Primary care priorities and challenges in Camden
By Dayna Fondell
For the past seven years, I have worked with safety-net health systems to design innovative approaches to care delivery that better serve patients. At the Camden Coalition, I lead clinical strategy for our Clinical Redesign Initiatives team. As part of this work, I conducted a series of interviews with our primary care partners across Camden. The themes were consistent in each interview: These are practices that choose to serve a struggling city, are thoroughly aware of the impact of social needs on their patients’ lives, and recognize that they are all working to address difficult, entrenched problems. Their shared commitment and passion for learning from each other made it easy for me to understand how Camden providers came together to successfully reduce avoidable hospital readmissions through the 7-Day Pledge.
The interviews also revealed the challenges that remain for primary care offices in Camden. In the changing health care landscape, primary care providers are being asked more and more to address the behavioral health and social needs of their patients. But while Camden providers recognize the need for these additional services, they are working under challenging circumstances. About 37 percent of Camden residents live below the poverty line and 57 percent are Medicaid recipients, compared to the national averages of 12 percent and 21 percent, respectively. In addition to the difficult task of improving the health of patients experiencing social challenges, primary care practices must also navigate the complexities of Medicaid and Medicare billing in a particularly crowded payer mix, due to the high number of managed care organizations operating in the region.
The concerns expressed by our partners in clinical and administrative roles provide insight — not just for the city of Camden, but for other communities seeking to address the priorities of safety-net primary care providers and the pressures they face.
Shared priorities of our primary care partners
While our primary care partners are heterogeneous in many ways, some common themes and priorities emerged from my conversations across multiple primary care settings. The primary care staff I spoke with identified the following priorities:
- Reporting on clinical quality measures required by payers. Practices are required to report on a variety of quality measures to insurance providers, HRSA (Health Resources and Services Administration), and the NCQA (National Committee for Quality Assurance) recognition programs. Many practices are also working to better capture quality data and improve their performance on these measures.
- Revising their models for billing and payment. Many practices are working to shift their teams, staffing, and internal operations to respond to the shift towards value-based payment.
- Expanding or incorporating services in behavioral health and diabetes. Camden providers are working to add services to address the behavioral health needs of their patients. They are also providing patients with more diabetes education and services.
Social barriers and system constraints
While trying to address and respond to these priorities, primary care staff in Camden are also acutely aware of the social barriers faced by their patients. They identified challenges around housing, food, and transportation, and acknowledged the impact of poverty on their patients’ lives. As one provider said, “I can prescribe the best diabetes medicine available, but if the patient can’t pay their copay, it feels like there is nothing I can do.” Aware of the shortage of resources, some providers said that they are uncomfortable asking a patient about social barriers that they can’t address. Said one provider, “It’s easier to ask a question when you have an answer or solution to give to the patient.”
But while many staff want to support their patients’ efforts to mitigate the social challenges that impact health, they know medical and mental health systems are not adequately meeting their patients’ needs. The most common challenges cited by our primary care partners include difficulty in accessing specialty care and behavioral health services, and long appointment wait times for both. Some clinics are working to bring additional services into primary care to try to improve access for their patients, but say that many of their patients are still waiting months for appointments.
Frequent medication formulary changes, prior authorization requirements, and shifting network contracts are also challenges that delay patient access to medications and consume huge amounts of staff time. As one provider said, “Imagine what we could do if nurses weren’t on the phone all day with the pharmacies and insurance companies? What we could do with all those hours back…”
Changing roles and added pressures
For many primary care providers in Camden, the complexity of patients’ health and social needs and their frustrations with the health care system can often feel overwhelming. With the high rates of poverty, there is an ongoing need for high-touch interventions for patients with complex health and social needs. But providers say that they are limited with their ability to address patients’ complex needs within a 15-20 minute appointment. And while they are grateful for the increase in care coordinators and navigation services in Camden, they say it’s not always clear who is working with their patients and what the other services are responsible for addressing.
Many practices affirmed that additional screenings around social determinants of health, behavioral health, and adverse childhood events are important, but also worry their clinics will not always be able to do the necessary follow-up and manage the increasing workload to address identified issues. They fear that things will fall through the cracks as they try to keep up with multiple demands — improving quality metrics, completing documentation, providing additional treatment in behavioral health and addiction, responding to electronic health record requests, and meeting patients’ needs and expectations.
Supporting patients in changing their health behaviors can be difficult under the best of circumstances, and it is further complicated by the social and economic challenges that patients face in managing health and accessing care. On managing the challenges in population health, one provider said, “I feel like I am responsible for everything a patient does or doesn’t do.” In addition, the shift towards value-based payment requires practices to take on a greater level of accountability for a whole population that is based on administrative attribution, not necessarily based on patients who actively attend the practice. This increases the pressure on primary care to try to impact quality measures and reduce hospital utilization for patients they may have never seen in the practice and have had difficulty reaching because of outdated or disconnected numbers.
Staying resilient and engaged
Despite these challenges, the Camden primary care community has shown incredible resilience. Clinics are working to adapt and learn about external resources, as well as identifying funding to hire onsite social workers, outreach workers, and care managers. Many providers have dedicated their careers to serving Camden residents. While there are signs of burnout, clinical staff have maintained a high level of empathy with their patients and value ongoing relationships with them. Overall, their frustration seems directed not at patients, but at the system as a whole.
Our primary care partners also have a strong desire to learn from each other and support the Camden community. In our meetings with providers and clinic staff, I have found that when patients switch clinics to access resources or services that better meet their needs, many are supportive of the change, rather than being territorial. While many practices find clinical measures like HEDIS (Healthcare Effectiveness Data and Information Set) valuable, they are also interested in exploring other metrics that more fully capture how clinical care can affect patient outcomes, such as the patient-provider relationship, patient retention, learning about the patient’s sense of purpose, and general harm reduction approaches.
As I spend more time in Camden, I have seen this energy and curiosity play out when partners engage with us — they add meetings to their day to discuss pilots, participate in cross-sector case conferences, and attend after-hours meetings and events. Despite working long hours at the clinic, many clinicians and administrators go above and beyond to push for system change across the city. I look forward to seeing what we can accomplish as a group in the coming year, and how the Camden Coalition can continue to evolve, advocate, and invest in systems that support our partners as they serve Camden patients.