Transforming
Primary Care

At the age of 52, “Carla” found herself in a downward spiral as she struggled with diabetes, depression, and the after-effects of domestic violence.

The loss of a loved one deepened her depression, and she lost touch with the people she could count on for support. Feeling overwhelmed, she began to neglect the medical appointments, blood sugar testing, and medications that helped keep her diabetes in check.

The impact of her disease and stressful life issues put Carla at very high risk for hospitalization. It also made her a perfect candidate for an innovative chronic disease management program developed by the Social Work Department at Mount Auburn Cambridge Independent Practice Association (MACIPA). With a referral from her primary care physician, she was assigned a personal health coach to help her set and achieve goals that would help her regain control of her diabetes and improve her well-being.

MACIPA includes more than 500 physicians practicing in a variety of settings in Greater Boston, and it was one of the first physician organizations in Massachusetts to adopt the Blue Cross Alternative Quality Contract (AQC) in 2009. With incentives for physicians to improve quality and outcomes while slowing the rate of spending, the AQC has helped foster a broad vision of what primary care can do for high-need, high-risk patients. At MACIPA this means that three health coaches with social work training are available to guide patients like Carla on the path to better health.

Corp-2-MACIPA-650x352pxHealth Coaches Linda Asadoorian and Nasya Smith

“We’re adding to the traditional health care model by creating a partnership with our patients and catering to the whole person,” says health coach Nasya Smith. “We help them manage their chronic conditions and also help them find ways to improve their quality of life with activities and interests they enjoy.”

Each health coach has an active panel of 40 to 50 patients they work with for six months, in person and through weekly phone calls. They develop supportive relationships with their patients; provide a safe environment for them to talk about difficult personal issues; offer counseling in self-advocacy and empowerment; encourage medication adherence and follow-up with specialists; make referrals to therapy and support groups; and connect patients to community resources.

Patients enrolled in health coaching also benefit from individual case review by a team that includes the health coaches, MACIPA’s social work director, a psychiatrist, a pharmacist, and a primary care physician. Dr. Edward Kowaloff, who practices at Belmont Medical Associates, is a member of the review team. “The health coaches are helping people with complex issues that take more time than a regular office visit will allow for,” he says. “At our case review meetings, they get feedback and advice from multiple perspectives, which can lead to fast-track solutions for our patients.”

When Blue Cross developed the AQC model, it changed the future of payment reform. Organizations like MACIPA were able to provide services and care that is traditionally not covered by insurance but clearly would help patients with chronic diseases improve the quality of their lives and eventually lower health care costs. - Barbara Spivak, M.D., president of MACIPA

After six months of health coaching, “Carla” has met with an endocrinologist, she is regularly testing and recording her blood sugar, she feels motivated to begin major lifestyle changes regarding diet and exercise, she has stabilized her average blood sugar level (A1C), and she is reporting far fewer signs of depression. Her health and outlook on life have improved, and she is no longer at risk for another major setback.

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