Provider Spotlight

We sat down with Dr. Jonathan Arend, an internist at Mount Sinai Doctors Internal Medicine Associates (IMA) to discuss innovative models of care and leveraging a variety of care team members to address complex patient needs, meeting quality performance standards, and successfully implementing change in a practice.

Could you tell us about your current role and how you got here?

I did my residency at Montefiore in the Primary Care Social Medicine Program. After my residency, I worked at Union Health Center in Chelsea with a primarily immigrant population where I had the opportunity to experience some new and innovative care models. Because the union was self-insured and assumed the total cost of care for the population, they were only concerned about keeping patients healthy and out of the hospital. So it didn’t matter how many patients we saw or how many tests we ordered, only the quality of care we provided. That meant that we had a lot of freedom to do creative things that aren’t traditionally paid for by insurance companies, such as health coaching and care coordination. What was particularly innovative was our empowerment of medical assistants to perform most of these tasks. For example, my patients would often come to the clinic just to meet with my MA for teaching and goal setting around chronic diseases like diabetes,

After a few years of practicing full-time, I decided I wanted to branch out a bit — into both administration and teaching related to alternative models of care. Today I continue to work as a clinician, I teach in the internal medicine residency program, and I have administrative roles both in IMA and across the health system, focusing on quality improvement and population health. So, for example, I help lead initiatives to optimize performance on preventive care, chronic disease care, rates of avoidable hospitalizations, and unnecessary use of other high cost health services

What’s your practice like?  What does your staff structure look like?

IMA is not a typical primary care setting. We have over 130 residents, who see the bulk of patients, and they’re supervised by upwards of 30 faculty members. Everyone is part-time. So it’s a complicated staffing structure, which poses unique challenges. But over the years, we have worked very hard to adapt our processes to address some of these challenges.

Residents are here for two weeks and then off for six weeks, so we really have to prioritize venues for communication and protect time for team meetings and huddles. We have nine teams of residents that rotate through, and each team has their own social worker and care coordinator. The care team meets every Monday morning to look at the patients scheduled for the week and to try to anticipate their needs. They also spend that time looking at their quality data so they can see how they are doing with meeting the needs of their patients, both as individual providers and as a team. Connecting patient-level planning with our quality performance drives home the point that we’re accountable for outcomes, not just patient visits. Over time, this has created a culture of quality and accountability.

In addition to working closely with social workers and care coordinators, we are continually finding ways of leveraging the skills of other members of the care team, such as clinical pharmacists and medical assistants.

Can you tell us how you incorporate clinical pharmacists into your practice?

Working with an embedded clinical pharmacist was completely new to everyone here.. Before she joined the practice, we assumed she’d be a good resource to answer medication questions, but we’ve come to find out she can be a tremendous help with a wide array of issues. In addition to medication management, she works with patients with chronic diseases on lifestyle management. She follows patients over the phone and conducts home blood pressure monitoring. She acts as a liaison to community-based health coaching programs. She manages an interdisciplinary outreach team to improve medication adherence. She has provided training to nurses and other staff members. And she coordinates a number of quality improvement projects.  

I had one patient who had poorly controlled blood pressure, diabetes, and back pain. Every time she came in, we would deal with the diabetes and back pain and then before I knew it, there was no time to address the blood pressure. This is a great example of how a pharmacist can be helpful — one day, I sent her a quick message while the patient was in front of me, she took the patient back to her office, did some health education, and began looking over all of her medications. She then spent time working with her over the next several weeks, mostly by phone. This patient was on a lot of blood pressure medications, some of which she was taking and some which she wasn’t. The pharmacist was able to dive into why the patient wasn’t taking her medications, switched her to combination pills to simplify her regimen, set her up with home blood pressure monitoring, called her every week to follow up on the readings and adjust the medications, and referred her to YMCA’s blood pressure self-management program. Since then, my patient’s blood pressure has been completely controlled.

Tell us more about how you incorporate MAs to your practice. What kinds of tasks do MAs perform in your practice that may be outside traditional MA duties?

At Union Health Center I came to appreciate the potential of team-based care and have incorporated some of those practices here. We have put a great deal of work into making sure that all members of the care team are working at the top of their license. MAs currently perform a number of task that would have been unheard of here in years past. For example, when we first became an ACO, providers were expected to administer fall risk screenings, so we created a best practice advisory, which is a prompt in the EMR to administer a questionnaire to patients. Compliance with screening was static at j around 30-40%. We recognized that with increasing demands to perform on quality metrics, tasks like this really added to the physician’s workload, so we decided to have our MAs do this while taking the patients’ vital signs.  If patients screen positive, a second BPA is triggers, which alerts the provider. Six months after transitioning this duty to the MAs, compliance was 75%. This is one of many screenings the MAs regularly perform , and we’ve since expanded their scope to include more complex tasks such as , retinal photography for diabetic eye disease screening. The key to ensuring the success of efforts to expand these types of roles is not the technical training; it’s culture change.

What advice would you give to the small private practice physicians who are looking to optimize their staff and workflows?

Start with the resources you have right in front of you and make sure you’re using them in the smartest way possible. Beyond that, I’d look to redesigning workflows. Oftentimes we have inefficiencies in the way things are carried out in the practice that can be corrected. And although every clinical setting is different, identify best practices from others and think about how they can be applied to your practice. Again, the most important aspect of practice transformation is culture change. All members of the care team must be willing to reconsider traditional roles and think creatively about how to work together to achieve the best possible outcomes for their patients.

If you are interested in being featured in the MSHP Provider Spotlight Series, please contact Tiffany Cheng at Tiffany.Cheng@mountsinai.org.

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