Wednesday, August 13, 2014
The urgencies of care: here, there, and everywhere
The New York Times just devoted a particularly prominent portion of its rarefied real estate to the issue of urgent care delivery outside of its traditional domain. The article in question was housed in the Times’ “Business Day” section, and reasonably so. Julie Creswell, the author, referenced a market of $14.5 billion that is growing briskly. So business it is, and big business at that.
But it is, of course, also my business, and yours, because it represents an evolution in how so-called “health care,” or more correctly injury, illness, symptom and disease care, is rendered. On any given day, it could be you, or me, or someone we love who has need of this changing system. That invites us to ask: are the changes good? Are there associated perils?
Naturally relevant provisos will follow, but I can provide the basic punch line right away: the changes are indeed good.
Access to care is an important element in the quality of both health care, and the overall public health. All too often small problems neglected for a while turn into larger problems. Barriers to care propagate just such costly misfortune.
Even if everyone had a primary care provider, and of course not everyone does, there would be barriers to walk-in treatment. Some practices are able to carve out time for walk-ins, but many have patients booked from open to close. There is no place in such practices for the unscheduled laceration or migraine. I worked in primary care internal medicine for roughly 15 years, and none of my practices comfortably accommodated unscheduled patients.
The traditional alternative, of course, has been the emergency department. The liabilities of that approach are mostly self-evident. A laceration of a finger, or a recurrence of migraine, and the innumerable variations on this basic theme, are urgencies, but not emergencies. In any given busy ER at any given moment, there may be heart attacks and strokes; seizures and gunshot wounds. I worked for some years as an emergency physician, notably to support my family while completing my preventive medicine residency, and there were times when the place was packed with people trying to die in various ways all at the same time. My job was to prevent that, and that put lacerated fingers way down my priority list.
But that was likely poorly received by the unfortunate soul with the cut finger who waited five hours to get the requisite 15 minutes of care needed to sew it up.
The time-honored approach to this has been an area of emergency departments dedicated to less emergent need. The urgent care movement likely traces its origins to emergency department triage to either the main area of blood and guts, life and death; or the suite of exam rooms devoted to lesser crises. Put that suite of rooms for lesser crises in a space all its own and the urgent care center is born.
Triage is the essential matter here. One potential hazard of urgent care centers is that a true emergency could turn up at the door, and the resources on hand might not be inadequate to deal with that. All such centers should have someone capable of triage serving as the receptionist. That would allow for a swift redirect to an emergency department when warranted. Such cases should be rare, and efforts to educate the public on the distinctions between urgencies and emergencies should make them that much more so.
Another potential concern about urgent care centers is that they will tend to rely on the cost-effective care of so-called mid-level providers, namely physician assistants and nurse practitioners. I have worked closely with both PAs and NPs over the years, and this doesn’t worry me at all. My mid-level colleagues have mostly been excellent. Like all of us in medicine, they need to be acutely aware of what they don’t know, so they get help when help is needed. But that is just as true of us physicians. The scariest thing to me in all of medicine is the practitioner who thinks they know more than they do, whatever alphabet soup follows their name. The evidence is clear that much basic medical care, and particularly the kind of care that fills up urgent care centers, can be delivered very ably, and at lower cost, by non-physician providers.
So what we have so far is one potential liability: people could wind up at an urgent care center who really ought to be at a hospital. But without recourse to an urgent care center, those folks might just wait it out at home, where they would likely be worse off by far. Capable triage and efficient referral at all urgent care centers turns this liability into an asset.
Other assets are quite clear. Urgent care centers can reduce wait times and costs. They can let emergency physicians focus on emergencies, and primary care providers focus on the scheduled visits of longitudinal care. I think stand-alone urgent care centers are a growing trend for good reason.
But a focus on urgent care networks only in the context of historical “health care“ delivery is limited; they have the potential to go beyond it. I know, because I have been privileged to participate directly in one such innovation.
RediClinic is a network of clinics providing routine, sub-urgent care on demand. They are unique in many ways, the most obvious being location: they are housed in supermarkets throughout Texas.
The provision of sub-acute care in a setting as heavily trafficked and generally convenient as a neighborhood supermarket is rather innovative in its own right. But the RediClinic leadership had an epiphany some years ago about going beyond health care to the general care of health. The idea was to establish a clinician-guided weight management program that could be offered right in the very supermarket where clients would be shopping for food.
When this idea was brought to me, I loved it, and the rest is history. I worked with RediClinic to develop the Weigh Forward program, which has gone on to be the first weight loss program formally certified by the American College of Preventive Medicine. It is also among the reasons why RediClinic was recently acquired by Rite Aid, raising the prospect of rapid expansion of Weigh Forward into a program available nationwide.
I know this example best because of my direct involvement in it, but I can think of many others. Treatment centers for sport-related and orthopedic injuries might be housed in or near fitness facilities. Perhaps care for sleep disorders could be housed in or near mattress stores. Easy access to mental health counseling might prove both beneficial and cost-effective in high-stress worksite settings.
Increasingly, we have access to urgent and sub-urgent disease and injury care here, there, and everywhere. Done right, this is distinctly advantageous. But the next great frontier in health care is exactly that, the care of health, rather than the treatment of established disease. There is an urgent need for more of that as well- with a particular emphasis on the 6 factors known to be most influential on overall health and well-being: tobacco use, dietary pattern, physical activity, sleep, stress, and social connections.
Urgent care centers can also figure among the health care innovations that direct clinical resources to support lifestyle as medicine. They can and they should, because it is an area of both great opportunity, and considerable urgency—and everybody’s business.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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