Episode 34: Managing Innovation in Primary Care ft. Nic Nguyen, MD

Speaker A: Hello, and thanks for listening to Healthcare360, a, uh, podcast by Beth Israel Leahy Health. I'm, um, Rob Fields, the Chief Clinical Officer. We took a little bit of a break over the fall for the holidays, let people regroup. But we're back in the new year, and I'm very excited to have a good friend and colleague, Nick Nguyen, joining us today for starting the new year. So welcome, Nick.

Speaker B: Thank you so much. It's a pleasure to be here.

Speaker A: Yeah. So, Nick, for those of you that are not part of the Beth Israelihi system, is an unbelievable leader in our, uh, system and has done, um, just a tremendous amount to contribute to primary care and some bunch of exciting things that we're gonna talk about today. So welcome, Nick, and tell us a little bit about your journey, if you will, like what brought you here and why you do what you do.

Speaker B: Yeah, absolutely. So thank you for that introduction, those kind comments, and, you know, I'll preface by everything that we do is a product of the team. So I'm only here because of the team that I work with and the people that I connect with. But I am a family physician by training, tried and true, and I honor that. And I continue to practice at this point, but I've also now become the chief medical officer for primary care, as well as the interim chief medical officer for the medical group. And I know we probably will talk about that a little bit later. My trajectory to this place, to this role, was not a, uh, straightforward one. I never thought that exactly. I never thought that I would be in leadership. I started off my career in academics and. And then went into practice for Beth Israel, starting a practice de novo. And my heart was, and still is in providing care to patients. As time went on, I realized that I could help people, uh, beyond the practice. Another practice, another team, another region. And that just sort of grew over time. Whatever best practices we found in terms of forming a culture, a team, a community within a, uh, healthcare setting, we were able to expand that. And as time grew, we were able to do that for the entire care team and call that care team experience, and to link that to clinician experience as well as patient experience, which is all linked. We will probably dive into that a little bit in a second, too, and slowly trickled my way to becoming an ACMO and then a cmo. At the end of the day, what drives me in this role is the fact that I can still advocate and help, uh, the people at the front lines and connect that to the decisions we make as leaders in an organization. To ensure that we can be the best that we can be in this market, this challenging market for our patients, their families, the communities, as well as our hard working care teams.

Speaker A: Yeah, it's not an easy task. You know, I think primary care in general, I mean, as you know, family doc, myself, and I mean even going back to training, even back to med school, I remember sitting with my dean of student affairs at the time and saying, why are you going into family medicine? You know, it's a waste of your brain and all that stuff.

Speaker B: Sure.

Speaker A: I know I wasn't alone in that type of advice or guidance. So you're starting off from that sort of mindset.

Speaker B: Yeah.

Speaker A: Where you have folks that when they do primary care, selecting for folks that often just really want to do it, they feel it sort of as an integral part. How has that been for you personally? And also, what do you observe in the folks on your team, the docs and apps on your team that are doing primary care? How does that sort of affect them in their daily life in terms of. Feels like they're fighting upstream sometimes?

Speaker B: Yeah. I think a lot of primary care clinicians, whether they're physicians or apps, probably had similar experiences to what you mentioned, which is they might have been subtly or overtly discouraged from going to primary care. I think that guidance, it doesn't come from a bad place. You know, I think people recognize that primary care is difficult and historically has been undervalued by the system, by organizations and maybe even by the community that I think by the US health system. Yeah, exactly. Yeah. And I think that's changing over time. And one of the things that our organization, bilh, has done well and could continue to improve on, but has done well, is to make clinicians that are in primary care feel valued. And that shift, I think will help people go into primary care, primary care more and does help people in our organization at the front line feel like, okay, I made the right decision by going to primary care despite any advice I might have gotten before because I am in an organization that says, you know, the majority of the care that we're going to provide by 2030 is in the community and the DNA and infrastructure of that care is primary care. So it is challenging. And we could talk about the challenges in primary care and what our frontline folks face, but at the end of the day they want to feel, feel valued and that desire is still there. And I think that our organization is striving to do that.

Speaker A: Yeah, I mean, it's just human. Right? You want to feel Respected, you want to feel valued, you want to feel, I think people know that the work they're doing is worthwhile. It's sometimes nice to have other people know that too.

Speaker B: Yeah, yeah, yeah.

Speaker A: Let's talk about those challenges. I mean, you're obviously both as a, uh, clinician seeing patients and dealing with it, but also as a leader trying to address them in broad strokes. Tell me about that.

Speaker B: Yeah, it's a great question and it harkens back to your first question about, you know, why were people discouraged to go into primary care? Because the truth is it's challenging and it continues to become challenging on multiple fronts. The demand for primary care, as we know, is just vastly outpacing and outstripping people that are going to primary care, whether they're clinicians or other members of the care team, medical assistant, nurses, staff. There's just so much more demand. Patients are living longer, they're having more complex need. And also the world is changing. Patients are expecting different things from their primary care team. So it's no longer about the brick and mortar going to the office once a year and getting everything done there and getting your prescription written on pad of paper, taken to a local pharmacy. It really is having access to your primary care team almost 24 7. Can I message my clinician by portal message? Will they respond within 24 hours? Can you do the refill for a 90 day refill instead of a 30 day refill at the local pharmacy? Can I get this fancy treatment or medication? Can you refer me to this specialist that I heard about on US News or something like that? The demands are not just only increasing in volume because the sheer amount of patients that need care and need primary care, but the diversity of those needs and asks and demands are evolving quickly at a rate that traditional primary care models just can't keep up with. So the people who are in the midst of all of that chaos and that change and those demands and expectations are our primary care teams, which is starting to make for a more challenging sustainability long term for anybody in primary care. We're seeing a lot of medical assistant nurses, front desk staff, administrative folks, primary care clinicians, just not staying in the game as long as they used to because they we can't keep up with all these demands.

Speaker A: Was that worse during the pandemic or post pandemic?

Speaker B: You know, interesting. My impression might be skewed was that it was actually better during the pandemic because during the pandemic what happened is everyone had one mission, which is figure out how to survive Covid how to keep people safe. And in some ways it simplified what the mission was, uh, and there was an appreciation for healthcare in a way that had almost been forgotten. I think that post pandemic and post Covid, although Covid's still around, it has magnified the issues that were starting to escalate pre pandemic, which is the sheer amount of work, expectations, demands and the diversity of those asks coming from the community. You layer on top of that the different technologies and electronic health records complications that we have to face. It just becomes a large pot of things that we need to sort out. And for us in leadership, that's what we have to do. We have to sort out what we need to evolve into, what we need to advance and what are the things that we can do to bring it back to basics. Because at the end of the day, if we sit down with an advanced practice provider or a physician in primary care and we ask them, what do you want to do? They'll say, I want to take care of my patients, I want to see them, I want to be able to provide them, you know, evidence based, top notch care and I want to be able to send them to that the rest of the system in an easy, seamless way where I'm not dealing with the prior authorization, where I'm not trying to get them in the door with a specialist, you know, in three months instead of six months, where I know where to send them for a CT scan, you know, I want a system that I can stock into easily and take care of the patient.

Speaker A: Right. Uh, you know, as you stated, when we get more specific to bilh, we have had explicit and goals around providing community based care through the majority. We already are at the majority, but even more of a majority of care provided in the community based setting.

Speaker B: Mhm.

Speaker A: And we've also explicitly stated goals around the growth of primary care, the development of primary care. And maybe at the highest level, we want to make BLH a destination site to practice primary care, recognizing that we fall short of that today and we're working towards that goal, but that's certainly the future vision for how we get there. What would be required, if you think about it, for our primary care physicians just generally to feel that, I guess on a day to day, like what kinds of things would be most impactful to the workforce experience?

Speaker B: Yeah, it's another great question. And how much time do you have?

Speaker A: We can have two episodes.

Speaker B: I think the first thing that most primary care teams will say to feel like they are able to Take care of their patients in the comprehensive, safe, thorough way that they had envisioned or dreamt of when they went to primary care would be just resources. And I know that's a hard proposition because every health system is strapped and they're trying to allocate resources where the red flags and urgent issues are. But in a world of a plethora of resources, that's what people would probably say, you know, Nick, Rob, um, we need more mas to help room patients. We need more nurses to help triage things and give people good health kinds. We need health care coaches to have people live healthier lifestyles. We need navigators who can help the patient get to their oncology appointment and also get an easy MRI scheduled or get a colonoscopy or mammogram that I'm trying to schedule. We need more behavioral health. Right, to be paired with us so that mental health issues can be cared for. We need some social work health or social determinants of health. There's just so many facets that we encounter in primary care that eventually impact their chronic disease, their preventative health. And the resources are just not quite there at this time. So a lot of it falls back on a team that was originally designed to just care for, you know, the routine physical and diabetes and maybe the blood pressure, hypertension.

Speaker A: Yeah.

Speaker B: So resources would be a big one and then just integration and docking into a network that's well coordinated and seamless. And that is something that I know we're working on as a system and hopefully we can continue to evolve as an organization on that front. And we could talk more about that.

Speaker A: Yeah. And related to that, you know, we do a lot of work in POP health. It's obviously been a big part of my personal career, but it's certainly a big initiative for us at BLH in particular as we see the growth in our government insured patients. And we're working towards value as a strategy for sustainability there and for outcomes. But what has always been true is a disproportionate share of the responsibility for success falls on the primary care docs. Just like a lot of other things. What is your sense of how value based care and population health efforts have landed for I would say the average population primary care physician, they view it as a hope, as a pain, as, uh, just another layer, you know, what is the next phase to sort of make that beeline? Because in my mind, philosophically, they should be aligned with some of the goals and the workforce experience issues that you just outlined. If we do this to Its fullest extent. Yeah, obviously we're not quite there yet, but maybe just thinking about that.

Speaker B: Yeah, it's a tough question to answer. I mean, ideally, you know, the thought of value based care and population health and the health of a general community should be the mission, the first thing that primary care team members think about. Unfortunately, it's probably something that they think of. Second, after they think about, you know, surviving their day and getting through one patient at a time. Right now, if the team is equipped to really take care of one patient at a time as comprehensively as well as possible, that will contribute to the overall picture, whether it's value based care, clinical outcomes for a population or community health in general. Having said that, we also need to think broader and bigger and think differently about how these primary care hubs and primary care team members can contribute to value based care, population health, health, the community. And we have to be able to evolve a little bit the way that we manage the day to day as well as the community that we're set in. So, you know, when we think about group visits, right. A different type of model that cares for a subset of people that have a similar health challenge, but reaches a lot of people and creates those connections. We know that in our system and in other system that has paid to significant dividends and has had positive outcomes on population health and value based care performance, thinking about registries. Right. And being more strategic about partner with things that have historically been outside the walls of a primary care space like pharmacists and population health specialists and health coaches. All the different things that, you know, are necessary to be successful in these new models. Because if we aren't thinking a little bit differently and creatively and extending ourselves and connecting with different members of a multidisciplinary team, the one patient at a time M is not going to get us there. Unfortunately, even though it is sort of the crux of our experience.

Speaker A: Yeah, I'm going to shift gears a little bit, Nick. So one of the things that I know that you have been a huge part of is integration work across as a young system. You know, part of the sub themes in this podcast has been our stages of integration. The story of BLH a little bit, at least in several of the podcasts. And you are part of a team that worked really hard to create a singular identity for the vast majority of the primary care services we provide across the system under what is still known as BLH primary care. Can you share a little bit about that journey and maybe more importantly, what that has driven from an identity standpoint and positive way for the teams.

Speaker B: Yeah, I love that question. And it's very personal for me because my career started in BI as a solo practitioner in a practice of just me and one medical assistant. But I realized quickly that I wanted and needed to be very close to that medical assistant. And then eventually we added another provider and then a nurse and a practice manager. And it was really key in my mind to broker, uh, the different parts of a team member. And as my role grew, it became about brokering multiple practices together and then multiple regions together and multiple different parts of the care team together. So the concept of integration for a larger system is very exciting to me. And we've, as you've stated, gone on that journey and it's been full of challenges, but also, I think, wins. So when we think about integration, there are two things in my mind. One is how do we bring people together? And in that sense, we become cultural brokers of the organization. But how do we do it in a way that creates consistency, standards, sharing of best practices without losing that local autonomy and personality of the team that's on the ground and knows itself and the community it serves the best? I think that's the balance that I do believe that BH is striking more successfully than perhaps other systems in the market. So we are able to come together as an organization and say, well, let's really prioritize how we're helping our patients with hypertension, diabetes be as well managed and in control of their disease as possible. And we can align on some of these tactics like point of care, A1Cs, and home blood pressure cuffs. But at the same time, we're not going to come down at the practice level and say, you have to do it exactly this way or this way or this way. We give guidance, we give parameters, but we allow for people to govern, will govern, or manage themselves to a certain extent and practice the medicine that they're best at for the patient that they serve. So I think integration for primary care has been coming together, you know, having that consistency and that sense of belonging and culture, setting some standards and parameters, but at the end of the day, allowing for some local variability that gives people the respect that they deserve, which is they know their patients better than we do. Right. And we have to hear them out. So that balance has been really important in terms of, of BLHPC's integration as well as its growth. And that's what's attracted a lot of clinicians and care teams from outside of our system to come to our organization. One of the other parts of growth and integration has been, fortunately or unfortunately, it's been a really tough market for private practices and independent practices. And many of them have been hesitant about joining large organizations because of what they feared they might lose, which is a lot of independent autonomy. And thankfully, we've been a refuge for those groups and practices who have come to us and realized, wow, I can get so much more support. I can connect with other practices and share best practices and learn things, but at the same time, I don't feel like I've lost the soul of my team and the practice so we can get more tactical. But I thought I'd.

Speaker A: Yeah, no, that's super helpful. And now you're taking it. As you said in your intro, you're now the interim chief medical officer for a new group, BILH Medical Group, which is starting to bring together many of our community sites in a similar way. And we're on a journey. Right. So it's not everybody, but we're starting to kind of organize ourselves a little differently while BLH primary care really continues as it was for the most part. It's now going into specialty care. And maybe some initial thoughts from you would be helpful on what might be the same or different in that journey that you took with primary care, with the specialty care practices.

Speaker B: Yeah, it's really exciting for the future. And I think one thing we've always realized in primary care is that we can't do it alone. And we have to be able to have collaboration and relationships with our specialty colleagues, our hospital colleagues, so that we really can be consistent and aligned on what the patient journey is. When they come from the primary care and they go next to the cardiology team and then they end up hospitalized for heart failure and then they go home with some at home services and then unfortunately they bounce back to the ED like what does that journey look like and how can we be coordinated as a team? So that story and that concept is the reason why I think a medical group concept makes sense. So that we can really make sure that what we're messaging to our primary care folks is the same message that is understood by our specialty and hospital colleagues too. So again, the concept of cultural brokering. Right. I'm, um, going to sound like a broken record, but that really is what ties us, which is bringing all the different parts of a patient's care journey together, which includes the specialist. The medical group definitely sets us off on that journey and certain, you know, community based specialists will come into that Fold. And we're excited to have that dialogue and earn that trust with the specialists, uh, as well as get to know each other even better. Because, you know, a lot of specialists in primary care folks have said the days of us all rounding up the hospital and knowing each other. Yeah, back then it almost, uh, seemed like medicine was a little bit simpler and maybe that's because of what we knew and didn't know. But now it's really siphoned off into who's at the hospital, who's in a specialty clinic and who's in primary care. So my hope is that with the medical group and the team that is behind it, that we'll be able to bring some of the spirit of that collaboration, transparency and just real time communication between primary care, specialist care and hospital care back to what it was before I said at the opening. Some of it is innovating and evolving to almost get back to basics and our ability to care for patients and even outside of the medical group, I think that there's a lot of opportunities for the different parts of BILH to connect with each other. Just because something is in or not in the medical group doesn't mean that we shouldn't collaborate on initiatives around, you know, innovative things like cardiac rehab and the virtual cardiac rehab, which we can talk about in a bit. The mission is ultimately the same and we should be able to speak more to each other.

Speaker A: Yeah, well. And as you bring it up, there's no way to address some of the challenges in primary care and in healthcare broadly. It's not just primary care. Without thinking about a change in the care model and innovation, whether it's innovation via change in process or workflow or innovation because of a device or a technology or some of both. I know that you are working on several things. You know, you're at front and center and a ton of this change and innovation. If you can highlight a few of those things that, that kind, uh, of help build us out for the future.

Speaker B: Yeah, I think harkens back to something I said earlier, which is we have to evolve. And that's really challenging because when things are tough, especially at the front line, the mentality, and I've had this mentality before as a frontline physician, which is everything is broken. But please don't change anything, you know, because we're really good as human beings and as healthcare team members to survive the conditions that we're placed in. And once we get to that survival mode, that's when we're like, okay, please don't change the dynamics, because I've learned how to adapt and survive. But things are still broken. So we have to evolve. But I do think innovation makes people nervous. Care, model, transformation, innovation, those are all things that as leaders, we breathe. Uh, but it makes frontline team members nervous. One thing that I think our system has done differently is when we think about changing something or adding an innovation, we're really trying to meet a need that has been identified by our frontline team members.

Speaker A: Right.

Speaker B: So for instance, you know, we are now in the stages of piling an AI scribe, which is really, really exciting. And that only came from the fact that our frontline team members were saying, you know, there's so many documentation demands and I have to write everything down. And you want me to focus on eye contact with the patient and patient experience, like, find me a tool that will write down everything that I am discussing with the patient. So that's an innovation that's coming out of a need. Another need is the one that we talked about in terms of virtual cardiac rehab. It's really challenging for hospitals to maintain the brick mortar cardiac rehabs. And that's not to say that this innovation will replace that or cares for exactly the same acuity of patients. But we have to find a way to still have an option for patients who have cardiac rehab needs and can qualify for this. So I think that. And there's many others. Right. RPM and integration of CGM for diabetes. And I'm sorry, I'm using, you know, medical lingo now, so, you know, people can look this up afterwards. But what I think is important is we have really aimed to innovate to meet a need or a burning platform. Sometimes health systems innovate for the shiny newest thing that will get them a lot of attention. But we're trying to focus on the things that, uh, again, get us back to basics and allow our team members to really do the things that they think are best for our patients.

Speaker A: Yeah. Nick M. You know, as you've highlighted, this work is really hard. What you're doing is really hard. But I have always found you to be an optimistic person. So I wonder, as we close, if you could share with us your hopes for the future and your sense of optimism of how we'll evolve at, uh, BLH specifically, but maybe just, you know, broadly also.

Speaker B: Yeah, absolutely. I mean, I'm optimistic because I believe in primary care and if anything, you know, through my career I've come to realization that it is becoming more and more and more important, you know, as primary care. And now community based care with primary care and specialists and our, you know, hospital community partners, all of that is going to be where the battle needs to be fought and help healthcare. To be quite honest to me, it's a challenging time and there are stressors out there and it's important for leaders like ourselves to be positive, optimistic, have a lot of empathy, validate and listen to all the concerns at the front lines. But I'm hopeful for the future because I know that the importance of community based care is not going away. Right. And that is very clear. We're getting clearer to health systems, health system leaders at the state level as the payer insurer level. I think people are coming to the realization we need to invest our energies, our mission, our resources, our dollars into community based care. And so that gives me hope for the future in terms of the sustainability and our ability to care for every single patient close to home.

Speaker A: Yeah. Well, Nick, thanks for what you're doing. You know, we thank you here in Cambridge, but I know the teams thank you very much for your leadership and what you're doing and thanks for joining us today.

Speaker B: Yeah, of course. And again, thank you for having me. And it's a pleasure chatting with you. And again, a big shout out to the entire team and continuum across blh. The frontline folks are really the ones that are making the magic happen, so the credit goes to them.

Speaker A: Yeah, no doubt. Well, thank you again. And if folks have ideas or thoughts for future podcasts, please hit us up on social media and leave some comments and also please rate us on your favorite podcast app. Thanks for listening.