Give the people what they want: Alan Glaseroff’s radical approach to patient empowerment

If you were to show up in Alan Glaseroff’s office as a person with diabetes and, let’s say, numerous complications, putting you into that group of 5% of Americans whose care consumes 50% of the national health care spend, he would ask you: What bothers you the most? in order to start developing a patient-centered plan of care. The visit would likely end with a discussion of the question: If things go well, what do things look like a year from now? What are your goals?

By focusing on the patient’s goals, and developing a multi-pronged approach to helping patients achieve those goals, Glaseroff and his team are able to introduce behavior change that will improve a patient’s health, and help patients achieve better-than-avergage adherence to new, healthy behaviors, and a significant reduction in the burdens of disease. Glaseroff says:

[To quote] Don Berwick . . .  “People need to become citizens in the improvement of their own work.” . . . I think self-management is the similar idea that patients need to become citizens in the improvement of their own health — [as] subjects rather than objects  . . . . [This can allow] you [to] design very specific workflows for patients that much better meet their needs than telling people what to do — which is usually the model of medicine practiced in the context of chronic illness.

Join Alan Glaseroff at Diabetes Innovation 2013, and hear more about his patient-centered approach to primary care and chronic disease management.

Have a listen to our interview (press play); read the transcript after the jump.

Here is the full transcript of our conversation:

Interview with Alan Glaseroff, MD, Co-Director, Stanford Coordinated Care, Stanford University

August 2013

David Harlow: This is David Harlow for Diabetes Innovation and I’m speaking today with Dr. Alan Glaseroff who is Co-Director of Stanford Coordinated Care at Stanford University. Hello Dr. Glaseroff. How are you today?

Alan Glaseroff: I’m well, nice to talk.

David Harlow: So, please let us know a little bit about Stanford Coordinated Care, what is that exactly?

Alan Glaseroff: So, it’s a program designed to be an innovation model for helping patients who have complex chronic illnesses. What it generally means is people who not only have the diagnoses of chronic illnesses such as diabetes, but often also have already had some complications from those things, and have been identified as being at high risk for future adverse outcome and high spend.

So our program is designed to work directly with employers who are seeking better ways of managing the 10% of their employees or dependents who end up accounting for 50% of the cost of their health plan every year and we — our payment model, which is not fee-for-service, but rather capitation plus a shared savings arrangement, allows us to the freedom to design a set of services that that accomplish the job of getting people to do better rather than confining what we do to what’s reimbursable under fee-for-service currently which unfortunately generally doesn’t cover all the important stuff.

David Harlow: Right. So you’re contracting with self-insured employers to provide these services?

Alan Glaseroff: Correct.

David Harlow: Okay. And how long has this center been operating?

Alan Glaseroff: So we’ve been — we opened our doors a little over a year go. I arrived with my wife Dr. Ann Lindsay who is the other Co-Director about a year and a half ago from our work doing similar work in Humboldt County in Northern California. Our work up there actually began focusing on diabetes — and I have a Type 1 myself and I developed it 30 years ago after I had finished my medical training — and that experience of waking up one day with a 1000 blood sugar and a healthcare system that was ready to tell me I was going to die young and suffer along the way kind of changed my whole focus of practice around, issues around self-management, empowerment of patients, activation of people and then the commonality of that model across all chronic diseases rather than just diabetes.

And we were able to get a community web-based registry going in Humboldt where we ended up with about 93% of all of the patients with diabetes in the county in a single database, and worked with the providers of the community to achieve NCQA recognition for diabetes as an entire county which at the time an unprecedented thing.

David Harlow: That’s remarkable.

Alan Glaseroff: We’re talking 2003 and then by 2011, we had seen a 29% drop in the death rate due to diabetes in Humboldt while in the same period of time California was unchanged as a whole. So we figured that we don’t understand exactly what we did that made the difference. Essentially what we did was installed the chronic care model work that came out of Group Health and Ed Wagner in Seattle with a special focus on chronic disease self management.

David Harlow: Right. So are there a handful of high return practices that you’ve been able to identify and roll out in your current practice location or would you say it’s more of a philosophy that you’ve applied to practice?

Alan Glaseroff: No. We basically — we’re well past philosophy and we have tools — team-based care. It’s using a model of continuous improvement within the clinic so that everyone becomes — using a Don Berwick quote, he says “People need to become citizens in the improvement of their own work.” And I think self-management is the similar idea that patients need to become citizens in the improvement of their own health — subjects rather than objects – and, well, too often they’re treated as objects by the healthcare system, and then ways of assessing patients to figure out both what they bring to the table in terms of their own level of activation and skill set and then also what they’re facing in their lives.

And if you put those two things together, you can design very specific workflows for patients that much better meet their needs than telling people what to do — which is usually the model of medicine practiced in the context of chronic illness.

David Harlow: That’s a very important point and I think that over time what we’ve seen around the country is that this is a pattern of behavior that people fall into — both clinicians and patients. So you clearly have been addressing this on the clinician end. Is this a difficult transition for patients?

Alan Glaseroff: Well that what we’re finding is our patients are the people who are the victims of this, and they’re very able to describe what’s been happening. And the turnaround is rather than focusing on our goals, and our goals might be improving your A1C or your blood pressure or your LDL or stop going to the emergency room as much or stop being admitted because those are the big drivers of cost, and our goals become what the patients’ goals are.

So we start every intake with: What bothers you the most? — and we don’t presume to know until we ask, and then by the end of it we of the intake, we ask people: If things went well what would it look like a year from now, what are your goals? And then our focus is really helping them achieve their goals, not ours. We find over time that the patients become more interested in our goals because we’ve been paying attention to their goals, and —

David Harlow: And I assume that by addressing their goals you’re meeting many of your goals at the same time?

Alan Glaseroff: Right, but if you start with your goals to people who have been perhaps ill-treated by healthcare or their lives in general, going back to childhood, you’re not going to succeed — they just — you’re just another thing to tune out essentially and not listen to. We talked about patients in denial and I don’t think that that’s really the right term. They’ve just taught themselves that it’s a better path to set aside those kinds of thoughts and go about satisfying their more immediate needs like eating and doing the things that they enjoy to do which often are not healthy things to do.

David Harlow: So what you’ve described is really a patient-centered approach to care as manifested in the care of chronic disease. Are there any other elements of this sort of patient-centered model that you want to add to this description?

Alan Glaseroff: Well, that the other thing is having the team. We use the slogan: “having the team and the time to do the right thing” and when you’re talking about patients that are costing a lot of money and the average patient in our program — I think the year before we saw them the average spend was about $58,000 a year in our system — you have a lot of room to do better if you create services that really meet their needs.

So our program is a team, not just a doctor; every patient has a care coordinator who is a medical assistant who has received more training — who has their own panels of patients. We have a licensed clinical social worker, a physical therapist who focuses on chronic pain, a pharmacist who is also a certified diabetes educator who — her job is treating to target by protocol. And then the doctor role is sort of organizing the team, treating the sick people, the acute illness, and then managing their specialty care which is another big source of spend where rarely do the patient’s goals surface during the interactions with the specialist.

So we actually at times attend specialty visits of high import either physically or virtually in order to make sure that we can represent the patient’s goals and issues to the specialist so that they can hone in on what the patient actually cares about.

David Harlow: Excellent.

Alan Glaseroff: That — for minute-to-minute savings return on investment, I think the time we spend managing specialty care is the winner of all the things that we do.

David Harlow: Do you address some of the rehospitalization issues, the readmission issues? Is that part of the specialty care?

Alan Glaseroff: Yeah very much. Readmissions is a subset of this work, and hospitals are the ones on the hook for readmissions unless a medical group is at full risk in an HMO arrangement or more and more ACOs are appearing where there is not full risk, but at least there’s interest in cost.

David Harlow: Yes.

Alan Glaseroff: And so that the groups are starting to be interested, but the hospitals have historically been the ones who are looking at healthcare reform and are worried about becoming the insurer for the patient for the first 30 days post-discharge, so they tend to look at it from what can we do to bridge the transition from hospital back to primary care to specialty care. And our focus is what happens even past then, but its not a bad model to go visit and meet a patient in the hospital, do a home visit a day later if they’re high-risk and then work on their activation around their condition so that they can be more effective self-advocates to get their needs meet down the road. So that’s essentially what I think the readmissions work is. And our experience says: don’t focus purely on the medical that really attended the psychosocial and environmental as well.

David Harlow: So that seems like an incredibly resource-intensive project though I imagine as you described that the payoff in terms of, both in terms of cost savings and in terms of improved experience for the patients the payoff is there. I’m wondering if the practice model that you describe is something that you see as scalable or transferable to other clinicians and practice sites? Is there, is there something aside from a binder full of protocols that folks would need in order to be able to move in this direction?

Alan Glaseroff: Well, if this turns into something that is unspreadable it has no value to us, I think, except for the small number of patients touched by it. So what we’re doing is — there are two fronts that we’re really making progress in this regard. One of which is that we’re faculty to a four state Medicare CMMI grant collaborative spreading this work that’s being led by the Pacific Business Group On Health and their name for it is the Intensive Outpatient Care Program. So there are multiple medical groups and insurers and hospital systems in Oregon, Washington, California and Arizona who are undertaking this work.

The ambition over three years is to reach 27,000 patients, which would be by far the most ambitious effort in this regard ever done if its successful and they’re using our model which is very satisfying on our end, and it does seem to be spreadable.

And then we also operate a team training center, so teams that want to engage in this work can come be immersed in our work for two days and then leave here having not just heard about it or receiving the binder as you’ve described, but experiencing the work and then we can supply support after that to help them get it up and running, and help problem-solve. There are a lot of problem-solving issues within institutions to get this work underway because it really is a — it’s a payment reform initiative. It’s a care redesign initiative. It’s a patient empowerment or activation initiative and all of these things are generally not funded in the current payment system.

David Harlow: I understand that you were involved in getting Humboldt County, involved in the Aligning Forces For Quality project under the Robert Wood Johnson Foundation.

Alan Glaseroff: Yeah I was Co-Director of that project and I actually still have that title.

David Harlow: Okay and that’s continuing that’s a long term effort, and I’m wondering if you could describe how your work sort of keyed in with the Aligning Forces for Quality approach?

Alan Glaseroff: My daytime job back when I was in Humboldt was split between working at a medical practice that my wife and I had for 30 years, and then being Chief Medical Officer of the county-wide IPA that did all the diabetes work. My wife was the Public Health Officer, so we were able to kind of bring the whole thing together. And the parts of the RWJ grant that really supported this work, AF4Q [Aligning Forces for Quality] were two-fold. One was a real investment in patients and what RWJ called ‘Consumer Engagement’ that allowed us to spread the chronic disease self-management program designed by Dr. Kate Lorig at Stanford widely across the whole community.

And I think we made a deeper penetration in the populations — those with chronic disease — than any other geography had ever done, and we saw tremendous results from that, and that was directly funding by Aligning Forces. And then we also were able to the Priority Care Initiative which was the same work we’re doing at Stanford Coordinated Care partnered with the Public Employee Retirement System in California and Anthem was the Insurance Administrative Services Organization. And that work was very, very successful and was supported to some degree by Aligning Forces.

David Harlow: Very interesting. So it sounds as if you’ve been addressing these issues for quite a while and that you’ve been working both with clinicians to train people to take this approach and working closely with patients as well to achieve a commonality of interest and really a measure of patient education in addition to clinical care.

Alan Glaseroff: Right. Well, generally patient education has been dispensed as a punishment to people not doing well. You know it’s like if you don’t behave I’m sending you to the principal. You know it’s kind of how and what we find is a lot of the patients who are in the lowly-activated group are people who didn’t know well in grade school and were punished a lot and very often — and this is very, very interesting kind of cutting edge work that we’re beginning to really focus on — they appear to have suffered an inordinate amount of adverse childhood experiences and it’s everything from abuse and neglect to sexual molest and having a parent in jail and a drug addicted or a substance abusing parents, and it’s all of the social disruptions that lead to a horrible childhood.

And what there’s an emerging area of research that’s really focusing on the adverse childhood events as causing metabolic syndrome which is the precursor of all of the Type II diabetes pain we’re seeing in society right now. So that becomes a very different mandate in terms of how do you approach such people and I’m hearing a phrase called Trauma-Informed Care that I think will be the area of the future in trying to understand why people don’t do everything in their power to live long and feel well which has been the source of ongoing frustration for medicine forever.

But as we become more shrill in our exhortations to patients, we find that we become less and less effective. And it’s only by turning the model on its head and asking people what they really care about that you can awaken people that have been mainly injured by their interactions with healthcare over the years.

David Harlow: Well, this has been fascinating. Thank you very much. I have been speaking with Dr. Alan Glaseroff, Co-Director of the Stanford Coordinated Care Clinic — and this is David Harlow for Diabetes Innovation.

Diabetes Innovation 2013