Ochsner 65 Plus: Restoring the Joy of Practicing Primary Care

The ability to serve as the first point of contact in a patient’s care and to deliver coordinated, comprehensive and continuous care—as well as cultivate meaningful relationships over each patient’s lifetime—used to be the hallmark of primary care. However, as demands on primary care providers have increased—including larger patient volumes, additional metrics and administrative burdens—many PCPs are experiencing burnout or “moral injury,” according to Kenny Cole, M.D, System VP of Clinical Improvement and an internal medicine physician at Ochsner Health.

“It started to feel like there weren’t enough hours in the day, that no matter how fast I was running, I couldn’t keep up,” Dr. Cole says. “I was always saying I’m sorry. I’m sorry I’m running late, I’m sorry I couldn’t get you in sooner, I’m sorry it’s taken five days to get you your lab results. The mission of primary care is so ideal and so noble, but when all you have is 15 minutes to see a patient, there is not enough time to think about and diagnose complex issues or develop relationships. Because of this mission failure, there is more PCP moral injury, there are more PCPs leaving the practice and there are fewer medical students choosing primary care.”

One study that really brought the issue home, according to Dr. Cole, noted that it would take a PCP 27 hours to complete all of the recommended preventive, chronic and acute care, and documentation and administrative tasks expected of them in a day. But that same study also showed there is a remedy: team-based care.

That led Dr. Cole to design and help develop Ochsner 65 Plus: freestanding community clinics built upon a foundation of value-driven care. These clinics take a team-based, holistic and proactive approach to care for a population that needs more care, frequently presents with more complex issues, and benefits from more time with providers.

The 5 M’s of Taking Care of Older Adults

The Ochsner 65 Plus clinics are built around the “5 M’s” of taking care of the senior population: mobility, mentation, medication management, what matters most to each patient, and multi-morbidity, according to Dr. Cole.

“Here, they’re not just seeing a PCP; they’re surrounded by an interdisciplinary care team,” he says.

That team typically includes physicians, advanced practice providers, RN care managers, medical assistants, health coaches, licensed clinical social workers, dietitians, fitness instructors, clinical pharmacists and physical therapists. The care team provides patients with physical, mental and social care.

Patients benefit from extended time with their physicians and custom care plans that focus on the “5 M’s.” They have full access to workout equipment, dedicated staff and exercise classes offered in the 65 Plus fitness center. Social and educational activities are available daily in the 65 Plus community room.

“I believe the most important thing we’re giving patients and physicians is more time,” Dr. Cole says. “We have time to think through diagnostic complexity and detect issues at a point where we can intervene clinically and therapeutically to prevent complications. All patients, at least once a year, get a ‘Timed Up and Go’ test and a 30-second sit-to-stand assessment. Immediately following those assessments, we can connect patients with physical therapists or fitness instructors and get them in the gym to prevent a potentially hip-fracture-causing fall.”

What Is the Ochsner 65 Plus Clinics’ Formula for Success?

Offering a differentiated primary care experience for people aged 65 and older, these clinics have a high growth potential through multichannel marketing. Clinics educate Medicare-eligible patients about the advantages of Medicare Advantage plans and value-based healthcare delivery, which benefits payers.

Physicians and other care team members spend more time with patients—because no provider’s patient panel size exceeds 500 patients. The team creates customized, goal-oriented care plans for each patient, then follows up to evaluate. A "worry score” is assigned to each patient and reevaluated at every visit to ensure patients are receiving the right level of care, timely follow-ups and other appropriate outreach.

The clinics achieve high HCC recapture rates through coding and documentation excellence, prompting gap closures and high-quality patient experiences. Total cost of care is reduced through health outcome improvements and avoidance of inappropriate use of emergency departments and hospital readmissions.

“It’s a unique model of care that can be scaled and replicated in other markets,” Dr. Cole says. “We seek to deliver a very patient-centered experience, focusing on what matters most to each patient and their individual health-related goals, as well as how to overcome obstacles to achieving those goals.”

Ochsner 65 Plus clinics also offer education and guidance about advanced care planning and end-of-life care to ensure patients’ wishes are honored.

Designed to Promote the Best Possible Patient Outcomes

Even the clinics’ interiors feature an intentional, patient-centered design. The lighting and flooring chosen for each location reduce glare that may mimic holes or obstacles to aging eyes and create a tripping hazard. Handrails along the walls further reduce the risk of patient falls.  

There is a clear focus on fitness, nutrition and holistic health, with resources available to help patients improve everything from their heart health to their balance.

“The community room is very intentional, because the only risk factor that’s a more powerful predictor of morbidity and mortality than social isolation and loneliness is cigarette smoking,” Dr. Cole says. “Everything offered there—from arts and crafts, to card games, to healthy cooking demonstrations and educational sessions—is focused on improving the health and well-being of our patients.”

Improving Performance, Patient Experience and Physician Satisfaction

Ochsner 65 Plus clinics measure their success by maintaining their targeted patient panel sizes and reducing readmission rates and emergency department utilization.

At this point, patient experience scores in the clinics are in the 90th percentile, greater than 76% of patients have their diabetes under control and greater than 82% have high blood pressure under control. Completion of annual wellness visits exceeds 80%, and the HCC recapture rate is greater than 86%.

“Essentially, what we are trying to do at these clinics is allow PCPs to connect with a deep sense of purpose about why they went into primary care in the first place and to deliver incredibly coordinated, team-based, comprehensive and continuing care,” Dr. Cole says. “This reduces the burden of moral injury and restores the joy of practice to provider and offers patients opportunities to achieve their best possible outcomes.”

Ochsner 65 Plus clinics are now open to serve older adults in Covington, Baton Rouge, Metairie, Pensacola and Ridgeland, and more are planned in coastal markets in the Carolinas, Georgia and Florida. If you are interested in working with Ochsner 65 Plus in one of those markets, or know a primary care physician who might be, reach out to Rachael Kermis, M.D, System Medical Director for Ochsner Health 65 Plus, at rachael.kermis@ochsner.org.