Primary care transformed: A provider story

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Kim McGuinness has been an adult nurse practitioner for four years, and a registered nurse for six years before that. She went into nursing to help people, but was getting increasingly frustrated and burnt out. Patients with chronic conditions like high blood pressure and diabetes were coming in month after month with no improvement in their health status. “I felt like I was just running through the motions,” she says. “You know, ‘Here’s your next script, let’s give you more medicine.’”

Last year, Kim became a Super-Utilizer Fellow through a partnership between the Camden Coalition and Crozer-Keystone Health System, working in a primary care office two days a week and spending three days a week in the community, going on home visits and supporting care teams in Camden and the Delaware Valley. She has been learning all the aspects of our healthcare hotspotting model, from data collection to interprofessional teaming to the financial and management aspects of building a program to care for patients with complex health and social needs. And she says her practice has been completely transformed.

Where she was once burnt out she now feels energized, with the tools she needs to effectively care for patients with complex health and social needs.

“I think one of the biggest things I’ve learned is that if I only focus on my goals, I’m never going to help the patient or get through to the patient,” she says, “because they’re so focused on their goals, or there are other things that are keeping them from reaching the goals that I have. I’ve changed that focus to what the patient’s needs are.”

“I’m able to take a step back now. Instead of feeling so narrow and tunneled when a patient comes in with these complex issues, I feel like I’m able to break down those issues better and take it piece by piece.”

One of the biggest changes that Kim made is incorporating basic behavioral health screening and management into her visits. “We talk a lot about feelings,” she laughs. “There’s a joke among my students that I have a box of tissues in every room, and patients go through at least one of those boxes a day.”

Addressing patients’ underlying emotional issues can lead to breakthroughs, but requires give and take on both sides. Kim talks about a patient who came in demanding pain medication, a common struggle in health care settings that many providers have trouble addressing empathetically and effectively.

“I remember looking at his chart before he came into the office and immediately shutting down and saying to myself, ‘I’m not giving him these meds.’ And as I was doing that I became aware of how I was feeling, and allowed myself to open up and listen to what he had to say first before having that judgment, because that was just my initial instinct that had been coached into me. During that visit he was able to disclose some things that had happened to him in his history, and we talked a lot about how mental health and things that happened previously in his life affect his physical being. I did end up giving him pain meds that day, but we also came up with a plan that included seeking out behavioral health. And that felt really good. I was meeting the patient’s current needs, but also working on the true cause of what was causing that pain. If we had just worked on his back pain, we weren’t going to get anywhere except for continuing to give him meds and injections.”

Kim has finished her Super-Utilizer Fellowship, but she is continuing her work with the Camden Coalition as a preceptor in our Interprofessional Student Hotspotting Learning Collaborative, which trains interdisciplinary teams of health professional students on healthcare hotspotting, storytelling, and patient-centered care.

She says she wants to teach her students the importance of feelings, those of both the patients and the providers, which she sees as a significant gap in current medical education. “In nursing school you’re taught about active listening, and I’ve always carried that piece with me,” she says. “But even though I was actively listening, I don’t know how much I was feeling. Or how much I was really hearing.”

Armed with her fellowship experience, Kim is ready to start transforming health care in the same way that she has transformed her practice. To be effective for all patients, practices need to move toward what she calls “common-sense medicine”: integrated behavioral and physical health care, more social workers to help address patients’ social needs, training in interprofessional teaming, and the ability to go on home visits.

“It’s not every patient that needs [these changes],” she says, “but it’s these complex patients we see over and over again that aren’t making any progress in their care. We need to delve a little deeper into their lives and figure out what their true barriers are. No matter how many times I talk to them about their blood pressure, if they don’t have a house to live in, or they’re being abused at home, or they don’t have a job, I’m never gonna touch that blood pressure.”


Read more from Kim on hotspotting and the Super-Utilizer fellowship, on the Primary Care Progress blog

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