Every clinical encounter begins with the taking of a patient history. But what sort of patient history do we use? American carers are increasingly acknowledging the needs of the whole patient in planning their care.
A number of the federally qualified health centres I have visited begin their patient interaction with the usual questions, weights and measures (collected by Medical Assistant of course). However, acknowledging the role of the mind and environment on health outcomes, they are also administering a depression and anxiety scale before the Doctor or Nurse Practitioner sees every patient. This enables the primary care team to draw in the “behaviouralists”, as they like to call them, as required.
In Albuquerque, they go one step further. Their intensive care program is now running from six sites in support of the most disadvantaged and multi-morbid patients. Every team includes a Community Health Worker. Many have come from poor backgrounds and started in healthcare as Medical Assistants via an eight week training program. The sparky ones have been isolated and trained via a three to five month, predominantly workplace based, training program. It begins with a three day intensive followed by two hours a week on video link. What does a CHW do? They address many of the social determinant of health holding patients back eg housing insecurity, access to poor nutrition, lack of insurance enrolment and social isolation. Mostly, their role is to build a relationship with the patient and their social supports and understand the background which has led to the current circumstance.
Yesterday I listened to a video case conference regarding a 29 year old with a tragic history. Left on a trash can lid at his father’s work the day he was born, the CHW talked of his “personal narrative of abandonment”. This was drawn out when attempting to design a program of engagement for his many serious chronic conditions. The participating specialty team inclusive of psychiatrist, endocrinologist, nephrologist, general medicine physician, internist and nurse practitioner all discussed his treatment plan with his social circumstance and relationship with his local care team as the underpinning framework for resolution. The role of the CHW? To keep building trust on a daily basis, find options through his social circumstance and provide the glue the rest of the clinical team needs to arouse interest in health for this patient.
Kaiser Permanente, one of the largest American insurers, screens all of its patients using a seven factor tool. Weighted insurance payments are provided to support higher levels of care for anyone who has any of the following in their history:
- mother was subject to beatings
- imprisonment of any member of the immediate family
- mental illness in any member of the immediate family
- sexual abuse
- physical abuse
- emotional and other forms of neglect.
If more than one of these elements is mentioned, the insurer knows the risks of poor adult health multiply. Why? Many studies have shown these folks are much more likely to engage in risky behaviours, seek immediate gratification and fear social exclusion, even if their associates are acknowledged as dysfunctional. So where is our similar approach to stratifying patients, even those from wealthier backgrounds, whose outcomes are just as bleak if their history includes the above risk factors? Where are our Community Health Workers? The University of New Mexico is training over 300 CHWs per year on behalf of organisations across the country. Many jurisdictions are recognising that medicalising social issues is an expensive and ineffective way of delivering outcomes. Most importantly, these jurisdictions are recognising that only by bundling social care into health care will the efforts be financially sustainable. When will such insights reach Australia?
Tracey Johnson, General Manager, Inala Primary Care