Combating Chronic Disease Requires Reimagining Primary Care

Nearly 40% of Americans have a chronic disease, according to the Centers for Disease Control and Prevention, with rates only climbing. That’s an enormous number, with equally large implications. It almost goes without saying that living with conditions like heart disease, diabetes, hypertension, cancer or obesity can redefine how you interact with the world, often not for the better. That intangible idea of “quality of life” becomes all too tangible and real. Compounding this is the aging process itself, which takes its own toll on health. We’re all aging, of course, but the number of people in the 65 and older club is growing every day. This group will make up 23% of the American population by the year 2050, according to the?Census Bureau??-- up from 17% in 2022. And while life expectancy is increasing,?the gap between healthy years and total years is expected to widen.

To navigate these uncertain waters, many people dealing with chronic illness or the health effects of aging look to their primary care provider for guidance. A sizeable number, in fact, see the same physician or advanced practice provider for years or even decades at a time, building a relationship of trust for handling both everyday health problems and more serious conditions. Here at University Hospitals, we have a large cadre of talented primary care providers, and it’s no exaggeration to say that they are the indispensable lifeblood of our system.

That said, the worsening crisis of chronic disease is causing us to rethink some of our assumptions and develop new approaches to caring for our patients. As a result, our primary care providers are taking on an additional consequential role – with the goal of achieving even better health outcomes for our patients. They are partnering as part of a new initiative with diverse divisions across our health system. The goal? To help our patients more successfully control damaging chronic diseases and get the preventive screenings that are so essential to good health.

We see it as nothing short of reimagining primary care.

This effort, known as Systems of Excellence, draws on the collective expertise of our immensely talented caregivers – dedicated employees from data science and analytics, IT, patient access, population health, specialty care and many others. The aim is to reduce unnecessary variation in care, standardizing and optimizing care for UH patients with chronic kidney disease, heart failure, diabetes, chronic obstructive pulmonary disease, hypertension and weight management concerns.

Here's how it works: Pairs of primary care providers and specialists work together with the population health staff to develop clinical practice guidelines for optimizing care for these conditions. There are rules, checklists, algorithms and processes whereby the treatment for the chronic disease is optimized at every level, all approved by an internal advisory board. This provides more clarity to providers about when a patient with a chronic condition can be managed by a primary care provider – which seems to be more often than previously thought -- and when a trip to a specialist is warranted.?

A key part of this winning formula is a detail-oriented focus on each individual step of the patient’s care journey – and relying on what has already been shown to be effective.?

Our Systems of Excellence framework, for example, was adapted from our successful Centers of Excellence initiative, which provides highest-quality care in hip and knee replacement, atrial fibrillation, cochlear implant, bariatric surgery and cervical and lumbar spine. These high-value, integrated care programs embrace a patient-centered approach, promote best practice guidelines and eliminate unnecessary treatments and procedures.?

But none of this work goes anywhere without patient participation. As a result, outreach is key. Data analysts help identify patients whose care can be optimized, and population health starts making contact. These may be people who’ve stopped coming to primary care appointments, for example. Systems of Excellence is designed so our providers can easily see and track the entire group of patients assigned to them for care. Then we can go about the work of making sure that those who are being seen are getting the right care, and those who haven’t seen a provider in a while are encouraged to come in for care.

It’s early in the process, but already we have evidence that this approach is working for our patients and our providers.

Take the example of diabetes. Our Systems of Excellence formula relies on extensive collaboration with primary care providers and referrals to a range of disease management programs addressing social and clinical determinants of health. Recent results published in the journal?Population Health Management show that every intervention we initiated led to statistically significant reductions in hemoglobin A1C among our patients.?

Another target for Systems of Excellence is guideline-directed medical therapy for heart failure. For heart failure with reduced pumping capacity, known as ejection fraction,?optimal guideline‐directed medical therapy is estimated to reduce mortality by more than 70% in addition to improving quality of life, despite being under-used. We’re determined to change that through Systems of Excellence.

In addition to this groundbreaking, multidisciplinary work on chronic disease, our primary care providers at UH are also tireless advocates for their older adult patients on Medicare, partnering with divisions across our health system to make sure they get the care they need. One key initiative is a full-court press on Annual Wellness Visits.?Surveys show that?fewer than 20% of Medicare patients are getting this dedicated primary care encounter that focuses on scheduling preventive services such as vaccinations, bone density tests and screening tests for cancer, chronic conditions and cognitive problems. Patients are missing out on some clear benefits, including?greater use of preventive services to detect or stave off disease and?lower personal Medicare spending.

At UH, our Primary Care Institute launched a?multifaceted quality improvement effort to boost Annual Wellness Visits for our Medicare patients in 2018. Like many hospitals and health systems, we had completion rates for Medicare patients hovering just over 20%. But six years later, our results now show that focusing on the problem in a systematic way can yield dividends.?

In 2018, our primary care practices reported 24% Annual Wellness Visit completion for their Medicare patients. In 2023, that number was 70%. In fact, in 2023 our Primary Care Institute providers performed almost 10,000 more Annual Wellness Visits than in the previous year.?

The key was simply making it a priority. We identified those patients who needed an Annual Wellness Visit and strategized at a granular level about how to contact them, even to the point of scripting phone interactions. Providers taught other providers how to work these visits into their practices more efficiently. Because we at UH see such value in these visits, we all united behind a singular goal. We know these visits will only grow in importance with the continued aging of the population.

Of course, the job is not done. To meet ongoing challenges, we will continue to promote Annual Wellness Visits for our older adult patients – as well as the full suite of services they and patients of all ages can receive.

The numbers speak for themselves. When more of our patients have taken advantage of an Annual Wellness Visit, good things have happened.?

Breast cancer screenings have increased from 60% in 2019 to 81% in 2023, while colorectal cancer screenings have grown from 50% to 74%. At the same time, patients with diabetes who had uncontrolled A1C have decreased from 31% in 2019 to 17% in 2023, while patients with hypertension under control have increased from 66% to 75%.

At a time when national healthcare spending has hit $5 trillion for the first time, these visits are just one of the many ways we’re working to keep patients healthy while reducing their healthcare costs – the key dual goal of value-based care.

That’s the power of proactive, innovative primary care, and we’re proud to be leader of it here at UH.?