Joe's Story: How a Capitated Payment Model Lets Me Be the Physician I Want to Be.

For many years I cared for Joe, following him through diagnoses of strokes, end-stage renal disease, and metastatic prostate cancer. Gaining his trust, coordinating his care across specialist visits and hospitalizations, and helping him and his family clarify goals of care took an investment of time and relationship-building. I was able to spend this time with Joe, and all of my medically complex patients, because I had taken a job in a Program of All-Inclusive Care for the Elderly (PACE), a fully capitated model of care. With care organized around the patient instead of the visit, this payment model transformed my work life. As I reflect on the care that I provided for Joe over the years, I consider how health care organization and finance can either help or hinder our ability to provide patient-centered, coordinated, continuous care for our patients. Evolving payment models can help make space for family physicians to provide the robust primary care we are trained to deliver.

Clinical Decision-Making for Older Patients With Multiple Chronic Conditions: A Case-Based Exercise for Medical Students.

INTRODUCTION: Over half of patients over age 65 in the US have multimorbidity, defined as having three or more chronic diseases, but most clinical research on chronic disease management focuses on single chronic diseases. An expert panel convened by the American Geriatrics Society has provided a framework of guiding principles for clinical decision-making in patients with multimorbidity. This resource describes a session for second-year medical students at the end of their preclinical curriculum, in which students practice using a framework for clinical decision-making for patients with multiple chronic diseases. METHODS: In this 90-minute small-group session, students work with faculty mentors to apply that framework to a hypothetical patient with multimorbidity. They consider patient preferences, review relevant evidence, estimate a prognosis, consider clinical feasibility, and devise a treatment plan that maximizes benefits, minimizes harm, and enhances quality of life. RESULTS: Approximately 180 students have completed the multimorbidity session. Outcomes data suggest that the session helps students master key concepts in management of the patient with multimorbidity. DISCUSSION: Prior to entering the clinical arena, medical students need to develop foundational skills that have not historically been part of preclinical curricula, such as accurately estimating prognoses, eliciting goals of care, and understanding the limitations of evidence regarding treatment outcomes in older patients. This session, one in a series of case-based exercises designed to train preclinical medical students in core competencies for care of the older patient, is a useful tool for medical educators looking to enrich the geriatric content in preclinical curricula.

Academic health centers and community health centers partnering to build a system of care for vulnerable patients: lessons from Carolina Health Net.

Academic health centers (AHCs) are challenged to meet their core missions in a time of strain on the health care system from rising costs, an aging population, increased rates of chronic disease, and growing numbers of uninsured patients. AHCs should be leaders in developing creative solutions to these challenges and training future leaders in new models of care. The authors present a case study describing the development, implementation, and early results of Carolina Health Net, a partnership between an AHC and a community health center to manage the most vulnerable uninsured by providing access to primary care medical homes and care management systems. This partnership was formed in 2008 to help transform the delivery of health care for the uninsured. As a result, 4,400 uninsured patients have been connected to primary care services. Emergency department use by enrolled patients has decreased. Patients have begun accessing subspecialty care within the medical home. More than 2,200 uninsured patients have been assisted to enroll in Medicaid. The experience of Carolina Health Net demonstrates that developing a system of care with primary care and wrap-around services such as pharmacy and case management can improve the cost-effectiveness and quality of care, thereby helping AHCs meet their broader missions. This project can serve as a model for other AHCs looking to partner with community-based providers to improve care and control costs for underserved populations.

Intimate partner violence.

Intimate partner violence (IPV) is a common problem affecting many women who present to obstetrics and gynecology practices. It takes on many forms, including psychologic/emotional, physical, and sexual abuse, and its effects on the health of victims and their children vary. Although many women's health care professionals may be uncomfortable inquiring about IPV, a knowledge of patients' IPV victimization may help physicians develop a better understanding of patients' presenting symptoms and health risks, form more effective therapeutic relationships, and work toward reducing the myriad health risks associated with IPV.

Intimate partner violence.

Intimate partner violence (IPV) is a common problem, affecting large numbers of women, men, and children who present to primary care practices. It takes on many forms, including psychologic/emotional, physical, and sexual abuse, and its effects on the health of victims and their children are varied. Although many primary care physicians may be uncomfortable inquiring about IPV, a knowledge of patients' IPV victimization may help physicians develop a better understanding of patients' presenting symptoms and health risks, form more effective therapeutic relationships, and work toward reducing the myriad health risks associated with IPV.

Community care of North Carolina: improving care through community health networks.

The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.

Intimate partner violence among Latinas in eastern North Carolina.

This article explores the correlates of intimate partner violence (IPV) among rural, southern Latinas. A sample of 1,212 women in blue-collar work sites in rural North Carolina completed a questionnaire assessing IPV and other social, demographic, and health-related variables. Social and demographic correlates of IPV were examined. Adult lifetime prevalence of IPV in Latinas was 19.5%, similar to that of non-Latinas. As compared to Latinas who did not experience IPV and non-Latinas who experienced IPV, Latinas who experienced IPV were more likely to lack social support and to have children in the home. Agencies that provide services to victims of IPV in the rural South need to be prepared to meet the unique needs of Latina immigrants.