Healthcare 2 (2014) 280–283

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Health care snapshot

Flipping primary health care: A personal story Kedar S. Mate a,n, Gilbert Salinas b a b

Department of Medicine, Weill Cornell Medical College, 525 E. 68th Street, NY, New York 10065, USA Rancho Los Amigos National Rehabilitation Center, Los Angeles County

art ic l e i nf o

a b s t r a c t

Article history: Received 23 May 2014 Received in revised form 15 September 2014 Accepted 2 October 2014 Available online 4 November 2014

There is considerable interest in ideas borrowed from education about “flipping the classroom” and how they might be applied to “flipping” aspects of health care to reach the Triple Aim of improved health outcomes, improved experience of care, and reduced costs. There are few real-life case studies of “flipping health care” in practice at the individual patient level. This article describes the experience of one of the authors as he experienced having to “flip” his primary health care. We describe seven inverted practices in his care, report outcomes of this experiment, describe the enabling factors, and derive lessons for patient-centered primary care redesign. & 2014 Elsevier Inc. All rights reserved.

Keywords: Innovation Patient-centered Flipping health care Delivery system redesign Primary care

1. Article text In education these days, a promising innovation is “flipping the classroom”: instead of using classroom time for didactic instruction and doing homework at home, homework is done in the classroom and didactics are done at home.1,2 While the logistics and planning take some investment of time and energy by lesson planners and teachers, there are now many such experiments in education that are showing promising early results. This has provoked health care providers and innovators to consider how we might “flip” health care.3,4 There are many apparent advantages to a “flipped” educational system: students move through the didactics in their home environment, mastering content at their own pace, and then work on problems with the expert [teacher] in the classroom to help facilitate when they hit roadblocks.5 The literature describes the changing role of the educator from a “sage on the stage” to a “guide on the side.” In traditional classrooms, all students must learn the didactics at the same pace; in the flipped classroom, students can progress from one set of problems to the next at their own pace, mastering the content as they advance.6 Problem solving becomes the focus of classroom activity, not didactic lesson plans. The other advantage is that the world's best teachers can be brought to the students. Lesson planners can use the video and online lessons from Khan Academy, Coursera, edX, or other expert knowledge providers and master teachers to deliver the very best

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Corresponding author. E-mail address: [email protected] (K.S. Mate).

http://dx.doi.org/10.1016/j.hjdsi.2014.10.003 2213-0764/& 2014 Elsevier Inc. All rights reserved.

lessons taught in an engaging and provocative way.7,8 Definitive evaluations of these methods are not yet available, but preliminary studies indicate that students and teachers are more satisfied using these approaches and that students perform better in flipped learning environments.9–11 Several health care practitioners are applying principles of flipping care to the design of clinical spaces, service delivery and operations, and communication between patients and providers.3 Yet, despite the interest and active experimentation with flipping care, patient testimonials of flipping health care are rare in the literature. Here we describe the experience of one of the authors, Gilbert Salinas, who during a recent fellowship year was forced to flip his health care. That experience presented lessons, which we describe below, for innovators interested in pursuing flipping strategies in the future. 2. Gilbert's story When I was 17, an accidental gunshot injury left me with partial paralysis from the waist down. I survived the injury, but was left with multiple chronic health care needs. I see my providers in California, where I live, on average eight times a year for medications, routine management of cholesterol, triglycerides, urinary tract infections, insomnia, and, at times, overwhelming chronic pain. I interact with others in the health care system to acquire medical devices: wheelchair parts, spare tires, urinary catheters, and other supplies. For more than ten years, I have trusted my caregivers with my complex health care needs. We have evolved together, learning

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from each other and building a trusting relationship. Last year, I was offered the opportunity to participate in a prestigious fellowship program in Cambridge, Massachusetts. Accepting the fellowship meant a move that would be disruptive for anyone, but for me it came with other considerations. Cambridge is an old city – rich in history and educational opportunity, but full of cobblestone streets, harsh weather conditions, limited wheelchair accessibility, and very far from the health care providers I have come to trust and love. As I considered my move, my options were to forego my current health plan for the year, find an alternative plan, or keep my existing insurance and work with my existing providers to “flip” my care. What might “flipping health care” mean for patients like Gilbert? To understand it requires first looking at the current state: a typical clinic visit and what is expected of (see Fig. 1). In a typical clinic visit, patients are seen by a provider; vital signs are checked; labs are reviewed; medications are adjusted and refilled; a physical exam is done; the provider listens, coaches, and provides knowledge about how to live with specific conditions and illnesses.12 What happens at home? The patient's conditions, ailments, and illnesses meet “real life,” which contextualizes the knowledge gained in the clinical encounter. The patient makes adjustments to lifestyle, behavior, routine, medications, etc. – to the extent that they “make sense” for the patient. Sense-making of the lived experience of illness is what happens at home. So what would “flipped” health care look like? Most of the elements of the clinic visit can now be performed at home through technology-enabled environments. Vital signs can be monitored, continuously or intermittently;13 medication review can be done virtually14 or in person, at home, using community health workers;15 phlebotomists can travel to the patient, or patients can go to convenient local laboratories for blood draws;16,17 although still developing, several components of the physical exam can now be done via technology over the internet or telephone (aspects of the cardiac, pulmonary, and skin exams, for example). At the conclusion of this information gathering, clinicians and patients can converse about concerns, hopes, goals, and worries over secure video or teleconferencing systems.18 Medications can be adjusted and e-prescribed. Reminders can be placed. Home environments can be surveyed, pill bottles checked. Coaching by providers,

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which is currently limited to one 15-minute session once in a while, can now be delivered asynchronously by clinicians via email, chat, instant messaging, and “just-in-time” educational reminders via email and SMS technology.19 Coaching patients towards better living and better health can now be a continuous process, rather than a staccato relationship with peaks in communication around clinic visits and major valleys in between. So if all of these formerly clinic-based activities can be performed at home, what is left to be done in the clinic? First, there are times when patients, all patients, will require a face-toface encounter; technology will not render periodic face-to-face check-ups irrelevant. So some traditional clinic visits will continue, but these will be fewer and time may be freed up in the regular clinic day for providers to address what are likely higher-acuity patients who require face-to-face encounters. In addition, what used to happen at home, patients' conditions meeting real life, can now be brought into the clinic environment, either in simulated interactions (such as those around taking medicines with medication counselors or making nutrition choices with the nutritionist), or in real-life meetings where groups of patients living with the same or similar illnesses gather to discuss how they negotiate living with their chronic conditions. Such “clinic visits” may not take place in the clinic at all; in fact, they are more likely to take place in churches, community centers, grocery stores, and department stores. In these circumstances, clinicians are not the experts; patients are the experts, teaching one other how to cope with their conditions. Clinicians are the “guides on the side”— technical facilitators, available as a resource when clinical questions arise, but in no way the authority on what it takes to live with conditions like congestive heart failure and diabetes. These group visits may take place in real environments or virtual ones (e.g., PatientsLikeMe, the Big White Wall).20,21 The advantage of virtual settings is that they preserve anonymity, which may be desirable for many individuals. Clinicians are available to provide onsite clinical support as required of patients. Routine conditions can be easily managed in this way; pregnancy has been managed this way for years (for example, Centering Pregnancy)22 and outcomes have been favorable.23,24 But more complex conditions can also be managed this way and under significant resource limitations; for example, in rural Rwanda, Partners in Health has been managing complex HIV patients using visits like this for years.25

Fig. 1. Flipping Primary Care: Gilbert's experiences at home and in the clinic before and after flipping his primary care.

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Gilbert's decision to “flip” his own health care – and the results of that experiment: Of the choices available, the only one that made sense to me was to “flip” my primary care and stay with my health plan and my trusted health care providers, despite moving 3,000 miles away. I took an evidence-based approach to this decision, knowing that if any aspect of my health started to show signs of failure, I could deteriorate rapidly and I might need to cut my fellowship short. In June 2013, I collected baseline data on my renal function, lipids, and pain levels. These would be the “outcome measures” of my experiment in flipping care. There were seven things I did to flip my care. First, I made very few clinic visits (nine the year before vs. three during the fellowship year); the majority of my contact with my physicians and providers was done by email and telephone. Second, all of my medication refills and general counseling were done online. Scripts were filled 10 days early to allow for processing and shipping to my Cambridge home. Third, I took on a much more proactive role in self-managing my diet, exercise, and daily habits. I used fitnessand diet-tracking apps to understand my daily cardiovascular activity and patterns of consumption. My health plan's own digital health-coaching tools were very helpful and are directly linked to my health record, so my providers could understand my progress from a distance make informed recommendations to me about diet and exercise. Fourth, I had to make a change to my process around durable medical equipment. Before, I would get urinary catheters in California, but this year I worked out a process to have the catheters mailed to my home in Cambridge. Fifth, I planned ahead for my wheelchair by ordering a push-assist product that helped to decrease repetitive motion injuries and extra tires. I found a place to live that was wheelchair accessible, and scouted out my daily route to and from where I would be working and attending classes. Sixth, because I require periodic episodic cortisone injections for pain in my left shoulder and right arm, I had to work out an in-person visit to the Brigham and Women's Hospital; my health plan agreed to cover these shots. Finally, I had my labs done by going onsite to a clinical laboratory and having the results emailed to my providers in California. The results of this effort have been striking. I have never felt better. My levels of pain are under control; I no longer take pain medication on a regular basis, as I had prior to my experiment in flipping care. I have more energy and my sleeping patterns have improved. My lipids have actually improved for the first time in a very long time, and my renal function has been stable. I have not had a urinary tract infection in many months. I have saved myself money in the form of co-pays, and I have saved the health care system money by being healthier, requiring fewer visits and fewer medications (pain meds in particular) over the year. My physician's time is not spent on management of my behaviors; she and I have a great relationship and she feels inspired by this work. My productivity has improved, with fewer absences from work because of appointments or not being well enough to go to work. Most importantly, I feel happier and healthier, and I am amazed that I have been able to accomplish my goal of being healthy during this year away from my providers. It has transformed my sense of what is possible and has encouraged me to take further ownership of my health. After an initial period where incorporating health considerations into my daily life felt forced, they have now become second nature; I take my health and well-being into consideration with every decision I make. Gilbert's experience of flipping care was not straightforward or easy by any means—and, to be sure, neither the experience of flipping nor the experience of care in a flipped model might be for everyone.

The preparation that went into Gilbert's flip was substantial, as systems are not currently set up to accommodate a patient who is “flipping” his or her care. There are also certain points—for example, the need for cortisone injections—that required interactions that could not be “flipped.” Gilbert's health plan was very accommodating and was instrumental in helping to organize this change in business as usual. This was critical, and not everyone will have the ability to work with an accommodating health plan. Without these supports, the notion of flipping health care will remain a challenge in our present health care environment. Nevertheless, this example provides evidence that a different model of care delivery can be built with face-to-face visits substituted by mostly virtual connections, with an integrated mail-based supply chain, and a laboratory and minor services system that is distributed so people can access them just-in-time wherever they are in the US. It is possible, even within the existing system, to “flip” aspects of primary care and improve outcomes, improve the care experience, and reduce costs.

Conflict of Interests The authors have declared that no conflict of interests exist.

Acknowledgments The authors would like to acknowledge and thank Jane Roessner for her review and comments on drafts and revisions of this manuscript and Nigel Deen for citation and reference assistance. References 1. Lage MJ, Platt GJ, Treglia M. Inverting the classroom: a gateway to creating an inclusive learning environment. J Econ Educ. 2000;31(1):30–43. 2. Bergmann J, Sams A Flip your classroom: reach every student in every class every day. Eugene, OR: International Society for Technology in Education; 2012. 3. Robert Wood Johnson Foundation. Flip the Clinic. RWJF. May 14, 2014; Available from: 〈www.fliptheclinic.org〉. 4. Bisognano M Flipping health care. 25th Annual National Forum on Quality Improvement in Health Care. Orlando, FL; 2013. 5. Fulton K. Upside down and inside out: flip your classroom to improve student learning. Learn Lead with Technol. 2012;39(8):12–17. 6. Block JH, Airasian PW, Bloom BS, et al. Mastery Learning: Theory and Practice: Holt. New York: Rinehart and Winston; 1971. 7. Khan Academy. May 14, 2014; Available from: 〈https://www.khanacademy.org/〉. 8. Bozeman Science. May 14, 2014; Available from: 〈http://www.bozemanscience. com/〉. 9. DeGrazia J, Falconer J, Nicodemus G, et al. Incorporating screencasts into chemical engineering courses. In: Proceedings of the ASEE Annual Conference and Exposition; 2012. 10. Day JA, Foley JD. Evaluating a web lecture intervention in a human – computer interaction course. Educ IEEE Trans on. 2006;49(4):420–431. 11. Moravec M, Williams A, Aguilar-Roca N, et al. Learn before lecture: a strategy that improves learning outcomes in a large introductory biology class. CBE-Life Sci Educ. 2010;9(4):473–481. 12. Goroll AH, Mulley AG. Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 7th edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014. 13. Suter P, Suter WN, Johnston D. Theory-based telehealth and patient empowerment. Popul Health Manag. 2011;14(2):87–92. 14. Newsome J. Virtual medication therapy management: the cornerstone to a pharmacy renaissance. J Am Pharm Assoc: JAPhA. 2013;53:2. 15. Kenya S, Chida N, Symes S, et al. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature HIV Med. 2011;12(9):525–534. 16. Heath G, Cameron E, Cummins C, et al. Paediatric ‘care closer to home’: stakeholder views and barriers to implementation. Health Place. 2012;18 (5):1068–1073. 17. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol Ser A: Biol Sci Med Sci. 2001;56(10):M603–M608. 18. Schwamm LH. Telehealth: seven strategies to successfully implement disruptive technology and transform health care. Health Aff. 2014;33(2):200–206. 19. Adams SR, Goler NC, Sanna RS, et al. Peer reviewed: patient satisfaction and perceived success with a telephonic health coaching program: the natural

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Flipping primary health care: A personal story.

There is considerable interest in ideas borrowed from education about "flipping the classroom" and how they might be applied to "flipping" aspects of ...
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