlighted her experience with lifestyle medicine, particularly as a medical director for the Ornish heart disease reversal program at Midland Health in Texas. The program's holistic approach, addressing nutrition, exercise, stress management, and group support, has shown significant health improvements, including a 47% reduction in health care costs and long-term patient adherence.

Dr. Patel also discussed an intensive lifestyle program for Midland Health employees, which led to a $2 million reduction in hospitalizations and a $1 million savings in pharmacy spending, demonstrating lifestyle medicine’s financial and health benefits.

Greiner then asked panelists to provide additional details about their programs, particularly what elements were critical to success and challenges they continue to face.

Dr. Patel attributed the success of her programs to building strong patient support systems through clinical and community resources and ensuring access to a multidisciplinary team. By focusing on behavior change strategies, rather than simply providing information, patients were empowered to take control of their health.

However, challenges were also outlined in implementing a whole-person care approach. Delaney criticized the current fee-for-service model and highlighted the need for a better reimbursement process.

Dr. Roth also discussed risk score, echoing a conversation from other panelists. He explained that his organization’s whole-person risk score incorporates over 500 factors, including chronic diseases, care utilization, medication adherence, and appointment attendance, to assess patient health. This score helps prioritize proactive outreach to patients, especially those at higher risk or who haven't visited in a year, with navigators working to ensure they receive necessary care.

These panelists’ successes offer a promising future toward whole-person care. However, Greiner highlighted the importance of still working toward changing policy to expand and scale successful primary care models, focusing on payment reforms and workforce strategies.