For four weeks, Eva Luo, an Open School student and an MD/MBA candidate at the University of Michigan Medical School and Harvard Business School, is doing a rotation at Iora Health clinic that serves workers in the culinary union in Las Vegas to learn about their model of primary care. While there, she’s also going to be working on a population health project through the Open School’s new initiative, the Improvement Change Agent Network, or I-CAN. Below is her third dispatch for our blog (read the first here). Look for more of her posts on our blog, and contact us at firstname.lastname@example.org if you want to write your own post.
It is officially flu
season in Las Vegas
. Thankfully, I do not have the flu, but I’m seeing
plenty of it at Culinary Extra Clinic. If you are
planning a trip to the Strip in the next few weeks, please wash your hands! It
was on a particularly busy, flu-filled day at clinic that I experienced the
true wonders of the Iora Health
of primary care.
After treating two asthmatic patients with the flu and shortness
of breath, I walked back into the central Huddle Room to catch my own breath.
But no rest was to be had in the Huddle Room. On a day like this, it should
have been renamed the Situation Room. Drs. Scott Jacobson, Andrew Schutzbank, and
Ali Khan, along with Clinical Operations Manager Dennis Leon, were in deep
discussion on how best to manage the condition of a patient. Nancy* had congestive heart failure and her body was retaining fluids. She’d been to
the hospital, but wasn’t getting better, so she came back to us.
“Do we have
they hit her with at the hospital?”
“How is she
have come here first. We can’t send her back to the hospital.”
Just as I regained my bearings in this burst of activity in
the Huddle Room, Dr. Khan looked over at me and said, “Let’s go!”
We walked into the patient’s room, and I met Nancy. She was slouched
in a chair and wrapped up in a sheet over her clothing, and her face looked sunken
behind an intricate headscarf. Nancy was using all of her energy to breathe
past all of the fluid that had accumulated in her lungs, abdomen, and legs.
Nancy and her husband explained what had happened: The fluid
accumulated quickly, and she gained weight rapidly, so they went to the hospital.
Nancy said the staff at the hospital paid her little attention, and gave her little
to no treatment. After two days in the hospital, she was discharged, still
miserable and about 10 pounds heavier than she should be.
Our physical exam confirmed everything she described. She
was not in any immediate danger, but we needed to do something quickly. Our
task was clear. We needed to comfortably help her remove the excess fluid her
body was carrying to provide her with relief and to avoid any continued damage
to her organs.
failure is a common chronic condition treated in hospitals. Emergencies
occur when patients notice that they are gaining weight or that they are
suddenly experiencing difficulty breathing. They’re usually admitted to the
hospital onto a floor with telemetry monitoring and treated. With the luxury of
rapid lab tests to monitor the progress of therapeutic regimens, straightforward
cases of congestive heart failure are not too difficult to treat in hospitals.
But Culinary Extra Clinic is a primary care clinic. How can
we help her without the luxury of 24/7 access to laboratory tests and
electronic monitoring? At an Iora Health clinic, when immediate danger is not
imminent, the answer is not to send her to the hospital. We believe in treating
the patient to the extent we can in their primary care home base, to avoid
unnecessary, expensive hospitalizations that don’t improve care, as Nancy’s
What ensued was a beautiful orchestration of clinical
expertise, operations ingenuity, and most importantly, a strong relationship
with the patient.
When Dr. Khan and I returned to the Huddle room, Dennis had
already returned from a trip to the Culinary Pharmacy next door and IV Lasix, a
diuretic to alleviate fluid retention, was not available. He wasted no time and
was already on the phone making calls to request IV Lasix and coordinating a
timely delivery of the medication to the clinic. Meanwhile, the physicians
brainstormed alternative diuresis options in case they couldn’t get the IV
Lasix. Nancy needed treatment before leaving the clinic.
Meanwhile, Chidimma Ozor, Nancy’s
health coach, was in the room counseling Nancy on next steps. She asked a
“Nancy, can you come back to clinic tomorrow?”
In an ordinary primary care clinic, the answer would likely
be “no.” Many primary care clinics don’t offer flexible appointments to
patients, so that they couldn’t even accommodate a patient like Nancy the next
day. And too often, the patients don’t have enough confidence in the providers
to want to return. But Iora strives to make it easy for patients to receive
regular care, with a flexible schedule in which nearly half of visits are
walk-ins. The close relationships that health coaches have developed with each
of the patients builds trust and encourages them to come to the clinic for help.
So the answer to Chidimma’s question was “yes.”
Over the course of the week, we carefully monitored Nancy.
She returned to clinic three times for re-evaluation. At each visit, we
carefully adjusted and administered her medications and monitored her for side
effects. Over the week, she lost about eight pounds. At her most recent visit,
she was smiling and breathing with ease. The fluid in her abdomen and legs had subsided.
Iora Health safely accomplished what the hospital wasn’t able to do — in the
comfort of Nancy’s own home.
Nancy’s situation is just one incredible case. There are
many more stories like this every day. Culinary Extra Clinic takes care of over
1,000 patients. Over 70 percent of the patients are in their fifties and sixties.
Many of these patients are managing several chronic diseases. Over 50 percent
of the patients are obese, almost 60 percent of the patients have diabetes, and
almost 10 percent have chronic kidney disease. About 50 percent are also
managing hypertension. Most chronic disease patients with the same demographic
characteristics as those seen at Culinary Extra Clinic often fall through the
cracks of the health care system and never make it to a physician until it is
too late, and they’re forced to go into the emergency room or the hospital.
Real continuous care, like I saw our team provide to Nancy, takes
a population health perspective on primary care and a true commitment from the
clinicians and health coaches to the health of the patients. As a result,
patients who the care team determine have a high “worry score,” or risk of
serious illness, are engaged enough to follow up at the clinic at least twice a
month. This is the extra quality that Iora Health has over the standard primary
As health care payment systems evolve toward rewarding
quality of care, and models like Iora Health continue to deliver great health
care outcomes, I’m confident we will see more and more primary care practices
adopt a patient-centered, team approach.
*Name has been changed to protect the patient's privacy.