Primary care transformed: A provider story

Kim McGuinness laughing with care team members in the Camden Coalition offices
Date
October 11, 2016
Camden Coalition staff and Community Advisory Committee members participate at the Housing and Community Development Network of New Jersey’s Annual Legislative Day at New Jersey State House
July 18, 2019
Camden Coalition joins the call to fully fund the Affordable Housing Trust Fund
To help secure FY2020 funding for the Affordable Housing Trust Fund, CAC members took part in HCDNNJ's Annual Legislative Day at the NJ State House.
Whitney Buchmann
July 16, 2019
From siloed systems to ecosystem: The evolution of the Camden Coalition’s complex care model
In this four-part series, we describe the phases of our care model as we addressed challenges and tested new solutions.
Kathleen Noonan and Kelly Craig
July 15, 2019
Graduates of Interfaith Homeless Outreach Council program reflect on their fresh start
Now in its 28th year, the Interfaith Homeless Outreach Council — or IHOC — has transformed countless lives.
Bill Nice
Camden Coalition care team member helps patient fill medication box.
July 11, 2019
Bringing it home: The shift in where healthcare is delivered
In this blog post for JAMA Forum, Lauran Hardin and Diana Mason write about two new opportunities to incentivize innovative complex care models.
Lauran Hardin and Diana Mason
Patient gives Camden Coalition care team member a hug during a home visit
July 3, 2019
New Jersey FY 2020 budget renews support for Camden Coalition’s Housing First program and officially recognizes organization as Regional Health Hub
New Jersey leaders have taken an important step toward better health outcomes across the state.
Kathleen Noonan
Kathleen Noonan speaking to graduates in caps and gowns
June 11, 2019
Bridging the public health-healthcare divide for better outcomes
The public health field has an opportunity right now to influence the traditional healthcare model in ways it has not in a very long time.
Kathleen Noonan

Kim McGuinness has been an adult nurse practitioner for four years, and a registered nurse for six years before that. She went into nursing to help people, but was getting increasingly frustrated and burnt out. Patients with chronic conditions like high blood pressure and diabetes were coming in month after month with no improvement in their health status. “I felt like I was just running through the motions,” she says. “You know, ‘Here’s your next script, let’s give you more medicine.’”

Last year, Kim became a Super-Utilizer Fellow through a partnership between the Camden Coalition and Crozer-Keystone Health System, working in a primary care office two days a week and spending three days a week in the community, going on home visits and supporting care teams in Camden and the Delaware Valley. She has been learning all the aspects of our healthcare hotspotting model, from data collection to interprofessional teaming to the financial and management aspects of building a program to care for patients with complex health and social needs. And she says her practice has been completely transformed.

Where she was once burnt out she now feels energized, with the tools she needs to effectively care for patients with complex health and social needs.

“I think one of the biggest things I’ve learned is that if I only focus on my goals, I’m never going to help the patient or get through to the patient,” she says, “because they’re so focused on their goals, or there are other things that are keeping them from reaching the goals that I have. I’ve changed that focus to what the patient’s needs are.”

“I’m able to take a step back now. Instead of feeling so narrow and tunneled when a patient comes in with these complex issues, I feel like I’m able to break down those issues better and take it piece by piece.”

One of the biggest changes that Kim made is incorporating basic behavioral health screening and management into her visits. “We talk a lot about feelings,” she laughs. “There’s a joke among my students that I have a box of tissues in every room, and patients go through at least one of those boxes a day.”

Addressing patients’ underlying emotional issues can lead to breakthroughs, but requires give and take on both sides. Kim talks about a patient who came in demanding pain medication, a common struggle in health care settings that many providers have trouble addressing empathetically and effectively.

“I remember looking at his chart before he came into the office and immediately shutting down and saying to myself, ‘I’m not giving him these meds.’ And as I was doing that I became aware of how I was feeling, and allowed myself to open up and listen to what he had to say first before having that judgment, because that was just my initial instinct that had been coached into me. During that visit he was able to disclose some things that had happened to him in his history, and we talked a lot about how mental health and things that happened previously in his life affect his physical being. I did end up giving him pain meds that day, but we also came up with a plan that included seeking out behavioral health. And that felt really good. I was meeting the patient’s current needs, but also working on the true cause of what was causing that pain. If we had just worked on his back pain, we weren’t going to get anywhere except for continuing to give him meds and injections.”

Kim has finished her Super-Utilizer Fellowship, but she is continuing her work with the Camden Coalition as a preceptor in our Interprofessional Student Hotspotting Learning Collaborative, which trains interdisciplinary teams of health professional students on healthcare hotspotting, storytelling, and patient-centered care.

She says she wants to teach her students the importance of feelings, those of both the patients and the providers, which she sees as a significant gap in current medical education. “In nursing school you’re taught about active listening, and I’ve always carried that piece with me,” she says. “But even though I was actively listening, I don’t know how much I was feeling. Or how much I was really hearing.”

Armed with her fellowship experience, Kim is ready to start transforming health care in the same way that she has transformed her practice. To be effective for all patients, practices need to move toward what she calls “common-sense medicine”: integrated behavioral and physical health care, more social workers to help address patients’ social needs, training in interprofessional teaming, and the ability to go on home visits.

“It’s not every patient that needs [these changes],” she says, “but it’s these complex patients we see over and over again that aren’t making any progress in their care. We need to delve a little deeper into their lives and figure out what their true barriers are. No matter how many times I talk to them about their blood pressure, if they don’t have a house to live in, or they’re being abused at home, or they don’t have a job, I’m never gonna touch that blood pressure.”

 

Read more from Kim on hotspotting and the Super-Utilizer fellowship, on the Primary Care Progress blog

Stay Informed

Join our mailing list to get the latest updates sent right to your inbox from the Camden Coalition.

Sign Up