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Innovative Stanford clinic to support chronic care patients

In a New Yorker article called "The Hot Spotters," Harvard surgeon Atul Gawande, MD, describes a 560-pound man in Camden, New Jersey, who suffers from multiple ailments - congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout and a history of smoking and alcohol abuse. The poor fellow spends more time in the hospital than out.

But he becomes part of an unusual medical practice in which he gets home visits from a health care team, follow-up phone calls, regular support and advice on how to change his lifestyle for the better. As a result, he loses 220 pounds, gets his diabetes and heart problems under control, gives up smoking and alcohol and no longer has cataclysmic health crises that land him frequently in the hospital.

Stanford aims to create a similar model of high-quality, affordable care through an innovative clinic scheduled to open next spring. The clinic will enroll patients with severe chronic disease, such as uncontrolled asthma, diabetes or heart disease, providing them with focused attention from a primary care team. It will include home visits when needed, regular phone check-ins, 24/7 availability, counseling in behavior change and coaching in self-care to help patients avoid health crises and hospitalization.

"The idea is to pay much closer attention to unmet patient needs," Arnold Milstein, MD, MPH, a Stanford professor of medicine, recently told me "The health-care system is designed to take care of patients in 15-minute intervals. In fragile patients, who are at high risk of emergency hospitalizations, 15 minutes a month is not enough. So we'll be much more carefully tuning into patients prone to health crises and understanding why they're struggling."

Milstein, who has been at the forefront nationally of developing approaches to high-quality, affordable care, calls it a patient-centered intensive primary care model. He's recruited someone of like mind, family physician Alan Glaseroff, MD, to direct the new Stanford clinic. Glaseroff, chief medical officer for the Independent Practice Association in Humboldt County, Calif., has developed an innovative model for chronic disease patients in the county which emphasizes self-management.

As I write in a release on the new clinic, Glaseroff says it is often lack of self-confidence that drives patients into costly care settings, such hospital emergency rooms:

"It's 2 in the morning, and you have a symptom. Either you panic and go to the emergency room or you have the skills to figure it what to do on your own," he said. "You have someone you can call for advice, and you may resolve it or decide to go to the office in the morning. It's all about empowering people to make their own decisions."

Glaseroff and his wife, Ann Lindsay, MD, who will serve as associate director of the clinic, will join Stanford Nov. 1. The innovative clinic initially will be open only to employees at Stanford University and Stanford Hospital & Clinics, as well as their family members, though plans are to make it ultimately available to other area patients.

Previously: Community-based workshops help patients manage chronic illness, Free self-management program offered to people with chronic illness and Lawmaker proposes Medi-Cal coverage of Stanford chronic-disease program

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