Team approach helps alleviate physician shortage
FARGO—Dr. Jennifer Raum sometimes joins Sanford Health colleagues to meet groups of patients battling chronic illness at a wellness center for healthy lifestyle coaching and activities.
Heidi Olson-Fitzgerald, a physician assistant, shares an office with three doctors at Essentia Health's clinic in south Moorhead, which was specifically designed to make it easier for providers to collaborate in caring for patients.
Both reflect a quiet revolution in health care, especially in urban settings, moving from a world of "the doctor will see you now" to one of "the team will see you now."
It's a critical tool Essentia, Sanford and other large health systems are embracing to address the worsening shortage of primary care physicians.
Demand for primary care is rising in Fargo-Moorhead and elsewhere in the region for a variety of reasons, including a population that is both growing and aging and the expansion of health insurance coverage under the Affordable Care Act.
"We're not going to be able to recruit ourselves out of this problem," said Dr. Joseph Bianco, an Essentia physician who is working with Olson-Fitzgerald on redesigning the delivery of primary care.
Waiting for service
Thus far, Essentia has been able to keep up with demand for primary care, said Olson-Fitzgerald and Kris Olson, vice president for physician services.
At Sanford, demand for primary care services in Fargo-Moorhead exceeds current capacity, said Ellen Cook, chief operating officer at Sanford Clinic.
"It's not growing as fast as it needs to keep up with the population," she said, adding that hundreds of patients are served daily, however, at walk-in clinics.
The biggest challenge, Cook said, is getting new patients in to see a doctor "on a timely basis."
Sanford has about 60 providers in primary care—internal medicine, family medicine, pediatrics and obstetrics-gynecology—accepting new patients in the Fargo-Moorhead area.
For new patients, the wait to see a well-established doctor can take several weeks. "We are particularly challenged in situations when a patient only wants to see their doctor and not another provider who may have an opening," Cooke said. "These take longer to get into."
The primary care shortage is widespread, but especially acute in rural areas. In North Dakota, with more than 1,500 licensed physicians, a projected shortfall of 260 to 500 doctors looms over the next 10 years.
Minnesota faces a shortfall of almost 850 primary care physicians by 2024, and a third of Minnesota's more than 7,500 physicians and nurse practitioners likely will start retiring in the next decade.
Treating in groups
Sanford's use of provider teams extends beyond the clinic. Patients struggling with chronic illness, including obesity and related ailments, sometimes meet with physicians, wellness coaches and health psychologists at Family Wellness fitness center.
Raum participates in these sessions every two or three months, with patient groups of six to 12. Evidence shows some patients do better in groups than individually.
"There's power in groups," Raum said, adding that she and her fellow internal medicine colleagues can accomplish more in promoting wellness by spending half a day seeing a dozen patients than individually in 90 minutes.
"I think that really does help with our access issues," Raum said. "We'd like to do more with group settings."
At Sanford's Broadway Clinic, she meets regularly in a staffing room with other members of her team to consult about treatment plans for patients. Medical residents in training also learn to work in teams.
In a case involving obesity, high blood pressure and arthritic joints, for example, the primary care physician meets initially with the patient and crafts a treatment plan, following up once a year for most patients, twice a year when needed, said Olson-Fitzgerald.
As a physician assistant, she meets more frequently with the patient, to monitor progress and to coordinate continuing care with other providers, including occupational and physical therapists, she said.
"I pull all of those resources together for the best quality care," she said.
The greater flexibility possible from a team also translates into greater convenience for the patient, Olson-Fitzgerald said. Care teams meet weekly to discuss patients.
"We've got happier patients if they can be seen in a timely manner," she said, adding that continuity of care is better when a team member steps in than when a patient goes to a walk-in clinic.
"There has been very, very little resistance," from patients, Olson-Fitzgerald said, adding that physician assistants and nurse practitioners now have become integral to health care delivery.
Team approach expands
Cooke, who agreed with Bianco that stepped-up physician training and recruiting is not a cure-all, said Sanford is moving as quickly as it can to expand the "medical home" delivery model in its clinics, in both internal medicine and family practice.
Some efforts will take time to reach fruition. For instance, some of the medical students Cook is recruiting won't be able to begin practicing until 2020.
Besides adding staff for provider teams, Sanford will be offering "video visits" with patients in North Dakota starting this spring.
So far, Sanford's number of primary care providers has remained stable, but services are strained by the sharp rise in demand, Cook said. But providers are committed to meeting patients' needs, Raum said.
"There's a reason it's called a medical home," she said. "We take this seriously. This is something we take personally and professionally. This is our community and if we can't serve our community, we're failing at what we do."