Health for the long haul: How GBMC is focusing on keeping patients healthy before they get sick

Dr. Robin Motter-Mast is excited.

Not only is she a practicing family medicine physician at GBMC Health Partners Primary Care - Hunt Manor, one of GBMC’s 12 primary care facilities, she’s also the healthcare system’s Chief of Staff and Medical Director of Care Transformation.

She’s excited because there’s a sea of change taking place in primary care, and GBMC is part of it.

Why primary care matters

In today’s fee-for-service model of healthcare, primary care gets short shrift. Well visits and prevention planning, which does not have to be done at a face-to-face visit, don’t typically involve a lot of reimbursement, but they are the foundation of a plan to improve and support a patient’s overall health.

“We pay for sick medicine,” explains Dr. Motter-Mast — meaning that doctors get paid for treating people who are actively sick. “We don’t pay very well, in our healthcare system, for keeping people healthy.”

As someone responsible for the care models at GBMC’s primary care facilities, Dr. Motter-Mast wants to change that. Instead of paying the specialist to treat someone with congestive heart failure, for instance, pay for the primary care interventions that could — and should — have come beforehand to prevent the heart failure.

These new value-based models of care are less focused on acute care occurring today, but more attuned to health outcomes, higher quality, better patient care and lower costs.

And those things matter.

According to one study, for every dollar spent in primary care, $13 is saved in the long run. That means primary care is a sound investment. It keeps people healthier by partnering with them in their care. And it keeps people out of emergency rooms, where up to two-thirds of the costly visits are avoidable.

What is advanced primary care?

GBMC practices advanced primary care, which is one of the reasons it’s recognized by the National Committee for Quality Assurance for having patient-centered medical homes.

The term patient-centered medical home (PCMH) refers to a practice where a patient’s team-based care and treatment is coordinated through their primary care physician. The physician works closely with an extended team of specialists and providers, resulting in patient care that goes beyond typical business hours.

“We’ve worked a lot in the last nine years to become more patient-centered and do a lot of care redesign within our primary care footprint,” says Dr. Motter-Mast.

A few key developments have made a difference.

• Electronic medical records. With its cloud-based EMR system, GBMC can share information seamlessly across its facilities, and patients can get streamlined care at whichever clinic or hospital or with whichever doctor is available to them. According to Dr. Motter-Mast, “EMRs have been a huge improvement in receiving information in a more timely manner, and being able to share the information in real time.”
• Telehealth. Using telehealth video visits allows you to talk with your doctor without leaving home. This is especially helpful for those who have mobility limitations. It also reduces the number of patients coming through the office and decreases the potential for inadvertent exposure of patients and staff to COVID-19. Dr. Motter-Mast encourages patients to utilize MyChart for their telehealth needs, and to call their doctor's office if they need help.
• Population health. There was a time when a doctor might not be able to answer a simple question like, “How many of your patients have uncontrolled diabetes?” The healthcare data that drives population health has changed all of that. “With population health, I can tell you exactly those statistics,” says Dr. Motter-Mast. “I can tell you how many patients you are caring for, how well you're doing with the care that you're delivering and how many of your patients have care gaps that need to be closed.”
• Team-based care. A decade ago, Dr. Motter-Mast practiced alongside a medical assistant and someone at the front desk. Now she works hand-in-hand with a social worker, a nurse care manager, a care coordinator, data analysts, a population health team, diabetes educators, and psychiatrists. “I have people and teams that are put together to try to help care for you even when you're not sitting in front of me,” she says.

Making a difference

The patient-centered approach is transformative, not just for the patient, but for doctors like Dr. Motter-Mast as well.

“You go into primary care because you really feel like you can make a difference,” says Dr. Motter-Mast. “You want to be ahead of the problem, not just treating someone who has an active medical condition. It’s about working with families, having long-term relationships with patients and impacting the well-being and health of your community.”