PHM, IDD Patients, and the Importance of Practical Approaches

PHM, IDD Patients, and the Importance of Practical Approaches


An organization’s computers may run on the most powerful software in the world, but if the servers aren’t plugged in, the system will be, shall we say…ineffective.

Same goes for the primary care provider office. That is, even with the right degrees and licensure, if staff isn’t “plugged in” before, during and after the patient sees the PCP, the whole concept of population health management can get thrown out of whack – especially for patients with intellectual or developmental disabilities (IDD patients).

Quite simply, everyone at the PCP’s office must be focused on patients to optimize value-based care, which is crucial when working with IDD populations. Further, staffers should be critical thinkers and have real-world experience to augment their professional credentials.

And the good news is that providers are making this transition.

What I’ve seen throughout my career working in both the private and public sector, and for insurers and providers alike, is that the “whole patient” concept works. And it’s the responsibility of the entire care team to promote wellness and preventive care, improve the quality of care, and work toward lowering unnecessary utilization costs.

So, what are some potential obstacles and practical solutions to ensure success with population health management?

Let’s start with reception. The front-line team plays such a crucial role when it comes to value-based care and communicating with patients, particularly when it comes to relaying patient complaints to providers.

For instance, if a patient is scheduled for an Annual Wellness Visit but tells the receptionist that they’ve been suffering from headaches, dizziness and blurred vision for the past few weeks, this needs to be documented so it’s the first thing the physician sees in his notes.

The patient may think that by telling reception about their symptoms, the physician will know about their complaints. But this isn’t always the case.

So, what’s the answer?

Make sure the front-line team is staffed with detail-oriented critical thinkers with good documentation skills. One of the primary goals of value-based care is to close communication gaps, and this is one of the simplest, most effective things a practice can do.

Yes, today’s PCP offices are complex operations. But despite the hustle-bustle, when a patient comes in, staff should know who that patient is, why they are in the office, and what to flag as important new information.

For another practical approach to addressing obstacles at the PCP’s office, let’s get back to the example of the patient complaining about headaches, blurred vision and dizziness, and say he’s an IDD patient that was properly flagged by the PCP as having neurological symptoms.

If the doctor refers him to both a neurologist and a psychiatrist, it’s the PCP office’s obligation to coordinate appointments, send reminders and work with social workers that offer support.

This is where the need for compassion comes into play. IDD patients will not always remember their medical appointments, arrange transportation or understand specialist office policies. Nor will they always understand what they need to do or how to navigate the system.

To improve patient outcomes, one-to-one support is critical; comprehensive communication with social workers is critical; and follow-up calls to transportation providers is critical. But above all, patience is required.

Everyone in the office needs to understand their roles and that they must take additional steps to ensure IDD patients get the follow-up care they deserve. In fact, it’s not just the right thing to do, it’s the law!

Lastly, in terms of hiring staff, PCP offices should screen applicants very carefully. While degrees and licenses are certainly important, a critical factor that PCPs should pay more attention to in the hiring process is the real-world experience that job candidates have. Potential factors to be considered include:

  • An applicant’s interest in a healthcare career, not “I need a job!”
  • Certifications in specialized areas of practice and years of on-the-job experience
  • Knowledge of Microsoft Office suite
  • Experience with EMR/EHR databases
  • Knowledge of payment and billing transactions
  • Look for applicants who ask questions about the provider and patient population

PCP offices are key elements of the healthcare landscape. And as the industry aligns with population health management, practical approaches will ensure their success with value-based care.