Rebuilding Population Health with Primary Care, Pharmacies, Health Coaches and AI: My Proposed New Model

Cheng Ruan, MD Executive Director of the Physician Transformation Institute, a 501(c)(3) not-for-profit organization that focuses on reducing burnout and modernizing medicine

The landscape of modern healthcare is fraught with complexities and challenges that significantly impact patient outcomes and overall health system efficiency. At the forefront of these challenges are two critical issues: polypharmacy and medical errors.

Polypharmacy, the simultaneous use of multiple medications by a patient, often leads to adverse drug interactions and complications. This phenomenon is increasingly common, particularly among the elderly and those with chronic conditions, and it poses a significant risk to patient safety. The intricate balancing act of managing multiple medications often results in decreased effectiveness and increased potential for harm.

Medical errors, on the other hand, represent one of the top causes of death in the United States. These errors can stem from a variety of sources, including but not limited to, misdiagnosis, incorrect medication prescriptions, and inadequate patient monitoring. The repercussions of such errors are profound, not only in terms of patient health but also in the erosion of trust in healthcare systems.

The root cause of these issues often lies in the fragmented nature of healthcare delivery. The traditional model of medicine operates in silos, with limited communication and coordination among different healthcare providers. This disjointed approach hinders the ability to provide holistic and effective care to patients.

As we delve deeper into the complexities of healthcare, it becomes evident that a transformative approach is necessary—one that bridges the gaps between different healthcare professionals and integrates emerging technologies for a more cohesive, effective, and patient-centered care model.

In the following sections, we will explore how an innovative integration of pharmacists, physicians, and health coaches, underpinned by the latest advancements in technology, can offer a promising solution to these pervasive challenges.

Role of Pharmacists in the New Model

In the quest to redefine healthcare, pharmacists emerge as pivotal players. Traditionally viewed as dispensers of medication, their role in our envisioned model transcends this perception, positioning them as key clinical collaborators with physicians.

Pharmacists possess a deep understanding of pharmaceuticals, their interactions, and impacts on the human body. By integrating pharmacists more closely into the patient care team, we can leverage this expertise to significantly reduce polypharmacy and its associated risks. Their involvement in the clinical decision-making process enables a more informed approach to medication management, ensuring that each prescription is not only necessary but also optimized for the patient's overall health regimen.

The collaboration between pharmacists and physicians can manifest in various ways. For instance, pharmacists can review patient medication regimens and suggest alterations to minimize drug-drug interactions and side effects. They can also play a crucial role in medication reconciliation, a process often overlooked in the current healthcare system, which ensures that all medications are correctly prescribed and aligned with the patient's evolving health status.

This integrated approach also addresses one of the leading causes of medical errors – incorrect medication. With pharmacists closely involved, the accuracy of prescriptions improves, leading to better patient outcomes. Furthermore, their accessibility in community settings positions them ideally to monitor ongoing treatments and provide timely interventions when necessary.

By redefining the role of pharmacists from mere dispensers to active clinical partners, we pave the way for a more holistic and patient-centric approach to healthcare. This not only enhances the quality of care but also significantly diminishes the risks associated with polypharmacy and medication errors.

In the next section, we will explore how health coaches further complement this integrated model, adding another layer of support and guidance for patients.

Incorporating Health Coaches

While pharmacists and physicians form the clinical backbone of our new healthcare model, health coaches bring an essential human-centric element to the equation. These professionals act as a bridge between the clinical aspects of care and the daily lives of patients, ensuring that medical advice translates into practical, sustainable lifestyle changes.

Health coaches focus on patient empowerment and education. They work closely with individuals to develop personalized health plans that align with their unique needs, goals, and circumstances. This involves not just adherence to medical prescriptions but also understanding and managing the broader aspects of health, such as nutrition, physical activity, and mental well-being.

A critical aspect of their role is to ensure that patients are fully informed about their medications. This includes understanding potential side effects, interactions with other drugs, and the importance of compliance. Health coaches can liaise with pharmacists and physicians to clarify any doubts and provide a cohesive care plan.

Moreover, health coaches play a vital role in medication adherence. They help patients navigate the complexities of their treatment regimes, reminding them of dosages and timings, and encouraging them through the challenges of managing chronic conditions. This ongoing support is crucial in preventing medication errors and ensuring effective treatment.

Their presence also addresses a key gap in the current healthcare system: the lack of continuous support and guidance post-consultation. By offering regular follow-ups and being accessible for queries, health coaches ensure that patients do not feel isolated in their healthcare journey.

Incorporating health coaches into our integrated model not only enhances patient compliance and education but also contributes to a more holistic approach to health and wellness. As we move forward, we will examine the successful application of this collaborative model in fields such as psychiatry and primary care.

Case Studies in Psychiatry and Primary Care

The integration of pharmacists, physicians, and health coaches is not just a theoretical concept; it has been successfully implemented in specific fields such as psychiatry and primary care, providing a blueprint for broader application.

In Psychiatry: Traditional psychiatric care often involves complex medication regimens, requiring careful monitoring and management. The collaborative care model in psychiatry demonstrates how psychiatrists, primary care doctors, and pharmacists can work together to optimize medication management and overall mental health care. Psychiatrists in this model do not just provide direct care but also support primary care physicians in managing mental health aspects of their patients. This collaborative approach ensures that patients receive timely and effective mental health services within the primary care setting, reducing the need for specialized psychiatric appointments and improving accessibility.

Pharmacists play a crucial role in this setup by advising both psychiatrists and primary care physicians on medication selection, dosages, and management of side effects. Their expertise is particularly valuable in managing polypharmacy, often prevalent in psychiatric treatments.

In Primary Care: The integration of health coaches in primary care settings has shown significant benefits. Health coaches in primary care assist patients in understanding and managing their conditions, bridging the gap between physician's instructions and daily life applications. They help in translating medical advice into actionable plans, thereby enhancing patient engagement and adherence to treatment plans.

These real-world examples illustrate the effectiveness of collaborative models in healthcare. By integrating various healthcare professionals, we can address the multifaceted needs of patients, especially in areas requiring complex care management like psychiatry and primary care.

Next, we will explore the hub-and-spoke model, which further exemplifies how this integrated approach can be effectively implemented in community healthcare.

The Hub-and-Spoke Model in Community Health

The 'hub-and-spoke' model is an innovative approach in healthcare that can effectively utilize the collaborative synergy between pharmacists, physicians, and health coaches. In this model, primary care practices (the 'hubs') are closely linked with community pharmacies and health coaches (the 'spokes'), creating a comprehensive network of care that is both accessible and efficient.

Primary Care as the Hub: The primary care practice acts as the central point of patient care, overseeing the overall health management. Physicians in these hubs coordinate with various healthcare professionals to ensure that each patient receives a holistic treatment plan. This model allows for a more efficient use of resources and expertise, centralizing patient information and care coordination.

Pharmacies and Health Coaches as Spokes: Community pharmacies and health coaches extend the reach of primary care into the community. Pharmacies, often easily accessible to patients, become vital points for medication management, patient education, and health monitoring. Pharmacists in these settings work in tandem with primary care physicians, providing valuable insights into medication therapies and patient compliance.

Health coaches, as part of the spokes, play a crucial role in ensuring that the care plans devised in the primary care hubs are effectively implemented. They provide ongoing support and education to patients, helping them navigate their health journey and make informed decisions.

Group Visit Models: An innovative aspect of this model is the incorporation of group visit models, where patients with similar conditions meet for consultations and education sessions. These sessions, often facilitated by health coaches, foster a sense of community and support among patients, while allowing efficient delivery of healthcare advice and monitoring.

This hub-and-spoke model not only brings healthcare closer to the community but also enables a more personalized and integrated approach to patient care. It exemplifies how different healthcare professionals can work together seamlessly, each playing a unique role in the patient's health journey.

In the next section, we will draw parallels between this model and the influence of religious community models, illustrating how healthcare can similarly create a profound impact within communities.

Continuing with Section 6:

Comparison with Religious Community Models

The hub-and-spoke model in healthcare, especially in its community-centric approach, bears a striking resemblance to the organizational structure and influence of religious institutions. Just as religious leaders within churches, synagogues, temples, and mosques play pivotal roles in their communities, healthcare professionals within the hub-and-spoke model can wield a similar influence in terms of community health and wellness.

Centers of Influence and Trust: In many communities, religious institutions serve as centers of trust, guidance, and support. They are not just places of worship but pivotal points where people gather for communal support and guidance in various aspects of life. Similarly, in our integrated healthcare model, primary care hubs and pharmacy spokes can become trusted centers for health and wellness, where people turn not only for medical care but also for education, support, and guidance in their health journey.

Community Engagement and Outreach: Religious organizations are often deeply involved in community outreach, offering various programs and services that address the needs of their congregants. This model of engagement and proactive outreach can be mirrored in healthcare. Through group visit models, health education sessions, and community health initiatives, healthcare providers can actively engage with the community, promoting health literacy and preventive care.

Creating a Health-Conscious Community: Just as religious leaders often advocate for moral and ethical living, healthcare professionals can promote a culture of health-consciousness and preventive care. By being actively involved in the community, they can influence lifestyle choices, create awareness about health issues, and foster a proactive approach to managing health.

This comparison underscores the potential of the integrated healthcare model to not only provide effective medical care but also to build a strong, health-conscious community. The principles of trust, outreach, and community engagement that underpin religious organizations can be effectively adapted to transform how healthcare is delivered and perceived at the community level.

In the next section, we will delve into the crucial role of technological integration, particularly AI, in enhancing and supporting this healthcare model.

Technological Integration with AI

The integration of technology, particularly Artificial Intelligence (AI), into our proposed healthcare model is not just an enhancement but a necessity. AI has the potential to revolutionize how we approach patient care, making the model more efficient, personalized, and data-driven.

AI in Personalized Care Plans: AI algorithms can analyze vast amounts of patient data to help create highly personalized care plans. By considering factors such as individual health history, genetic information, lifestyle choices, and current medications, AI can assist healthcare professionals in devising more effective treatment strategies.

Enhancing Decision Making: AI can support physicians and pharmacists in making more informed decisions. For example, AI systems can identify potential drug-drug interactions that might be overlooked in complex polypharmacy cases, aiding pharmacists in their medication management roles. They can also provide predictive insights into a patient’s health trajectory, enabling early interventions.

Streamlining Communication and Coordination: The integration of AI in the hub-and-spoke model can streamline communication and coordination among healthcare providers. AI-driven platforms can facilitate the seamless exchange of patient information between physicians, pharmacists, and health coaches, ensuring that everyone involved in patient care is on the same page.

Patient Monitoring and Engagement: AI can be employed in monitoring patient health and medication adherence. Wearable devices and mobile applications can track health metrics in real-time, providing valuable data to healthcare providers and alerting them to any concerning changes. Additionally, AI-powered tools can engage patients in their health management, offering reminders for medication, appointments, and health coach interactions.

The adoption of AI in healthcare is more than just a technological leap; it is about creating a healthcare ecosystem that is adaptable, insightful, and patient-focused. This technological integration is key to realizing the full potential of our proposed model, making healthcare more responsive, efficient, and tailored to individual needs.

Absolutely, let's delve into the business and financial model aspect of this integrated healthcare system:

The Business Model: Financial Viability and Revenue Streams

For the integrated healthcare model involving pharmacists, physicians, health coaches, and AI technology to be sustainable, understanding and optimizing its financial aspects is crucial. While current reimbursement models like Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Transitional Care Management (TCM), and Principal Care Management (PCM) provide some financial support, they often fall short in covering the full costs of such comprehensive care. Therefore, exploring additional revenue streams and billing models is essential for the viability of this innovative healthcare approach.

Incident-To Billing Models: A promising avenue for supplementing revenue is the "incident-to" billing model. In this framework, primary care physicians can oversee the services provided by health coaches and pharmacists, allowing these services to be billed under the physician’s supervision. This model not only streamlines the financial process but also reinforces the collaborative nature of the care provided.

Behavioral Health Assessment and Intervention CPT Codes: The use of specific CPT codes like 96156 for behavioral health assessments and 96158 for behavioral interventions can be instrumental in this model. These codes enable healthcare providers to bill for the crucial services they offer in managing and improving patient behavioral health, an often overlooked but vital component of overall health.

Enhanced E&M Coding with AI Integration: The integration of AI in healthcare has opened new possibilities in Evaluation and Management (E&M) coding. With the 2021 CPT code changes, the criteria for Medical Decision Making (MDM) have expanded to include population health metrics, history from sources other than the patient, and the incorporation of external labs and imaging. AI-enhanced systems and health coaches can efficiently collect and manage this data, potentially increasing the level of E&M codes billed (e.g., 99214-99215).

Medication Monitoring Component: Pharmacists can contribute significantly by adding a medication monitoring component to the care model. This not only improves patient outcomes through better medication management but also enhances the MDM criteria, allowing for higher-level E&M billing.

Group Visit Models: Another innovative approach is the implementation of group visit models, both virtually and in person, as part of the hub-and-spoke system. These group sessions, led by health coaches, can be a cost-effective way of delivering healthcare services, especially in the areas of preventive care and chronic disease management.

To ensure the financial sustainability of this integrated healthcare model, a multifaceted approach to revenue generation and cost management is necessary. By combining traditional reimbursement methods with innovative billing practices and the strategic use of technology, this model can not only thrive financially but also provide high-quality, comprehensive care to patients.

Conclusion and Future Outlook

As we have explored throughout this blog, the integration of pharmacists, physicians, health coaches, and AI into a cohesive healthcare model offers a transformative approach to addressing the challenges of modern healthcare. This model not only targets the reduction of polypharmacy and medical errors but also champions a more holistic, patient-centered approach to health and wellness.

Transforming Patient Care: By breaking down the silos between different healthcare professionals and incorporating AI, we can create a system that is more efficient, effective, and responsive to individual patient needs. This integrated approach ensures that all aspects of a patient's health are considered and managed cohesively.

Empowering Communities: The hub-and-spoke model, akin to the influential role of religious organizations in communities, positions healthcare centers as integral parts of the community. This model fosters a deeper connection between healthcare providers and patients, promoting health literacy and proactive health management at the community level.

Embracing Technology: The integration of AI is crucial in this model, offering precision, personalization, and predictive capabilities that traditional healthcare models lack. This technological empowerment will pave the way for advancements in patient care and health management strategies.

Looking to the future, the potential of this integrated healthcare model is vast. It holds the promise of a healthcare system that not only treats illness but actively promotes wellness, a system where patients are empowered participants in their health journey, supported by a network of healthcare professionals and advanced technology.

The implementation of this model could redefine the landscape of healthcare, making it more accessible, effective, and attuned to the evolving needs of our societies. It’s an ambitious vision, but one that is increasingly within our reach as we leverage the synergies between healthcare expertise and technological innovation.

Want to learn more? Join as a member at Physician Transformation Institute!