Why It Matters
I walked back into the central Huddle Room to catch my 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.
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Dispatches from Las Vegas: Continuity — Can You Come Back Tomorrow?

By IHI Open School | Wednesday, February 4, 2015

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 openschool@ihi.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 model 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 IV Lasix?”       

“What is her creatinine?”

“What did they hit her with at the hospital?”

“How is she feeling?”

“She should 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.

Congestive heart 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 hadn’t.

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 crucial question:

“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 care clinic.

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.

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