Defining Team-Based Care: Insight from Gary Wiltz, MD

August 2015, Vol 3, No 8 - Inside Patient Care

In a recent interview with Inside Patient Care, Gary Wiltz, MD, Executive Director/Clinical Director, Teche Action Board, Inc, Franklin, LA, discussed the National Association of Community Health Centers and Teche Action Clinic, as well as improving patient care using a multifaceted approach to care.

What is your background?

A: I’m a native of New Orleans, Louisiana, and I take pride in saying that I was born at New Orleans Charity Hospital in 1953.

I had the good fortune of being educated by the New Orleans public school system. I attended Tulane University School of Medicine in New Orleans as an undergraduate and did my internal medicine residency there and at Charity Hospital.

During medical school, I earned a scholarship from the National Health Service Corps (NHSC). The NHSC had a program where every year that your tuition was paid for by them, you were obligated to pay them back with a year of service to an underserved community. That’s how I came to the Teche Action Clinic in Franklin, Louisiana.

Teche is a Native American word for snake that describes the body of water that traverses through this community—the Bayou Teche, which is located about 100 miles southwest of New Orleans, in bayou country.

I was assigned to the Teche Action Clinic after I completed my internal medicine residency at Tulane University School of Medicine, and I had a 3-year commitment to pay back. That was in 1982, and as of July 2015, I will be serving my 33rd year here—so, I came, and I stayed.

It’s sort of like a reverse version of the television series Northern Exposure; I call it “Southern Exposure.”

We started off as a community health center, with a staff of about 5. The clinic was in danger of losing its funding, because it did not have a provider. When I joined, I was appointed as the Medical Director. My first boss was the first pediatric nurse practitioner in the state of Louisiana. She was new to her position as the Chief Executive Office (CEO), and I was new to my position, which was an interesting story. When I came in, she immediately told me that I was going to be the Medical Director. I, of course, had no clue what that was. I pointedly asked her what that meant because I went to medical school, not medical director school.

We had an operating budget of about $100,000 just for the Franklin location. The clinic was originally created to serve the migrant sugarcane workers in this community. If you fast-forward to today, I’m now the CEO. I became the CEO 10 years ago, after serving as the Medical Director for 23 years. We now have 10 sites serving about 20,000 people.

The mission of community health centers and the National Association of Community Health Centers (NACHC) is to go out and actually serve the underserved. Our official mission statement says that we promote the provision of high-quality comprehensive and affordable healthcare that is coordinated, culturally and linguistically competent, and community-directed for all medically underserved populations.

Right now, we are serving more than 23 million people nationwide, touching roughly 1 of every 14 Americans. Our lead is mostly primary and preventive care, but the hallmark of what we do is that we are community-based. We serve as the primary care medical home (PCMH) for the patients we serve.

Most centers provide not only primary care, but also oral health and mental health. A lot of us have patient-enabling services and translation, and most of us have onsite labs. A lot of us have onsite pharmacies. We have patient assistance through Medicaid and Medicare education. We also provide transportation.

In my setting, 45% of the patients we treat are uninsured. They work, but can’t afford insurance. We also happen to be in a state that did not accept Medicaid expansion, exacerbating the situation of uninsured patients.

In what capacity does the interprofessional team deliver optimal access to high-quality care?

A: Let me start off by saying that the old model of a lonesome doctor going into a community and changing that whole population is gone. You can have a very satisfying career and a panel of patients who you follow—like I have for 30 years or so—but if you are really going to make a difference, and change the health of the population that you are focusing on within your community, it’s going to take a team approach.

In that regard, the NACHC, and our centers, have made a concerted, deliberate effort to all become certified as PCMH institutions. That means we endorse the team-based concept that everyone is an important member of the healthcare team.

Now, we are trying to define what that team is—and you can check with the NACHC staff — we’ve been doing surveys to define the concept. Because that team and what it consists of has not been clearly defined in the literature, it varies from institution to institution, but the basis of it would be a provider. That provider can be a doctor of medicine, nurse practitioner, or physician assistant, in conjunction with the registered nurses or licensed practical nurses, as well as oral health component, behavioral health, and even financial operations folks.

Pharmacists are an integral part of the team approach, because we put the patient in the middle, and then we surround them with all the members of the team. What is the connection that we have? The glue, if you will, is the electronic health record, which serves as a reminder and prompter, as well as a way that everyone can be accountable for the care that the patient receives. We base our treatment on age, dynamics, disease progress, ethnicity, and all the factors that pertain to that particular patient.

We will know when that patient needs preventive screenings and diagnostic testing. Every member of the team is responsible for making sure that nothing is missed. When you have a team approach with multiple hands and eyes participating, the likelihood of things being overlooked diminishes. We’ve had long-standing, well-established relationships with the community pharmacist.

Pharmacists are an integral part of the healthcare team; they not only provide retail services, but also deliver medication therapy management. Also, as part of the daily care meetings that we have, they discuss the best options for the most efficacious pharmaceutical treatments that we are considering, taking into account the financial, behavioral, literary, comprehensive, and linguistic challenges that our patients have. That is an integral component of what we do.

As that model of care gets introduced to the country, people will embrace that model. It is going to be more organized, more standardized, and accepted. Then, as the data come forward, I think that will demonstrate the positive impact that team-based care is having on healthcare outcomes. Patients will have the expectation that a team is going to guide their care, and it’s not going to be left up to just one individual.

Then it’s the partnership that we form with those patients—they take responsibility, too—but we’re there for them. It’s actually a great concept when you think about it. Not only do you have a primary care provider, you have a whole team that’s looking out for your care.

What changes in healthcare are you seeing that are impacting patients today?

A: A lot of what we also do is providing social services. There are times when you walk into the room with a patient, and the last thing they need is a healthcare provider. I’ll give you an example: you walk into a room, you’ve already prestaged the patient visit using a checklist of the things that they need to have done (eg, the patient needs a pap smear or a mammogram).

I had an occasion recently where a provider was telling me that they walked into the room with the mind-set that he was going to discuss with a patient scheduling a mammogram and pap smear. The patient told the provider, “Look, I just lost my house. I couldn’t pay my rent. They’ve cut off my lights,” and that was the priority for the patient that day. She needed to see social services, legal aid, and then try to find housing and shelter; her mammogram and pap smear were the last things on her mind and had to be put off. It is not uncommon that we have patients who present with a lot of what we call “the social determinants of health.” That’s a whole other topic for a whole other discussion, but a lot of the problems we see are related to that.

Another challenge is that there’s more information available. We see it all the time with people who have access to the Internet—they have WebMD, and all the different applications that you can get—but then how do they interpret some of the things that they have questions about?

They still need a healthcare provider, or someone on the team to explain some of the things they are reading and that they may have questions about. The provider guidance and treatment recommendations that we can get will come out of the team approach and will create those positive outcomes.

This is the wave of the future. We call it population management, where you have a team that is assigned to a patient population panel, and then you are responsible for all the elements that I described earlier when that patient comes in.

We have to know their age, ethnicity, gender, and the preventive things that they need to have done, as well as the disease that they may be dealing with. Then we carry out all the recommendations to make sure that they are getting the proper testing and therapeutics that they need.

What are some of the opportunities you have observed in healthcare and team-based care?

A: We’ll have the opportunity to improve health through the aspects of the patient’s life, affecting how they approach wellness, illness, social determinants, and behavioral health.

If you smoke or use tobacco, then we can offer tobacco abatement, or smoking cessation. The same applies to patients with problems with alcohol and nutrition, and these solutions can be reinforced on the retail level. We are trying to mitigate some of those elements of patients’ lives to positively change their health.

It will be an open door for providing guidance; the patient, as a partner in their care, will accept the treatment recommendations, and that will ultimately improve their health. It is almost like doing an inventory for them, on them, and having it reinforced on multiple levels.

We have campaigns that have been very effective. In one campaign, we are involved with the American Cancer Society, the Centers for Disease Control and Prevention, the HMO Cancer Research Network, and The Alexander and Margaret Stewart Trust. It is called FLU-FIT, and patients getting their annual flu vaccinations are offered take-home colorectal cancer screening tests. At that time, we also remind them if they are due for a colonoscopy, fecal and colon testing for colon cancer, rectal screening, and a total rectal cancer screen. That is a big one that we’re going to be pushing in the coming months—the FLU-FIT campaign.

The American Cancer Society hopes to regularly screen 80% of patients aged ≥50 years for colorectal cancer—one of the most curable, preventable cancers with early detection—by 2018. That’s a great opportunity that exists, and we’ve partnered with a lot of the retail pharmacies to do that.

What are some other projects you are currently working on?

A: Every month is designated as some sort of awareness month: February, Heart Month, is when we have the Million Hearts campaign; March is Colorectal Cancer Awareness Month; and October is Breast Cancer Awareness Month. Every month there is some entity or disease that is highlighted.

When you talk about community health, you have a national campaign, as well as a local campaign. In Louisiana, as a state, we have probably 2 or 3 times the national rate of diabetes. We have campaigns that focus on diabetes awareness and treatment, and improvement of that condition.

Hypertension and obesity are big issues that we have nationwide. When you have a common theme, then you can have common partners, and a team approach, and are able to focus on those things. You can incorporate them into your practice, and then into a larger community.

That underscores what we’re all about in community health centers. Our name says it all; we’re community-based and community-responsive. We pick out things that are problems unique to each community.

There are certain things we deal with that are universal. If your community has a high incidence of diabetes, hypertension, stroke, or cancer, then we focus on it, and make sure that we are doing everything in our power to detect and prevent those things from happening.

The biggest challenge is dealing with folks who are working but who can’t afford health insurance to buy some of the diagnostic testing and therapies that they might need. Again, that’s one of the things that we’re sensitive to within community health centers. We have patient medication assistance programs, and low-cost medications that we provide through the 340B Drug Pricing Program.

A lot of pharmaceutical companies have made patient medication assistance available, but that can still be a challenge for folks who are working. It’s hard for them to afford health insurance, and some of them can’t miss a day of work. But that presents an opportunity for us to serve the public, because a lot of centers, like ours, are open 12 hours a day, 6 days a week. Some of the other centers are looking to extend their hours, too, so that they can accommodate working people.

How do you think team-based care will evolve in the next 5 to 10 years?

A: I think that the public is beginning to understand that they don’t just have 1 person looking out for them.

Of course, the patient is the primary keeper of their own health. When we bring someone in, one of the models that I use is the “Prayer of Serenity,” where the patient has to recognize what they can and can’t control, learn how to work on things that they can control, and, as an individual, improve their health.

They are not alone in this task, because they are surrounded by a team, a team that can help them accomplish the good state of health they’re attempting to achieve—whether that means we refer them first to a nutritionist or dietitian to go over healthy food and food choices, or just discuss exercise with that patient.

If, through nonpharmaceutical intervention, it is determined that the patient needs pharmaceutical intervention, then we pick what is best for that patient based on their demographic profile, financial status, and the whole 9 yards.

Then, any necessary diagnostic testing is done, followed by interpretation of the results of those tests. I think that as the American public comes to appreciate that there’s more power in a team than in an individual, that model is going to be embraced; this is the model of care that we are going to see moving forward.

Do you have any concluding remarks?

A: Just that we in the community health center world have always felt that we are part of a medical neighborhood. We like to think of ourselves as—and try to be—the PCMH for patients in the areas that we serve, but we know that we coexist with hospitals, home health, hospice, retail pharmacies, and all other elements.

We’re not the panacea, but we know that together we can improve the health of the country. We stand ready to work with anyone and everyone as we move forward with trying to improve community health, and then, ultimately, individual health that, I think, we’re all seeking to obtain.

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Last modified: August 21, 2015
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