(Keith Brofsky/Getty Images)

Simmi Gandhi — a family nurse practitioner at South LA’s UMMA Community Clinic — is at work early. When she calls a patient, she apologizes for waking the woman up. But she knew the woman was waiting for test results.

In Urdu, she tells the patient her mammogram shows the mass in the woman’s breast isn’t cancer. After Gandhi hangs up, she doesn’t miss a beat: She starts debriefing for her next patient, who’s been missing appointment for months.

“Looks like he has diabetes,” she says. “I had asked for him to be able to get an appointment six weeks thereafter, so that was back in September. That was cancelled, and then he didn’t come for two appointments that were rescheduled. And now he’s finally back.”

Simmi Gandhi is what’s called a midlevel provider — which includes registered nurses, physician assistants and nurse practitioners. These are medical professionals who are in-between physicians and lower skilled medical technicians and nurses. At the UMMA clinic, she provides a wide range of primary care people in need.

“A community like this has less resources,” she says. “A lot of the folks that live here have less education as I’m sure everybody’s aware, our educational system is stressed so the basic education people get around their bodies … is low.”

UMMA clinic sees many patients who have diabetes and hypertension but don’t know how to deal manage their illnesses. Doctors often come at a premium in community clinics — where salaries are lower — so midlevel providers often shoulder the workload.

In an exam room, Gandhi examines her long-missing patient, Hamdi Badar, a 52-year-old taxi driver originally from Indonesia. He’s had diabetes years, but because he’s been AWOL from the clinic, it’s now out of control.

Gandhi reminds him what poorly controlled diabetes can do. “Sometimes that can mean that you get problems with your heart, right, you remember that?” she asks him. “With your eyes? With your kidneys?”

Gandhi seems to have captured Badar’s attention. “I didn’t realize it was so bad like that,” he says.

About 2,000 patients walk into UMMA every year. Simmi Gandhi sees up to four patients an hour. Without her and her fellow mid-evel providers, UMMA couldn’t care for as many people as it does.

Five minutes away, at St. John’s Well Child and Family Center, family nurse practitioner Alexis Gomez is checking up on 74-year-old Rafael Baez. He has high blood pressure, diabetes and a history of heart failure. So Gomez questions him in Spanish  about his diet. Are you eating a lot of tortillas? No, says Baez. How about fruits and vegetables. Yes, Baez says. Gomez tells him that’s good, because fruits and vegetables are important to his diet.

Gomez has an unusual vantage point. He was a doctor in Cuba and a midlevel provider in the U.S. He sees the importance of professionals like him to fill a yawning gap in primary care.

Gomez puts it in simple terms: If St. Johns’ midlevel providers played hooky one day, it would be “a disaster,” he says.

Dr. Padra Nourparvar is the lone doctor at the same St. John’s clinic where Gomez works. He agrees with Gomez and says there’s a “always a shortage” of primary care providers in their clinic.

But Dr. Nourpavar says that doesn’t mean mid-levels can replace doctors. He says that’ll be true even as the patient load swells next year with people who’ll gain health insurance under the Affordable Care Act’s Medi-Cal expansion.

“You cannot completely substitute physicians,” he says. “Because then the quality of the care can go down. You need … [some] people with more experience and higher education to also be involved, to make sure that the quality is not compromised.”

Back at UMMA clinic Dr. Felix Aguilar its president and CEO, disagrees. ”The future is not with physicians; the future of primary care will be with what we call mid-level providers.”

Listen to the story:

A demonstration of CareSimple’s virtual house call.

Remember the really old days of house calls? A kindly doctor with a black bag would come to your house and treat your (often minor) complaint?

Frankly, I don’t remember those days either. But I have heard of the house call, and now Carena, a Seattle-based company, is expanding into California with a 21st century house call — a virtual house call.

It works like this: like everything these days, you first create an account. When you need care, you log on and request a visit. Within 30 minutes, Carena says, a doctor or nurse practitioner will contact you by phone or email (your choice). If it’s email, you will get a link to a secure “virtual exam room.” (The man in the photo above is Dr. Ben Green, in a virtual exam room.)

From there you are diagnosed. If you need a prescription, CareSimple says its doctors are licensed in California and can phone in a prescription to your pharmacy. The service is $25/month with a $5 per visit fee. Or you can pay for a single visit, without the membership. That’s $85.

Carena’s CEO Ralph Derrickson says this kind of service is driven by several factors, not the least of which is technological advancement which permits secure video conferencing. But Derrickson also points out that the prevalence of high-deductible health plans, sometimes $5,000, makes a service like CareSimple appealing financially.

“The way health care is getting paid for is changing,” Derrickson says. “The reality is that what used to be a $25 co-pay, in 2013 is becoming a $250 encounter. … We’re less expensive and done on your terms.”

And a visit to the ER can easily run over $1,000, which Derrickson says CareSimple can help clients avoid. If not, and a CareSimple doctor or nurse needs to refer you to the ER, then there’s no charge for the CareSimple visit.

Dr. Sophia Chang is skeptical. She’s with the California HealthCare Foundation and a practicing internist at San Francisco General Hospital. She wondered if this was a higher cost version of the nurse advice line and fretted about continuity of care, something which is already a challenge in American medicine.

“It’s great to be able to answer primary style medical questions quickly at the convenience of the consumer,” Chang says. “The problem is that when it may be something that requires more than simple triage. There’s no mechnamism to link this to any testing. It’s all phone interaction or video interaction.”

Derrickson and Green say the company’s statistics show that more than 80 percent of the time, they are able to resolve a visit with advice or prescription.

Green says the company has been in business for several years in Washington state, and they’ve learned well what they can and cannot manage. “We’ve developed skills, we’ve developed clinical protocols,” he says. “Our providers are a local group that we train independently here, and we focus on all the conditions that we are safely and effectively going to manage.”

He specifies sinus infections, urinary tract infections, stomach viruses, flu and rashes, as common conditions CareSimple doctors can safely manage.

They say all the doctors with the service are board certified, and their patient satisfaction rates in Washington have been greater than 95 percent.

Dr. Peter Broderick examines a patient’s x-ray while family practice medical residents look on. (Rebecca Plevin/KVPR)

The Central Valley suffers from an acute shortage of doctors — especially primary care doctors — but a new type of residency program aims to bring relief. These new “teaching health centers” are funded by the Affordable Care Act.

This new approach contrasts with traditional medical residency programs, which are often based at university medical centers in large cities and encourage specialty training.

With the recognition that medical residents often stay where they are trained, the idea behind this new approach is to place these young doctors not in large hospitals but in community health centers where they will focus on primary care.

“The hope is that more of the graduates from these programs will stay in these underserved settings, will work in these community health clinics, and hopefully address some of the shortages that we have with that population,” said Dr. Peter Broderick, the CEO of Modesto’s Valley Consortium of Medical Education.

In 2010 Broderick’s group opened the state’s first “teaching health center” — the Valley Family Medical Residency Program. It has trained 12 doctors a year since then.

The teaching health center model is gaining traction. This summer, the Sierra Vista Family Medicine Residency Program will welcome its first four residents to Fresno. California’s third teaching health center will be located in Redding.

Still, traditional programs play a huge role in training the Central Valley’s future doctors. UCSF-Fresno remains the largest provider of graduate medical education in the Valley, including 12 family medicine residents each year.

Gene Kallsen, the assistant dean of UCSF-Fresno, says the university and the teaching health centers share the goal of increasing the number of primary care doctors in the Valley.

But, Kallsen explains, UCSF-Fresno is blocked from growing its residency programs to meet the region’s needs for primary care doctors. A major one, he says, is a convoluted system that ties — and caps — the number of medical residents to the number of Medicare patients at a hospital. Once that cap is set, it can’t be changed.

“One of the barriers is that programs like ours can’t grow unless we identify new sites,” Kallen said. “We can only get federal funding for so many residents, and we live up against that cap.”

That’s where new programs, like the teaching health centers, come in.

“We’re not trying to compete with UCSF at all, and we don’t want to have that perception,” said Norma Forbes, the executive director of Fresno Healthy Community Access Partners. Her organization partnered with Clinica Sierra Vista to launch its Medicine Residency Program.

“This is a different model that we hope will grow the number of family medicine doctors,” she says. “There is room for both types of training residents here in the Valley and across the country.”

Forbes said the program follows a curriculum similar to more traditional family medicine residency programs. But residents at the teaching health center will gain experience with a variety of patients and procedures, instead of specializing in one specific type of medicine. She drew a distinction between the care offered at a large university hospital’s outpatient — or ambulatory care — clinics and that of community health center’s primary care clinics.

“Those primary clinics are free-standing and they are really focused on prevention and wellness — and working with patients from birth to death,” Forbes says.”And when you get into ambulatory clinics associated with more urban environment hospitals, you run into the specialization.”

She is confident that the teaching health center model will help train more doctors who are dedicated to serving Valley communities and slowly remedy the region’s primary care doctor shortage.  She hopes all of the program’s residents will practice in clinics in rural areas of the Valley after they finish their residencies.

“Our goal is to get 100 percent of them, all four of them (each year),  staying right here, so we can truly increase the number of doctors through this residency program,” Forbes said.

The program currently has a three-year grant from the federal government.

Back at the teaching health center in Modesto, Dr. Broderick congratulated medical student Dr. Gewel de los Santos for helping a patient reach a healthy weight. She responded with outright enthusiasm.

Valley residents can only hope that more family medicine residents are as excited about practicing in the region.

(Mercy Health: Flickr)

All day, every day, people make medical choices that have repercussions for common yet dangerous conditions like asthma, heart disease and diabetes.  Although chronic disease takes a greater toll [PDF] on people with lower socioeconomic status, chronically ill patients are part of every community. In California and across the country, public health officials and physicians keep searching for the best way to get patients involved in improving their health.

Some patients naturally want to be involved with their care. Other times it’s doctors and nurses who must try to encourage more engagement by their patients. “Whether to exercise or change their diet, take medication,” Dr. David Thom told me recently, “those are the bread and butter decisions that go into primary care.”

Thom, director of research in the UC San Francisco department of Family and Community Medicine, is launching a new study, exploring how patients make decisions when they work with a “health coach.” Often health coaches are trained medical assistants who join the primary care team. “Our belief is that health coaches are going to have a fairly different relationship with patients than providers do,” he says. “Their role in helping the patients make decisions will be clearly different than the providers’ role.”

For example, coaches may help patients prepare questions in order to make the best use of limited face time with their doctors. Coaches might also accompany patients to appointments or help them navigate between multiple departments in a medical center.

Many coaches are bilingual and for Thom’s research some are already trained and in place. Mission Neighborhood Health Center and Southeast Health Center, both part of the healthcare safety net in San Francisco, will be the first sites studied. Coaches meet with patients and sometimes patients’ families, follow up on the phone, and sometimes sit in on appointments. They have access to the doctors and other members of the primary care team.

As part of the Affordable Care Act, the federal health care overhaul, patient engagement is linked to reimbursement for providers. Hospitals and outpatient providers alike have new incentives to successfully educate their patients and demonstrate that their patients are participating in their own treatment.  With a two-year grant from the newly formed Patient-Centered Outcomes Research Institute the UCSF researchers hope to discover which elements of coaching improve patients’ abilities to make medical decisions, improve clinical practice and improve the patient’s experience of care. 

And it’s not just safety net patients who can benefit from coaches. In the heart of Silicon Valley, researchers studied a group of patients to determine how confidently patients were engaged in discussing their care with their healthcare providers.

Nearly all the patients in this study by the Palo Alto Medical Foundation (PAMF) were well-educated and had health insurance. More than a third had a chronic illness. These patients could easily envision asking questions and discussing preferences with their doctors. About 70 percent said they preferred a shared decision-making role, one in which patients and doctors contribute equally to medical decisions.

But drill down a bit more and that shared decision-making gets more difficult. Only 14 percent of patients said they would “voice disagreement” with their doctor if their own preferences conflicted with the doctor’s recommendations.

According to PAMF researchers, patients want to participate with their physicians in decision-making, but worry they might be perceived as “difficult” and that their care in the future would be compromised.

Forget the future —  patients’ care might be compromised right now, if they disagree with a recommended treatment, but say nothing. “Reluctance to express disagreement in the office may correlate with poor adherence outside the office,” the researchers noted. ”The findings point to the need to test interventions that explicitly allow patients to voice disagreement with their physicians.”

Eve Harris is a Bay Area writer. Check out her health blog, A Healthy Piece of My Mind.

(Photo: Kaiser Health News)

Medicare provides free screening on more than a dozen primary care tests, but a new poll shows that seniors are not receiving the benefit. The poll comes from the John A. Hartford Foundation and looked at Americans age 65 and older.

The Foundation was interested in whether seniors had received seven services that would support “healthy aging” including:

• an annual medication review
• falls risk assessment
• screening for depression

Only 7 percent of seniors received all the seven of the recommended services. Just over half (52 percent) received none or just one.

It’s especially surprising that doctors aren’t engaging patients in these wellness exams, since they get paid more for them. Again, from Kaiser Health News:

Medicare pays doctors about three times their ordinary office visit rate for asking about older adults’ ability to function, evaluating their mood, recommending preventive services, and connecting them with community resources during wellness visits.

“These are low tech, low cost interventions that are easy to do and that can have a huge impact on an older person’s medical care and their quality of life and function.  But too many providers and older adults don’t realize they’re important,” said Dr. Sharon Brangman, chairwoman of the board of directors of the American Geriatrics Society.

You might think that this gap in primary care might lead to dissatisfaction. But no. A full 97 percent of seniors reported being satisfied (and 69% “completely” satisfied) with the care they received from their primary care doctor.

Meanwhile, in the comments section of the Kaiser Health News story, one person wrote that both sides need to step up: “…older persons need education on how to interact and bring these issues up,” wrote J. James Cotter, and “physicians need to make better use of health educators who could do much of this.” But how hard is it to make both of these things happen?