Posts Tagged: patient care

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The Economics of Patient Focused Care

“Inpatient admissions were 5% higher, or favorable, compared to the prior year” reads a quote that appeared in a recent report for a nonprofit hospital. This sums up the fundamental problem with the U.S. healthcare industry; incentives of the system, providers and payers under a fee-for-service construct are not aligned with those of the most important person: the patient. While it’s noble for hospitals to care for someone during their time of need, a higher volume of admissions is not good for actual patients or the economy. The “healthcare” industry has in fact become a “sickness” industry in which medical costs and industry profits have spiraled out of control, while quality and health outcomes have severely lagged.

The challenge is: how do we create a system that aligns the incentives of patients, providers and payers while focusing on optimizing health?

A solution starts by changing the system from the ground up. Instead of operating under a fee-for-service structure, we need to invest in value-based primary care that puts an emphasis on keeping people healthy, rather than simply reacting when they’re sick. There are a few companies that are doing this and making a noticeable difference in this space – Iora Health is leading the charge and that’s what attracted me to join the company three years ago.

Iora’s high-impact, relationship-based care model is brilliantly and simply built around the patient and is tackling the enormous societal and economic problems of the U.S. healthcare system. By combining people, process and technology, Iora is able to save money, bring joy back to the practice of care, and improve the health of all patients (especially the most vulnerable – older adults).  

The first question people often ask me after learning about what Iora is working to achieve is, “How do you do this?”

It takes starting from scratch in built-for-purpose primary care practices that serve patients under value-based care arrangements with sponsors that share our vision of transforming healthcare. Rather than buying an electronic medical record off the shelf, we support these practices with our proprietary technology platform, called Chirp, that integrates population health workflows and clinical documentation. What you get is a care team and technology that support a care model that is built around people rather than billing codes.

The second question asked of me: “Is it working?”

Results have been amazing so far. Iora’s average Net Promoter Score for patients (a measure of customer satisfaction, with  a range of -100 to 100) is around 90, while the typical primary care doctor’s office hovers around 4. Our care teams love taking care of patients under this model, and hospital admission rates have dropped by 30-40% for patients who have had Iora’s care for a year or more. All of this shows that the Iora model is working by being able to keep patients happy, healthy, and out of the hospital.

This is the solution for the misalignment of incentives in today’s healthcare industry.  By spending more time and building deeper relationships with people, Iora is proving that we can educate and empower others to optimize their own health, while also encouraging health systems to follow suit. At the end of the day, we all want what’s best for people and that means focusing on the one part of the equation that matters most: the patient.

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An Uncommon Answer to a Common Question

“What do you do?” Over the years, I have answered that question hundreds of times. With over 20-years in healthcare (I think I need to stop counting!), the answer has changed: “I assess the causes of maternal and child mortality”, “I consult with companies regarding benefits strategies”, “I sell health insurance”,  or “I help people get second opinions.” In each company, I have always been in some type of external role, representing healthcare solutions to companies and individuals to solve industry “problems”.

However, since May 2016, my answer to that question has been: “I help restore humanity to healthcare.” “What does that mean?” is the common response. It inevitably starts a conversation about people’s experience with the healthcare system. As a mother of two daughters with some minor health concerns to monitor, to watching one of my closest friends undergo treatment for an inoperable cancerous brain tumor, to being the health advocate for an aunt who lost her brave battle to lung cancer, my personal experiences over the last few years have dramatically shifted my perception of an industry that I’ve built my career in. When you are put in the most vulnerable and compromising position of watching someone put their lives into the hands of another human being, it is humbling. I have been to dozens of other patients’ doctor visits. I’ve sat through multiple chemotherapy treatments. I’ve watched how the system treats not only the patient, but also those of us surrounding the patient. With all of my “industry” knowledge and access to the “best” medical minds, I still felt there was little I could do to impact the way that people actually receive care. What matters most when you have no control of your medical condition is receiving treatment from people with empathy, dignity and respect.  

I was fortunate to meet Iora Health’s CEO and co-founder, Rushika Fernandopulle, MD, many years ago when Iora was just starting. While I was immediately taken by the mission and vision, it was hard to appreciate how a completely new healthcare model could make a lasting difference. After being my family and friends’ patient advocate, I believe that most of the healthcare industry focuses on creating band aids rather than solving major systemic issues. As part of the Iora Health interview process, I visited our practices and experienced firsthand how Iora teams treat patients – and their health advocates – with a kindness and empathy unlike anything I’d ever seen. One gentleman while walking out of the practice with his daughter said to me, “I am down to one medication from five because of Iora’s help.” I left feeling strongly that this model should be the standard in healthcare, not the exception. Because of that feeling, I accepted the offer to lead the Business Development team in order to help make this a reality for as many people as possible.


Leading Business Development for Iora Health is a unique role. I am once again in an external role presenting a solution, but this time it’s for a massive healthcare issue: the desperate need for high-impact, relationship-based care. Now the end of that conversation that starts with “what do you do?”, ends with: “how can I receive my care through Iora?” It is privilege to be part of a team that makes a positive and lasting impact on people’s daily lives.

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Why Iora = Comprehensive Primary Care

Janice* joined Iora Primary Care after moving to the Seattle area from Idaho. In Idaho, Janice had several specialists who she had to see for her many medical conditions. She was pleased to learn that at Iora we do as much care in the practice as possible in an effort to streamline care and save patients from paying unnecessary copays.

Janice came to us with a long history of multiple complex medical conditions, which included chronic pancreatitis, diabetes, vascular disease and long term pain medication usage. Fortunately, one of the gifts that Iora gives their staff and patients is time. We have time to think about our patients from a comprehensive perspective and we ensure that the patient has time with their care team to feel heard and supported on their journey. Janice’s health care team, consisting of a doctor and Health Coach, worked with her to create a plan that would meet her complex health care needs.

We set up a schedule of routine appointments to see the doctor and address Janice’s multiple concerns. In addition, we  set aside time for her to meet with her Health Coach to address diabetes education and customize her medications to better fit her lifestyle. Even though she had been on insulin for years, no one had taken time to teach her about diabetes and how her other medical conditions affected her blood sugar. Through these coaching visits, Janice was able to stabilize her blood sugar and learn about the warning signs associated with it being too high or too low. She called whenever she had questions and, over time, became much more confident in managing her diabetes on her own.  

Beyond diabetes management, we also started working with Janice to address her chronic pain; at Iora we work to balance the need to treat people’s pain with the importance of doing it safely.  Sometimes that means we recommend changes in how people use pain medication and Janice was challenged by the compromises that this process requires. One day after she missed an appointment, I called her and learned that she had left Iora for a different primary care practice. As a team we were sad to lose someone we cared about and who we felt was truly making positive progress and life changes to better herself.

The Turning Point

About four weeks following her departure from Iora Primary Care, we received a call from Janice asking to speak to her former doctor. On the call she said that she realized she had “made a big mistake” and asked if the doctor would be willing to take her back as a patient. She went on to tell us that her new physician told her that in addition to her primary care doctor she would have to see two different specialists to manage her conditions and “I kept hearing in my head my Iora doctor saying ‘we can manage that for you here in the clinic.’ I didn’t want to go to all those other doctors!” Of course we were happy to welcome Janice back to the practice and resume the work we had been doing together towards a healthier, empowered life.

Over the next six weeks, after rejoining Iora, Janice gained new insights into how her choices in life affect her health through participation in one of our chronic disease self management classes. With options like classes, personal meetings with her Health Coach, and visits with her doctor, Janice grew optimistic that her life could become more than just one health crisis after another.

*Please note patient name has been changed to protect identity and private health information.

Health Coaches, Cori & Audra

Medicine Coupled with Compassion

Modern medicine is incredible. We can give you a pill and lower your cholesterol, give you a pill and lower your blood pressure. We can set a broken bone. We can save lives; we can extend lives. We can fix so many problems. It’s totally amazing.

But then there are all these health problems that biomedicine doesn’t have a quick-fix pill for. There’s no pill for loneliness, and it’s a common problem that definitely affects your wellbeing. There’s no quick answer for losing weight, or getting fit. Balance is a really important issue at our clinic. So many of our patients are afraid of falling and feel unsteady. There’s often not a quick fix for improving balance. I think that most of the time, when it comes to health problems like these, patients are kind of left to go it alone. Part of the health coach role is to support patients with problems that take more time. No doubt they have to put in the legwork, but they don’t have to do it alone.

Sometimes the role of the health coach is just to hear the patient and understand what they’re going through. At the Shoreline clinic we have two patients named Dan and Mary Ann. They have been married for a long time. And it is really obvious when you meet them that there’s a lot of love. They just have a very kind way of interacting with one another.

Dan was diagnosed with Alzheimer’s disease at a fairly young age: in his mid-sixties, which was devastating for Mary Ann. And this last year was particularly hard because Dan’s condition worsened quite rapidly. And as it worsened Mary Ann had to take on more and more caregiving responsibilities.

Audra is a health coach who works in Shoreline with me: Mary Ann and Dan are on her patient panel. For any of you that have been caregivers, you know it can be really taxing work. At one point Mary Ann was sending emails to her health coach, Audra, nearly every day. Often Audra would have really solid advice for her, or something tangible to offer. With the support of Dr. Levine and Debbie Yoro, our clinical social worker, the team provided care that was so far above and beyond the status quo. But sometimes Mary Ann would come to Audra with problems that didn’t have a clear answer. When this happened Audra would just hear her out and be there with her. What resulted was really special. Mary Ann developed a very trusting relationship with Audra and the care team as a whole. It was clear that Mary Ann felt like we were on her side: that we were a team. She knew we had her best interests at heart.

There’s no cure for Alzheimer’s disease. But what is so great about the Iora model is that it recognizes that, yes there is value in fixing people’s problems, but there is also so much value in helping them cope when their problems can’t be fixed. Mary Ann sent us a note recently and it included a quote from the poem ‘Kindness’ by Naomi Shihab Nye. It read, “Then it is only kindness that makes any sense anymore; only kindness that ties your shoes and sends you out into the day.” What I love about Iora is that it’s not just medicine. It’s medicine coupled with compassion. It’s difficult to measure the value of human compassion in medicine. But when you hear stories of real human experiences, it just intuitively makes sense. The care that is provided at Iora is so exceptional partly because we recognize the value of the healing relationship and actively work to foster meaningful connections.

Scott Jacobson

One Coffee at a Time

The work we do is challenging and sometimes it is easy to succumb to feelings of doubt, thinking that all our hard work is in vain. However, there are examples that highlight the difference we make. One such example is one of our Health Coaches, Vero’s, most challenging patients.

She is a 23 year old patient. When she came to us it was clear that she was suffering. She has type 1 diabetes, difficult enough for a young adult to handle yet she also suffers from ulcerative colitis. After an extended hospital stay and major bowel surgery, she was left with an ostomy, a difficult situation for anyone and particularly debilitating for a 23 year old.

Her surgeon told her she would have to get her sugars under controlled before they would reverse the ostomy. Dealing with an ostomy bag was not only a hindrance on her social life, it limited her job opportunities.

Not surprisingly, she also suffered from major depression which became a compounding factor in managing her multiple medical problems. She tried talk therapy but never really felt comfortable opening up. Antidepressants didn’t make a dent. She was mired in despair and despite our efforts to engage her in managing her blood sugars, Vero’s texts often went unanswered. We knew she would spend days in her room, crying and isolating herself. She would frequently break down while at work. We begged her to come in to talk to us.

Finally, one day without prompting, she did. We could tell she was on the edge and didn’t know where to turn. She had decided to put her trust in us as a last resort. She opened up to us and all her emotional and physical traumas began to trickle out. It was a very emotional meeting and it was only the beginning. We offered more therapy from a professional, but she really just wanted to talk to her Health Coach. We decided that coffee with Vero every other week would be a start. She left that meeting only a step back from the edge but she was moving in the right direction.

And then, Vero received a gift of beautiful flowers.

One Coffee at a Time Vero

The note reads:

I HONESTLY WANT TO THANK YOU FOR EVERYTHING THAT YOU HAVE DONE FOR ME EVEN THOUGH I AM A PAIN IN THE BUTT I’M SO GRATEFUL THAT YOU HAVEN’T GIVEN UP ON ME YOU TRULY ARE A GODSEND

Over the past couple of months Vero’s coffee meetings have been a huge success. She has shared some of her deepest secrets that have clearly been weighing her down and blocking her from moving forward. She has felt comfortable enough to establish care with Nina, our social worker, so she can get the trained help she needs in dealing with her significant past traumas. From a medical standpoint we are still working on her sugars with the goal of reversing her ostomy. She is by no means a picture of health, but we are taking baby steps, in the right direction.

This patient has been a huge reminder to me that despite the monumental task we have in front of us, we do make a difference in people’s lives, everyday. Because of the unconventional resources we have to help us connect with our patients, we are able to continue to find creative ways to make breakthroughs and put our most challenging patients on the track to leading healthier and more fulfilling lives. I know that there are times we feel like no matter how much we try to help our most challenging patients, that they can’t or won’t change. It is so wonderful to be reminded that by showing our patients that we truly care about them and that we won’t give up on them, our positive attitude can have an impact. Great job Vero!

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Commonality: finding the common threads

Commonality is the state of sharing features or attributes. It’s an amazing thing when that is found when providing a patient care, care they deserve. In October 2013, I remember sitting around the table in room seven at the Culinary Extra Clinic, Iora Health’s first Las Vegas practice that sits in the Stratosphere’s shadow. Every stakeholder was represented at the table: a very sick patient with multiple acronyms using most letters in the alphabet, a sponsor, a primary care physician and a clinical health coach. Each was there realizing this was the most important thing they could be doing at that time.

Let’s go backwards to go forwards. This patient is under 40 years old and is trying to get their second kidney transplant. They quickly became very ill and it was determined the right course of action was to send them to the emergency department. However, an even better course of action involved a direct admission. Direct admissions need cooperation and communication with the admitting physician, all hospitalists and sometimes sponsors.

The roundtable discussion on that fall day allowed the patient to raise concerns with yet another hospitalization. It allowed the health coach, who had the closest relationship to the patient, to provide an additional voice for the patient and advocate for their needs. It allowed the physician to make a sound clinical decision. And, lastly, it allowed the sponsor to witness all of this and provide input.

Everyone at the table had a voice. While it is not uncommon for physicians and sponsors, especially if they are benefit administrators or the insurance company, to have a voice, let’s be honest, at times they may have too much of a voice, too much to say, chastising patients for poor choices and/or costing the system too much money. But what if we all started to sit around the table and voice our questions, comments and concerns. What if the common theme or commonality amongst us is cooperation and communication? How would that change things? How would that change health care and restore humanity to that end?

These are all things to think about, to contemplate. While we do that, please, let us find the common threads amongst us: the desire to be heard, to be cared for and to be respected.