The American Academy of Family Physicians (AAFP) is addressing the changing treatment modalities associated with chronic diseases like diabetes through the patient-centered medical home (PCMH) concept and various advocacy efforts.

By: John Parkinson, Clinical Content Coordinator,

The traditional paradigm in primary care has been such that patients would come in for care of acute issues or annual check-ups. Now, with the development of wellness programs and initiatives like the patient-centered medical home, there is a greater emphasis on keeping people healthy and in the cases of people with chronic conditions like diabetes, preventive medicine is being applied.

Understanding the ongoing care needs of these types of patients, the AAFP, the largest family medicine organization, is backing greater utilization of the PCMH to help diabetes patients in the primary care setting. In the PCMH model, physicians are more actively engaged and take on more responsibility of patients. Greater responsibilities include coordination of care between the primary care provider and specialists, follow-up calls and medical reminders in-between visits.

While the development of the PCMH concept was written to encompass all chronic diseases and conditions, this treatment model especially suits diabetes patients. Their continuous care needs, combined with how the PCMH is meant to function, makes the two a good medical match.

The AAFP along with the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) released their “Guidelines for PCMH Recognition and Accreditation Programs,” position statement back in 2007. This statement developed by this joint coalition of professional, medical organizations wanted to inform its members to the importance of PCMH and give guidance when considering this treatment model.

The AAFP also recognizes the importance of fighting childhood obesity and is working with First Lady Michelle Obama, and it has also created its own Americans In Motion Healthy Interventions (AIM-HI) initiative looking to help physicians position fitness, including physical activity, nutrition, and emotional well-being as the treatment of choice for prevention and management of chronic conditions.

In addition to advocating on behalf of patients’ needs, the AAFP also serves its members by petitioning the federal government with regards to issues related to primary care physicians, educating its members through various programs, and recruiting future generations of family physicians.

AAFP’s governing body elected Glen Stream MD, FAAFP, MBI, (pictured, below, right) to be the next president of the organization. Dr. Stream will officially start his term at the AAFP’s next annual conference in mid-September. Dr. Stream has served in a number of leadership capacities including as president and co-chair for the Washington Academy of Family Physicians’ Commission on Legislation and Governmental Affairs. Dr. Stream has been a family physician for more than 25 years, and is now the chief medical information officer at the largest multi-specialty practice in Spokane, Wash. recently talked with Dr. Stream learning how the patient-centered medical home can help people with diabetes and what the AAFP’s top priorities are for the year ahead. For those who may not be as familiar with the organization, can you provide an overview of who and what the AAFP does?

Dr. Stream: We are the primary organization for family physicians. We have four strategic priorities in serving the membership including advocating for family physicians and what is best for them and the patients they serve; education; practice enhancement and redesign; and health of the public. Congratulations on being chosen as president of the AAFP. What are your major goals you hope to achieve?

Dr. Stream: I get asked that a lot and I think there was a time when people took their time in the leadership role in professional organizations and they had one specific initiative they wanted to get done. I don’t see our organization performing that way. We really derive our direction from our membership and our representative body within our membership. They set the direction of the Academy. It is the duty of our board and our officers to carry out that direction.

However, there are a couple of things that are going on that I’ll be happy to be overseeing as president. For one, we have taken a hard look at how we can align our organizational structure with our four strategic priorities.

I also look forward to expanding our social media strategy and getting more engaged with our members. I want to hear their concerns, and to let them know what the Academy is doing on their behalf. We often produce a quarterly article or a yearly report, but I think our membership wants to know what I might be doing on a day-to-day basis. I may let them know through social media that I am at a chapter meeting, or I’m on Capitol Hill and this is the member of Congress I’m meeting with or their staff. These are the issues we are talking about. I believe communication is very important. The AAFP has been one of the major medical organizations, along with a few others, who have advocated on behalf of the patient-centered medical home. Why is it an important initiative?

Dr. Stream: There was a report that was published in 2004 that was called the “The Future of Family Medicine.” One of the outcomes of the report was what was then called a new model of care, and that evolved into the patient-centered medical home. It originally started in pediatrics, with the idea of taking better care of the complicated needs for children who would see a general pediatric doctor and then other specialists.

What needed to be developed was a coordination of care mechanism. This idea of the patient-centered medical home is to have the patient be the focus.

In most practices, they have visit-based care now and physicians are not tracking their patients in-between appointments. In the PCMH model, and for my patients with diabetes, I have accountability for them in-between visits. I use electronic medical records and a digital disease registry to track them, so for diabetes patients that have not come into my office for an appointment in six months, they get a call from my office for blood work and a request to see me to go over the results.

In addition, it allows us to remind these patients to get their cholesterol tested and their eyes checked.

You take accountability for the patient and their chronic care management. The idea is also to have patients more engaged in their health and medical care. Outside of PCMH, primary care follow-up for diabetes patients can often be hit or miss. For example, if someone with diabetes comes in with a rash or a cold and that person is overdue for a blood test, a primary care practice might only catch it during those circumstances. Advocacy and petitioning the federal government is important to AAFP. What do you feel are some of the more pressing needs of AAFP in relation to government issues today?

Dr. Stream:
In the last four or five years, we have seen that healthcare has finally become a top-tier issue in the political arena. We have a broken healthcare system that needs significant retooling.

Our biggest political strength in our advocacy is our members. I reached out to my members of Congress yesterday, based on an e-mail that I got that said, ‘this is an issue that is active right now, you as a member may want to extend information and make them aware.’

That e-mail from AAFP was related to the current federal budget negotiations and primary care payments. Our number one issue in the near term is physician payment. Primary care services have clearly shown to save total healthcare dollars, yet payment for primary care services has historically been undervalued in our system. We were glad to see that there was a 10 percent bonus for primary care services in the Patient Protection and Affordable Care Act for five years. It was an incremental step toward reducing the pay disparity between primary care physicians and sub-specialty physicians.

It is a difficult issue to talk about because physicians certainly make a good income, but this is not just about take home pay for physicians. The majority of our members work in small practices, and payment for services is the only thing to keep their revenue stream going. If they can’t pay their bills or their staff, they are just like any other business that could close. And if you are a two-doctor practice in a small town and you are not financially viable and have to close your doors that community doesn’t have services for healthcare.

We also have a yearly congressional conference where our Academy and what we call our “other family of family medicine organizations” get together. With those organizations, we collaborate on Capitol Hill with a single voice. In thinking about diabetes care in the family medicine setting, practitioners are on the frontlines everyday, what are the areas where clinicians are doing a good job, and where are the areas where it is still a challenge to meet patients with diabetes needs?

Dr. Stream: In family medicine, I believe we have the highest rate of implementation of electronic medical records of any specialty. Our Academy has championed that for a long time. We have within the Academy, our Center for Health Information Technology, which gathers and disseminates information of preferred electronic medical records based on ratings by current members of the AAFP. We also have education on how to use health registries. It is part of our current maintenance of the recertification process to do a quality improvement project in your practice and one of the most common chosen is diabetes care. There is a program at the AAFP that is web-based and you can enter data along the way.

Diabetes has been such an evolutionary area of treatment that it can be a challenge to keep up with. There have been more new diabetes drugs released, so keeping up with possible medication options can be difficult for practicing docs. Our education programs target that need.

For those physicians’ offices that don’t yet have electronic medical records and disease registries, things can get missed, like minor medical problems or it can be overlooked to have their A1c or their cholesterol checked. The CDC announced in January that as many as 79 million Americans may have prediabetes. And separately, another one of the bigger areas of focus in the primary care treatment paradigm is the emphasis on prevention and wellness programs. Are there any particular initiatives or ways the AAFP is encouraging its members to look to help these patients to turn the tide of their obesity or prediabetes?

Dr. Stream: It’s a big potential disease burden in our country, not only for people having the health-related issues but the economic burden it will place on our healthcare system.

We are active in First Lady Michelle Obama’s childhood obesity program, Let’s Move, and we have our AIM-HI initiative. Also having the PCMH structure and through wellness screenings, we can identify people who have slightly elevated fasting glucose sugar. Then through educational services teaching patients about diet and weight loss, as well as potential medication therapy for prediabetes, these can all be parts of our overall efforts around diabetic care.

Originally posted by on July 29, 2011.