In Practice: Reflections from NPs and PAs

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

The Democratic National Convention is taking place at the time I’m writing this blog post. During an opening speech last night, the current First Lady referenced this phrase made popular by a former First Lady: “it takes a village.” I’ll pause here to say that I’m not going to get political in this blog — even though I might be getting a reputation for such topics (see here… or here). I do, however, spend a lot of my personal time these days watching MSNBC or CNN and the rest of the time keeping opinions about the 2016 presidential election to myself (unless you’re in my inner circle and then you might think it’s one of the only things we talk about lately).

Anyway, amid all of the discourse and rhetoric that comes along with the cycles of primaries, conventions, and debates, Michelle Obama’s reminder that “it takes a village” stood out to me this morning while I scrolled through my social media feeds containing snippets from last night’s convention. And this is because, whatever your politics, if you work in medicine in 2016, you understand this premise very well. Patients’ needs are increasingly complex, health systems and insurance companies have gotten larger, and everything seems interconnected. And because of these trends, in order to provide effective care, we need to identify patients’ needs, utilize the right resources, and build the best team for each patient.

Recently I needed to admit a patient to the hospital. She was reluctant to go, but her complex psychiatric, social, and medical needs made it clear to me that an admission would put her on the most efficient path to a comprehensive evaluation and a treatment plan. During my initial conversation with her, it became clear that I would lead the effort in getting her what she needed. Shortly after that, I began to identify those who would need to be involved for the greatest benefit to that patient. It started with the licensed clinical social worker who practices alongside me in our primary care setting. The patient had concerns and expressed anxiety, and therefore, as with all patients in our office who have behavioral health needs, I pulled in my colleague to assist in a way that only she can. The patient had already seen a specialist and another social worker within our hospital system, but since her hospitalization would focus on needs that they were currently addressing, it was clear that this physician and second social worker should be looped in. And thus, they became my second and third calls. Then there was the intake coordinator at the hospital, the attending physician who would receive my patient in the emergency department (a crucial provider based on her involvement in the transition from outpatient to inpatient and in prioritizing the patient’s needs), a third social worker who called me to get some background information, and finally a team of providers and nurses at the hospital during her several-day stay. The thing is, this doesn’t really begin to scratch the surface of the people who touched this patient’s journey. Other players include administrative staff who coordinate scheduling for the patient, those providing ancillary services (from chaplaincy to nutrition services), billing coordinators who ensure that services rendered are paid for by insurers, family members who provide support… the list goes on and on.

There is a lot of talk about redesigning health care, and a focus on primary care in general. Patient-centered medical homes, accountable care organizations, and other constructs are swirling around in the healthcare atmosphere as potential solutions to streamlining and improving care. It would take nearly all of my spare time (i.e., less time watching “Meet the Press” and “Morning Joe”) to become an expert on the particulars of these healthcare innovation models, and no one can predict which models, in what forms, will be implemented in the future (we have less polling data available here than for the presidential candidates). However, I do hope that whatever the future of healthcare looks like, it will emphasize the need for inclusive and well-integrated care teams. This is especially important in an age when we are also focusing on how to reduce healthcare costs. The truth is that almost all patients require more than a single provider to serve as their diagnostician, advisor, historian, advocate, and coordinator. More often than not, it really does take a whole village.