Transforming Primary Care at Stanford

Over the next three years, Stanford Hospital & Clinics will more than triple its primary care base, adding roughly fifty new physicians and other health care providers, establishing multiple clinics on the Peninsula and developing new models of delivering care. Ultimately, Stanford primary care plans to serve 100,000 to 200,000 patients, both in the remodeled Stanford Family Medicine and Stanford Internal Medicine on-campus clinics, as well as in multiple primary care clinics across the Peninsula.

"Stanford has always stood for excellence in highly specialized care, but the senior leadership of both the hospital and the medical school realize that society needs more than just excellent specialty care," says Sang-ick Chang, MD, MPH, the new assistant dean of clinic affairs tasked with revitalizing primary care at Stanford Hospital & Clinics and the School of Medicine. "As the health care environment evolves, it is important to build a regional primary base to refer into and support the excellent tertiary and quaternary care that is already established here at Stanford."

A primary care physician, Chang has served as chief medical officer for two of the Bay Area's largest public medical centers and is a noted expert in developing and managing primary care systems. After spending twenty-two years taking care of uninsured and underinsured patients, Chang knows what it takes "to do more with less" and how to connect disparate parts of a health system into a coordinated system of care.

"As a society, we need to find ways to rein in rising medical costs and improve the quality of care," says Amir Dan Rubin, president and CEO of SHC. "Dr. Chang has helped to advance these goals by designing and directing patient-centered evidence-based primary care systems that emphasize prevention and coordinated care."

Innovative, team-based care

This fall, Stanford is opening its first-ever community-based primary care clinic just seven minutes from campus at the Ladera Shopping Center on Alpine Road. The clinic is launching with four full-time doctors, with an additional six physicians joining the practice after the second phase of construction is completed early next year.

Chang's vision for this new primary care system is rooted in a team-based, comprehensive care approach that utilizes the unique skills of a variety of providers within the medical office and ultimately gives physicians more time with patients to listen to their concerns. In this approach, the physician is a team leader who oversees the care of patients, but is not the sole provider.

Patient convenience and speed of access are the primary tenets of this new model. The clinic will guarantee same-day access for patients by not fully booking each day. It also will offer the convenience of telemedicine for patients who have simple health issues that can be managed via telephone, e-mail or video conferencing. This allows patients to receive medication adjustments, for example, without taking time out of their busy days to drive, park, register and wait to see their doctor, Chang says.

The team philosophy changes the patient experience at medical appointments. Every physician will be paired with a care coordinator who will handle many of the administrative tasks once managed by doctors, such as medication refills, referral authorizations and patient counseling on preventive care. "There are a variety of components to taking care of patients, each of which can be handled by a different level of training or specialization," Chang says.

As the team-based model expands, Stanford's clinics will have in-house pharmacists to manage patients' medications, nurse case managers who can troubleshoot patients' complex social environments and help patients adhere to medication or treatment plans, and health educators to work with patients around health habits and making lifestyle changes.

"The team approach leverages the shrinking primary care manpower base so that doctors can care for a larger group of people and still provide excellent care," Chang says. "By decompressing the work day and having other people do some of the work, we can free the physician to spend more quality time with patients."

The payment incentives under this new model are also radically different. Rather than being paid per patient visit, physicians will be reimbursed based on balancing patient satisfaction, clinical safety and outcomes, and panel size. The physician's goal is no longer to see as many patients as possible, Chang says, but to keep people healthy.

Fully integrated, vertical care

In addition to opening the first off-campus clinic this fall, Stanford is revamping its primary care services on campus. Both Stanford Family Medicine and Stanford Internal Medicine will be moving into the newly remodeled Hoover Pavilion and will eventually adopt many of the team-based innovations being tested at the new off-campus clinic. Stanford also will begin morphing its successful executive health program into an expanded concierge practice to meet the needs of a growing population of patients who want this extra service.

To further integrate and expand its geriatric/palliative care practice, Stanford is contracting with long-term care facilities so patient care can be better coordinated between outpatient, inpatient and skilled nursing facilities. There are additional plans to build a convenience care center, which would offer expanded hours (evenings and weekends) for Stanford employees and patients, including patients receiving specialty care.

In another effort to improve patient outcomes and reduce costs, Stanford launched Stanford Coordinated Care earlier this year, its first-ever ambulatory ICU and the first in the region. At the coordinated care clinic, a team of physicians, social workers, physical therapists, care support nurses, patient care coordinators and patient navigators work together to help patients with complex chronic conditions avoid health care emergencies and take control of their health. This highly coordinated care is currently reserved for the very sickest SHC and university employees and their dependents.

By Grace Hammerstrom