LOS ANGELES — The common refrain about health care is that it's a broken system. A new joint program between the University of California, Los Angeles (UCLA) and the University of Southern California (USC), demonstrates a way to mend the system with a new patient-centered program that is getting raves from patients, as well as the residents and nurses who provide their care. Results from the program are highlighted in a study being released in September.
The program, Galaxy Health, debuted at Los Angeles County + USC Medical Center (LAC+USC) in 2012 with a goal of substantially improving a clinic for medical residents there and demonstrating to county officials how some intuitive and inexpensive interventions could dramatically improve patient care and physician and staff morale.
A UCLA/USC study published online Sept. 2 in JAMA Internal Medicine outlines how the Galaxy model works in a public setting.
"My hope was that Galaxy would reveal that a minimal investment and reorientation in delivery focused on the patient and enhanced access to care could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment," said David Goldstein, M.D., associate professor of clinical medicine at the Keck School of Medicine of USC and chief of the division of geriatric, hospital, palliative and general internal medicine at LAC+USC Medical Center, who conceived the Galaxy Health program. "I think it worked out well. It's not rocket science."
Goldstein was senior author on the study, which demonstrated a favorable effect on both patients and medical residents.
"We all know that fewer and fewer young physicians are choosing careers in primary care because of the difficult work schedules, lack of support and lower salaries," said Michael Hochman, M.D., the study's lead author, who conducted the research as a Robert Wood Johnson Clinical Scholar at the David Geffen School of Medicine at UCLA's division of general internal medicine and health services research. "What we did here was to move in the direction of a team-based approach and it resulted in improved satisfaction for physicians in training with their primary care experiences."
The Galaxy model established round-the-clock, seven-day-a-week access to physicians, urgent clinic appointments available within hours and coordinated care in the ambulatory environment. It was based in part on increasing interest in a concept known as the patient-centered medical home, which provides a team-based, coordinated approach to care aimed at making the primary care team central to the patient's health needs. While the concept may not sound that different from the traditional vision of high-quality primary care, Galaxy's innovation is making this vision a reality in a complex, disconnected health care system.
"Galaxy Health has proven its value and effectiveness, as measured by patient satisfaction, access to care, and provider satisfaction, in an incredibly challenging clinical environment," said Christina Ghaly, interim CEO, LAC+USC Medical Center. "Its remarkable success is to the benefit of our patients at LAC+USC Medical Center and can be a model for other safety net resident-run clinics struggling with implementing patient-centered medical homes."
The project was funded primarily by a three-year, $750,000 grant from UniHealth Foundation.
The study findings also support further investment in primary care, particularly in teaching settings where the next generation of primary care leaders will be developed, said Hochman, now the medical director for innovation at AltaMed Health Services, a large federally qualified health center in Southern California. There is now a shortage of primary care physicians, and the situation is expected to become more acute as baby boomers continue entering retirement age.
The researchers conducted their study at three primary care internal medicine clinics at LAC+USC, an urban academic medical center serving a safety-net population. They focused on expanded access to care, enhanced care coordination and team-based care. Galaxy Health included creation of a call center staffed by two care coordinators, telephone renewal of prescriptions, and up to five urgent care appointments available each day.
Input from patients and staff during prior focus groups was incorporated into the study. The researchers surveyed patients and residents before the intervention and again one year later. They also analyzed emergency room and hospital visit rates.
Though the clinics did not pass all the elements needed to qualify as a patient-centered medical home, overall their score jumped from a previous 35 to 53 out of 100 possible points. The satisfaction rating from patients increased from 48 percent to 65 percent in the intervention clinic compared with a jump from 50 percent to 59 percent in the controls. Patients were particularly pleased with access. Satisfaction with urgent appointment scheduling increased from 12 percent to 53 percent in the intervention clinic vs. 14 percent to 18 percent in the control clinic.
The composite satisfaction score for residents went up from 39 percent to 51 percent in the intervention clinic, but fell in the control clinic from 46 percent to 42 percent.
The study noted that emergency room and hospital visits were not reduced.
"This was an anticipated finding because we expanded access to care to an underserved patient population, and frequently when this happens there's a spike in emergency and hospital room utilization," said Arek Jibilian, M.D., assistant professor of clinical medicine in the Keck School division of geriatric, hospital, palliative and general internal medicine and a study co-author. "However, we believe that a sustained commitment to primary care will ultimately reduce emergency and hospital utilization and this is something we hope to see as the program continues."
Study co-authors are Steven Asch, Arek Jibilian, Bharat Chaudry, Ron Ben-Ari, Eric Hsieh, Margaret Berumen, Shahrod Mokhtari, Mohamad Raad, Elisabeth Hicks, Crystal Sanford, Norma Aguirre, Chi-hong Tseng, Sitaram Vangala and Carol M. Mangione. Additional contributors include Becky O'Neal and Roman Corral.
The demonstration was primarily funded by the UniHealth Foundation in Los Angeles. In addition, grants from the Robert Wood Johnson Clinical Scholars Program, the U.S. Department of Veterans Affairs (grant 67799 to UCLA); the UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684: and the NIH/NCATS UCLA CTSI (grant UL1TR000124) funded this study.
Article cited: Hochman, M., Asch, S., Jibilian, A., Chaudry, B., Ben-Ari, R., Hsieh, E., Beruman, M., Mokhtari, S., Raad, M., Hicks, E., Sanford, C., Aguirre, N., Tseng, C., Vangala, S., Mangione, C.M., Goldstein, D.A. JAMA Internal Medicine. Published online Sept. 2, 2013; doi: 10.1001/jamainternmed.2013.9241
ABOUT THE UCLA GENERAL INTERNAL MEDICINE AND HEALTH SERVICES RESEARCH DIVISION
General Internal Medicine and Health Services Research is a division within the Department of Medicine at the David Geffen School of Medicine at UCLA. It provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division's 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor/patient communication. The division's researchers have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp and Charles Drew University.
ABOUT THE KECK SCHOOL OF MEDICINE OF USC
Founded in 1885, the Keck School of Medicine of USC is among the nation's leaders in innovative patient care, scientific discovery, education, and community service. It is part of Keck Medicine of USC, the University of Southern California's medical enterprise, one of only two university-owned academic medical centers in the Los Angeles area. This includes the Keck Medical Center of USC, composed of the Keck Hospital of USC and the USC Norris Cancer Hospital. The two world-class, USC-owned hospitals are staffed by more than 500 physicians who are faculty at the Keck School. The school today has more than 1,500 full-time faculty members and voluntary faculty of more than 2,400 physicians. These faculty direct the education of approximately 700 medical students and 1,000 students pursuing graduate and post-graduate degrees. The school trains more than 900 resident physicians in more than 50 specialty or subspecialty programs and is the largest educator of physicians practicing in Southern California. Together, the school's faculty and residents serve more than 1.5 million patients each year at Keck Hospital of USC and USC Norris Cancer Hospital, as well as USC-affiliated hospitals Children's Hospital Los Angeles and Los Angeles County + USC Medical Center. Keck School faculty also conduct research and teach at several research centers and institutes, including the USC Norris Comprehensive Cancer Center, the Zilkha Neurogenetic Institute, the Eli and Edythe Broad Center for Stem Cell Research and Regenerative Medicine at USC, the USC Cardiovascular Thoracic Institute, the USC Eye Institute and the USC Institute of Urology.
ABOUT THE ROBERT WOOD JOHNSON FOUNDATION CLINICAL SCHOLARS PROGRAM
For more than three decades, the Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policy-makers on issues important to the health and well being of all Americans. This program is supported in part through collaboration with the U.S. Department of Veterans Affairs.
JAMA Internal Medicine