At a recent conference, I presented care redesign and care management strategies we implement in our Maternity Care Home Model for Medicaid patients. This model addresses all aspects of women’s health, including behavioral health, during the perinatal period, using a patient-centered and strengths-based approach. During the question and answer period, our model was criticized by an audience member for not addressing “patient responsibility.”
Her provider organization already had enough care management resources, she explained. The problem was not the providers, but the patients, especially those on Medicaid. She said the patients did not seem to truly care about their health; they missed appointments, avoided following physician orders, and were not available when care managers tried to reach out to them.
I have heard these same frustrations from providers before. Yet, assuming patients do not care is a false assumption; the truth is more complicated. In our experience, virtually all patients, especially patients on Medicaid, care deeply about their health. This misunderstanding is due to vastly different perspectives and the inherent assumption of equity, that all patients have similar needs and access to identical resources.
To shine some light on this issue, let’s explore two perspectives of the same situation.
The Provider Perspective
Dr. Smith, an OB/GYN at a busy office, exits an exam room at 9:45 am. Her medical assistant, Sarah, meets her in the hallway before she enters the next room. With 32 patients scheduled today after a long on-call weekend delivering six babies, Dr. Smith does not have enough time or energy to eat let alone stop to talk. Sarah says April Johnson has not shown up for her 9:30 am appointment. Dr. Smith shakes her head knowing this is the third prenatal visit April has missed in a row and she is already 25 weeks.
“What happened this time?” asks Dr. Smith.
“I’m not sure. I tried calling, but her phone is disconnected,” says Sarah.
“I don’t know what else we can do. She just doesn’t seem to care about making her appointments,” says Dr. Smith.
The Patient Perspective
April and Brad recently aged out of the foster care system. Like many other young adults exiting the system, they were given very little tangible support to make the transition into living independently. Neither received their birth certificate or Social Security Card, which are needed to apply for a job, housing, or food stamps.
The couple was staying on a couch at a friend’s house, but eventually had to move out. Being each other’s only support, they decided to live on the street rather than be separated into gender-specific shelters.
April is excited to hear her baby’s heartbeat at her OB appointment today. She also wants to ask the doctor about relief for her swollen feet. She checks the time on Brad’s phone, and sees that it is just past 7 am. It will take her 80 minutes and three buses to get to the doctor’s office, so she needs to leave now to make it on time.
April’s second bus hits traffic on the highway due to an accident, and she is five minutes too late to make her last connection. April waits on the curb for the next bus, knowing she will now be very late for her appointment. Finally, a bus arrives, and when she pulls out her remaining cash, she realizes it is too little and it will not be enough to get to her doctor’s appointment and back home. Already late and worn out from pregnancy and stress, she decides to just head home. She has no means to contact the doctor.
Redefining Our Responsibility To Patients
I wish stories like April’s were the outliers that happened only occasionally. Our patients, the ones who are expected to be solely responsible for their healthcare, are faced with daily challenges few providers consider when judging the actions of their patients. Will I be evicted today? Will my partner come home drunk tonight and hurt my children or me? Will we have enough to eat?
Like April, many patients have to make decisions with short-term benefits regardless of the long-term costs. Healthcare system providers, insurers, brokers, government officials, regulators, attorneys, and executives constitute a confusing and complex system. Most well educated individuals are barely able to navigate this Daedalus maze, yet we expect those who are hanging on by a thread to leap through hurdles with little support to get the care they need.
All providers want their patients to be friendly and compliant. Yet, providers have a responsibility to try to understand that there are real barriers to patients fully assuming their “patient responsibility.” As providers shift from fee-for-service to value-based care, it is imperative to shift our perspective from admonishment and finger pointing to a perspective which ascertains and understands the underlying causes for missed patient visits, misunderstandings about a patient care plan, or patients’ confusion about their health benefits.
In our Maternity Care Home Model, our dedication to shifting our perspective and incorporating trauma-informed care led to the addition of new resources, such as perinatal care coordinators (master’s level social workers), to facilitate deeper engagement and trust between physician and patient. This paradigm shift now allows our providers to understand the unique challenges our patients face and to identify and address their barriers to healthcare. As a result, patients are entering prenatal care two weeks earlier, 88% of our patients attend at least 10 prenatal visits, and our preterm birth rate has been reduced by 16% since the program began.
In a second article in this series, we will discuss in depth how we implement this shift in mindset in our Maternity Care Home Model. We will revisit Dr. Smith’s and April’s perspective to show how both are empowered when they each have the resources they need and how maternity care outcomes improve.
For more information on transforming maternity care, visit SignatureCareManagement.com.