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Care Coordination and the Iora Health Model

Posted: 24 Feb, 2014   Recommendations: 14   Replies: 47

With almost half of adults in the United States living with at least one chronic condition, the care and management of these patients in the current fragmented health care system is an area in need of further research and innovation (CDC, 2012). Care coordination has the potential to positively impact both cost and outcomes. Care coordinators take responsibility for the coordination and implementation of a patient’s care plan, bridging the gap between patient, practice and health care system in order to improve and facilitate continuity of care.

Iora Health has led the charge of innovative primary care by providing team based care in a range of practices around the country. Every patient is seen by a physician and a health coach to receive collaborative, patient-centered care. To share more about Iora Health’s approach to care coordination, as well as care coordination efforts in larger health care systems, we've invited the following panelists to lead our discussion:

   • Tara McCoy, health coach, Collective Primary Care, Brooklyn NY
   • Jeannette Salabarria, health coach, Culinary Extra Clinic, Las Vegas NV
   • Laura Duncan MD, MPH, physician, Dartmouth Health Connect, Hanover NH
   • Ravi Kavasery MD, physician, Iora Health Boston
   • Wendy Storch, nurse innovator, Iora Health Boston

This panel aims to highlight examples of how care coordination can be integrated in a range of health care delivery systems. Our panelists will offer insight on the following questions:

   1. What does care coordination look like in your practice, and how does this support patient engagement? Are there particular patient populations or health areas where you think care coordination can have the most impact?

   2. A lack of standardized guidelines for care coordination and care coordinators’ roles can make it difficult to implement this approach across delivery systems and practices—How have you managed this at Iora Health, and what advice do you have when it comes to creating and implementing future training, guidelines, and protocols for effective care coordination programs?

   3. How can we best integrate care coordination models in the current fee-for-service payment system?

   4. What role does health IT currently play in care coordination efforts, and what does the future hold for such innovations?

   5. Little research has delved into the exact mechanisms of care coordination that produce better outcomes, particularly due to the tendency of such research to focus on clinical and utilization measures. What measures should be assessed in order to determine the overall effectiveness of care coordination efforts?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, please take our short (4 question) survey before the discussion begins:

Looking forward to a rich discussion next week – please join the conversation and share your questions or comments for our panelists!



Pierre Bush, PhD Replied at 1:43 PM, 24 Feb 2014

I will be glad to contribute to this interesting discussion.

Elizabeth Glaser Replied at 2:02 PM, 24 Feb 2014

I would be very happy to participate.

Vivian Huang, MD, MPH Replied at 2:44 PM, 24 Feb 2014

I would be very interested to contribute and learn more on this issue.

Thom Walsh Replied at 2:44 PM, 24 Feb 2014

Looks terrific. Happy to be a part.


flores roberto Replied at 3:32 PM, 24 Feb 2014

Me gustaría poder contribuir, y además aprender mucho más sobre este tema.

Nachiket Mor Replied at 9:20 PM, 24 Feb 2014

I have visited with Iora Health in their "Freelancers" Brooklyn Office. I am a BIG fan of their approach and feels that it holds the key to challenges in healthcare coordination in India as well.

Sara Schwanke Khilji Replied at 9:31 PM, 24 Feb 2014

I've been wanting to learn more about Iora Health but haven't been able to make it to any of the live sessions in Boston. I'm looking forward to this discussion!

Anna Meltzer Replied at 11:08 PM, 24 Feb 2014

I am interested to learn more about care coordination, very important topic!

Isabelle Celentano Replied at 4:48 PM, 26 Feb 2014

Many thanks to all of those who have joined the Panel and expressed such interest! In order to better understand the impact of our Expert Panels and how we can improve them, don't forget to take our short 5-question survey. You can find the survey here:

In preparation for the start of the Panel I thought I'd share a few resources that might be of interest:

"Care Coordination: Building Continuity in a Fragmented Health Care System" - an American Board of Internal Medicine report of the ABIM Foundation's 2007 Summer Forum, where 120+ health care leaders convened to discuss care coordination.

"Reducing Fragmented Care: a Toolkit for Coordinating Care" - a toolkit to assist patient-centered medical homes with providing coordinated care that is supported by The Commonwealth Fund.

"Coordinated care in fee-for-service Medicare" - a chapter focusing on care coordination in the MedPac report to Congress on Medicare and the health care delivery system.

"Care Coordination Measures Atlas" - an AHRQ publication highlighting current care coordination measures and ways to develop a framework for understanding and creating new measures.

Please feel free to list any additional resources that you recommend before the panel begins on Monday. We look forward to hearing from you!

Attached resources:

LIZZY N IGBINE Replied at 5:07 AM, 27 Feb 2014

I will be happy to participate in this program.

Dr Shanta Ghatak Replied at 7:30 AM, 28 Feb 2014

I look forward to participate . But please let me know the time .....

Isabelle Celentano Replied at 10:10 AM, 28 Feb 2014

Our Expert Panels take place throughout the week with our Care Coordination Panel beginning Monday, March 3rd - Friday, March 7th. Members are welcome to participate at any time and can hear responses from Panelists during the week. Although our Panelists may not be available for discussion after Friday, we encourage members to keep the conversation going after the Panel has concluded.

If anyone has any other questions please don't hesitate to ask. We look forward to hearing from you!

Sam Basta, MD, MMM, FACP, CPE Replied at 3:09 PM, 28 Feb 2014

Would love to participate!
*Sam Basta, MD, MMM, FACP, CPE*
*Senior Medical Director, Clinical Integration, Sentara Healthcare*
*Associate Professor, Internal Medicine, Eastern Virginia Medical School*
*Founder and President, Healthcare Innovation by Design*
One Columbus Center, Suite 600 | Virginia Beach, VA 23462
T: 757-687-8190 |
| |

Elizabeth Glaser Replied at 1:47 PM, 1 Mar 2014

Happy and interested to join in on this discussion.

Laura Duncan Replied at 9:36 AM, 3 Mar 2014

Good morning,

I am a primary care provider at Dartmouth Health Connect, trained in Internal Medicine through Harvard's Primary Care program at Cambridge Health Alliance. I have cared for a multi-ethnic population of mostly Haitian, Brazilian, and other Latino patients, as well as immigrants from around the world during my training at CHA. I then practiced on the Navajo reservation, in Fort Defiance Arizona, 10 minutes from Window Rock, the capital of the Navajo Nation. From there, I moved to a small rural town in Utah, near my in-laws, where I practiced in a Hospital-based private practice. I have now returned to my Alma Mater and have the great privilege to work for Iora at Dartmouth Health Connect where I have been for the past 18 months.

I am thrilled to share in this discussion through GHDonline.

Care coordination is built into the Iora Model on several levels;

Health Coach (HC) - Patient: Patients have direct access to their personal health coach. The HCs come to know each of their patients well in regards to their values, preferences, ability and self-efficacy. The HCs have their finger on the pulses of their patients and the patients know that their HC can help them navigate the health care system.

Health Coach - Provider: We have built in time every day for the Providers to meet with the HCs. During this time, the HCs advocate for their patients needs, enabling timely, efficient, and well-informed clinical decisions on behalf of the provider. In a short time, the physicians can provide care of many patients, that would otherwise take many hours of direct patient face-to-face time to accomplish.

Team Huddle: Every morning, the entire team meets to discuss overnight calls, emergency room visits, admissions, and patients of active concern, as well as review the days schedule. This central component of our model enables us to keep close track of the health of our patients and share with each other ways in which we can reach out and improve the care of our patients. During this meeting, we identify which team member is best situated to take action on behalf of our patients.

Provider - Provider/Specialist: The Iora Model removes the financial incentives and barriers that are present in the current traditional model of health care reimbursement. Since we do not need to see the patient in person in order to bill for our services, we are able to be creative at how we coordinate care for our patients. We can use our time doing the work of patient care which includes discussing complex medical issues and sharing best practices with our colleagues, and consulting specialists on behalf of our patients.

Thom Walsh Replied at 10:50 AM, 3 Mar 2014

Great topic, terrific panel.

I have a question for the panel.

Do you have a measure for care coordination? If there's no specific measure, what metrics do you monitor?

I think this is important because, as a clinician in my early career I often felt as though care could be better coordinated, but now as a researcher I find it hard to quantify that feeling.

Ravi Kavasery Replied at 1:08 PM, 3 Mar 2014

Good morning! I echo Laura Duncan's excitement in having the chance to participate in this GHDOnline discussion with all of you.

I am a primary care physician at Iora Health's practice in Boston, where we currently care for members of the New England Regional Council of Carpenters and their family members. I received my M.D. from Yale School of Medicine and recently completed my residency training in Internal Medicine and Primary Care at Harvard Medical School's Brigham and Women's Hospital.

To answer Thom's question -- one of the metrics we use to measure care coordination and patient engagement is the Worry Score. This is a clinically meaningful stratification tool developed by Iora Health's team members that allows us to focus on which patients in our population require the most help -- e.g. those at highest risk of an acute event, ED visit, or hospitalization in the next 30 days or 6 months. The worry score utilizes multiple independent data sources -- clinician assessment, claims data, patient reported data. As you can imagine, patients who generate higher worry scores are generally ones on which we devote more of our time and resources to care coordination and patient engagement.

In addition, we've developed software features and good processes to ensure that the care coordination steps actually happen and are documented in a timely fashion, and loops aren't kept open. We are thinking about ways to analyze our own tasking systems to come up with further metrics to actually measure "goodness" of care coordination.

With regards to the first question posed above ("What does care coordination look like in your practice?"), the answer I would give is that it's nimble, highly collaborative, and it's creative. As Laura pointed out, because Iora Health's practices have a completely different payment model than traditional medical practices, we do not feel burdened by billing, filing claims, or squeezing patients into visits in order to deliver the care they need.

One of the first patients I saw after joining this practice was a middle-aged carpenter who called us because he had an acute, painful red eye that required urgent evaluation. Despite our concerns about his vision, he refused to come in for evaluation until later that evening, after his workday was finished. In traditional primary care, we might have recommended to the patient that he come in, and if he refused to do so, we would have documented our conversation, and he would have likely presented to an emergency room later that evening for opthalmologic evaluation. But we felt responsibility to our patient and were not constrained to a visit-based model. The patient's health coach and I offered to drive out to his job site to evaluate his eye, because we were sufficiently concerned, and told him that if his eye exam was not concerning, we'd let him stay on the job site; otherwise, we would bring him in for opthalmologic evaluation. The patient was shocked. Never before had he had a medical provider offer to come meet him, and even the threat of a visit was enough for him to engage with us and come in right away. We were able to get him seen by opthalmology that same afternoon, and he had several pieces of metal removed from his eye. In the end, we were able to get him to an ophthalmologist likely faster than he would had he gone to an emergency room, and certainly more cheaply. Plus, he was now set up with a primary care practice instead of needing to search for one after this acute episode was over.

Our belief is that while high need patients might certainly benefit more from high engagement models like ours, all patients (whether or not they are socially or medically complex) benefit from better coordinated care and engagement. That's why Iora Health's mission is to "restore humanity to healthcare." Indeed, much of what we spend our time doing in our practices is building relationships with our patients. If we can get that process right, then we are confident we will be better equipped to engage with them, coordinate their care, and improve their health experience.

Tara McCoy Replied at 2:18 PM, 3 Mar 2014

Good afternoon,

I echo Laura and Ravi's enthusiasm for getting to be a part of this panel and am very excited to learn from the discussion. Heres a quick bio:
I’ve been working for Iora Health in their Brooklyn Clinic for the Freelancer's Union for just over a year. Previous to working as a health coach, I was a research assistant at the Mayo Clinic in their transplant center. My research primarily was around bringing health coaching into the transplant setting and program development around caregiver stress reduction. During that time I also completed a one-year online health coach training program through the Institute for Integrative Nutrition. On track to apply to medical school, I was struck by the shortcomings of the current healthcare system, particularly in primary care and the prevention and management of chronic illness. As I questioned entering a seemingly broken system, I began researching healthcare innovators, which led me to find Iora Health. I belief whole heartedly in this model and am honored to be a part of the work Iora Health is doing to change healthcare delivery. I’m passionate about healthcare innovation, lifestyle and preventive medicine and women’s health, and hope to pursue a career as a clinician.

To begin, here are some ways we focus on care coordination at our clinic in Brooklyn:

-We emphasize proactively managing and reaching out to our patients; specifically focusing on unengaged patients, patients lost to follow up and higher risk folks. Our IT system is designed in a way that makes this sort of analysis of our patient panel easy to do and allows us to outreach and manage out patient population in a much more proactive way.
-Daily morning huddles allow the behavioral health staff, health coaches, nurses and doctors to discuss the days patients, go over any pending patient tasks staff is working on, and discuss high risk patients. Having the whole team meet daily allows for cross-pollination among different disciplines and keeps the team on the same page. Unmet care needs and coordination opportunities are often identified at these meetings and delegated to the appropriate staff member.
-Having a primary care clinician from our clinic on call 24/7 encourages patients to update us when urgent situations arise outside of office hours, so we can help direct them to their next best step. This may be waiting to come see us once we re-open or heading to the ED. This saves patients the feeling of being alone in their medical decision making as soon as our office hours end and has saved patients many trips to urgent care centers and EDs. This goes a long way to reduce fragmented care and unnecessary medical costs.
-Health coaches are able to partner with patients to make sure they follow through with things such as requesting medical records and updating us after specialist visits. These things often fall through the cracks and make care coordination difficult. Coaches also follow up after visits to make sure patients are following through with the care plan and if not, figure out why it may not be working for them. With a focus on relationship building “non compliance” is less of an issue and it’s better understood when it occurs.

Joaquin Blaya, PhD Replied at 2:38 PM, 3 Mar 2014

This is really interesting.
Can you talk about your funding model?

How come you're not in the standard medicare/medicaid model?

And do you are the replication of the Iora model possible (both the
financial and care models)?

Thom Walsh Replied at 3:07 PM, 3 Mar 2014

Ravi, do you have a reference for the Worry Score? I'd love to read more about it. I like that it is patient centered. And I understand that it helps you to focus on the patients who need attention the most. I not as convinced, yet, that it is a measure of coordination.

Tara, and others - I can imagine several teams that huddle each day, monitor worry scores, and have a primary care provider on call 24/7. I would also imagine that if we grouped 100 such clinics together, there would be variability in their performance. While they ALL may be WAY better than traditional "non-teams," there would still be a few teams that are incredibly good, most would be in the middle, and some would be bring up the rear - even though these 'poor performers' were better than traditional non-teams...

I'm describing a normal distribution. Variability exists everywhere and there is no reason to think there would not be variability in the performance of even Iora teams.

How would we visualize that variation? How do we recognize the high performers and learn what they are doing in order to replicate it?

These are important questions because the distribution of performance for teams may not lie completely superior to non-teams. That is, some non-teams could have great coordination and some team could have not so great coordination. The distributions overlap.

In such a case, you would conclude the teams are no better than the non-teams. That is, you end up with the JAMA study.

Laura Duncan Replied at 10:59 PM, 3 Mar 2014

In response to Joaquin's question on our funding.

My understanding of Iora's financial structure as a clinician is such. Iora, as a company that employs over 100 people, is funding by private entities who choose to invest in a primary care revolution. Each clinic is additionally supported by a Employee-based sponsor. At Dartmouth Health Connect, our sponsor is Dartmouth College. The sponsors contract with Iora to pay a fixed amount each month per employee enrolled in their respective primary care practice. The providers (MDs/DOs, RNs/NPs, and health coaches, etc) are salaried without financial incentives such as that seen with RVU-based incentives or accountable care's quality metric-based incentives. We are incentivized, not by finances, but by working in a practice that hires us for our integrity and then grants us opportunities for mastery of our profession, autonomy to perform our job with passion, creativity, humility, and empathy, and courage.

This model relies heavily on these core values. The application of this model elsewhere depends not only on the ability to break free from a fee-for-service model, but on the willingness to embrace these core values which motivate us all to work hard on behalf of our patients regardless of any financial incentives.

Our sponsors ultimately get a return on their investment (which can be upfront more expensive than usual care) when patients utilize healthcare resources more responsibly (fewer ambulatory-sensitive ED visits and unnecessary testing, healthier lifestyles with improved long-term health outcomes, better mental health care coordination leading to happier, more productive employees, etc.)

Our private funders get a return on their investment as the model is perfected and more and more Iora clinics operate with effective, efficient, and sustainable care.

Royce Cheng Replied at 11:20 PM, 3 Mar 2014

Thank you panelists - I really appreciate the thoughtful discussion so far.

Could you comment on Iora Health's strategy when partnering with outside providers? I imagine that no one IH site can fully integrate service providers along the entire care continuum (especially high complexity inpatient care, subspecialty care, and certain subacute services). I would guess that there are models for collaborating with affiliated but nonemployed providers that manages to align and coordinate care, even if the "outside" providers were to be on different EMRs and payment models. Where and how have these models succeeded? And what are the challenges that remain to be addressed?

Laura Duncan Replied at 11:31 PM, 3 Mar 2014

In response to Thom's question on how to we track coordination.

This is of great interest of mine because my experience of care coordination feels like a lot of work is being done on behalf of our patients, but the schedule does not capture that work in meaningful ways, yet.

Currently, we track patient visits to the office, phone/skype visits, and non-traditional visits (at patient's home or office or other - (I have seen patients in the bathroom of the hospital to check on their rash while I was at the hospital visiting a patient who was admitted. I just saw a patient at a restaurant celebrating his birthday and listened to his chest and made a plan for on-going care of his bronchitis. Many of my colleagues have their own stories of how they provided rational and safe medical care outside of the examining room.)

However, so much of our work at DHC also includes email encounters, which include email outreach to specialists. We currently do not track this care coordination.

Many of the Iora clinics, to my knowledge, employ a PDSA (Plan, Do, Study, Act) model to continuously try to improve our care coordination efforts. Each clinic has the opportunity to build a system that works best for their local work flow. We use a program, Confluence, to share in our findings and best practices with the other Iora clinics. Confluence serves as a repository for all aspects of Iora's evolving model which is shared company wide, so others may emulate or refine or learn from other's glorious failures.

At DHC, we have been cycling through many PDSAs on the topic of care coordination in an effort to figure out how our team can build in care coordination in a sustainable way. It often comes down to how much time can we parse out for HC-provider care coordination and Provider-specialist care coordination and Provider-Provider coordination, as well as Provider non-face-to-face time patient care (chart review, documentation, lab review and communication, patient email management) All of this is discussed during care coordination, but as opposed to in traditional care delivery, where less and less time is allocated to accomplishing this work, our model recognizes the time it takes to do all of these other important steps in the care of the patient.

It is our imperative at Iora to figure out how to best achieve effective care coordination. We will only ever know by trial and error. Our model is agile and designed to allow for swift PDSA cycles.

We welcome any ideas!

Laura Duncan Replied at 12:01 AM, 4 Mar 2014

In response to Royce's question on collaborating with outside providers.

I am aware of other models outside of our own that succeeds in cross-collaboration with outside specialists. I believe the key ingredients to good collaboration is TIME and COMMUNICATION.

Our health coaches serve as support staff for the providers. They help keep track of our patients who are admitted, seen in the ER, seen by specialists. It takes time to gather all of this information. With the help of the HC, I am able to stay abreast of my patients health care encounters. In the case of the specialist visit, we often reach out to the patient to check in on their understanding of the recommendation from the specialist and their ability/willingness to follow the plan. I often reach out to the specialist to clarify any outstanding questions and offer our support of the plan. We can help with arranging follow up blood tests, check in on side effects of medications, and monitor a patient's progress in between specialist visits, and can help expediate a necessary follow-up or defer an unnecessary follow-up visit. We can lighten the load for the specialist which opens them up to see more of our referrals.

In the case of the ER or hospital visit, we reach out to patients upon discharge, sometimes prior to discharge, to faciliate a safe transition home. Our aftercare of the patient, has the potential to impact readmissions.

At DHC, we are fortunate to have only a few outside providers to keep track of. We also have a portal into the major referral hospital's EMR, so we can see all of the notes and studies from these hospital encounters.

Iora has also just released a feature on our EMR that helps us keep track of specialist vists and procedures, pharmacy and immunizations, diagnostics, and hospitalizations which equips us as Primary Care docs to really be the keepers of our patients health care experience.

Dr Shanta Ghatak Replied at 7:40 AM, 4 Mar 2014

We used some sort of calculations regarding the ER patients - whether they
came back within a week after discharge or after one or two months later
This scoring was done in an industrial hospital in India where I worked for
a long time ! And this scoring was a part of my desertation while I was
evaluating quantitative techniques - should it be formal or informal for
patient care and satisfaction
Strangely the effectiveness of the scoring was lost if physicians and
registration desk came to know about it !

But the scoring pattern was effective in reflecting the quality of care .
If the patient did not return within a week he was better treated
/effectively treated so that he did not have to return to the facility soon
. But some did turn up within a week or even earlier with bad wounds or
discharging sinuses ....
Our response was good and though ethics was not accounted for ....we did
not disclose too much to the patients or the staff even
The outcome helped me to buy some more equipments and a generator for the
facility !!!
There were a very minimum few who developed complications and went on their
own to other private providers or facilities of their own choice -
attending their self chosen physicians /surgeons ....but they were few
Later we started networking with the tertiary care facilities and referral
services even for high end pathology and biochemistry tests when insurance
coverage became popular and a norm with our corporate medical care services
and Finance concurred !
I hope this helps some people somewhere ......

Thomas Brothers Replied at 7:59 AM, 4 Mar 2014

In it's quest to improve health and lower costs for a defined patient
community, does the Iora Health model engage with upstream/social
determinants of health at the level of the community?

(I have the Community Health Centre model in mind while asking this

Thanks very much for this discussion!

Ravi Kavasery Replied at 9:30 AM, 4 Mar 2014

Thom -- In regards to your question on the Worry Score, we've actually just submitted our algorithm for publication in a peer-reviewed medical journal. As soon as it is published, I'd be very happy to share the paper with you.

Shanta -- Thanks for sharing your experiences in India! That's surprising that the effectiveness of scoring (and, I'm assuming, the quality of care) was lost if physicians came to know about the scoring system. I'd love to hear your thoughts on why you think that was the case.

Royce and Thomas -- both great questions you ask. I have a few thoughts, will send them later this afternoon. Off to clinic!

Jeannette Salabarria Replied at 4:20 PM, 4 Mar 2014

Hi I am a Health Coach at our Las Vegas practice. A lot was already said about our practices and how we coordinate care. I believe a great part of what works with the Health Coach model is the dedication and quality time we have built around a great relationship with our patients. We are there for our patients to advocate and support them. Every patient is at a very different level of help and we are there to assist and meet them at where they are in their walk in their healthcare.

Joaquin Blaya, PhD Replied at 5:57 PM, 4 Mar 2014

A couple more specific questions about the funding.
When you mention that funders will get their returns when more
organizations adopt the model, what type of return are you talking about
e.g. financial, social (in what terms)?

Also is there advocacy or lobbying done on part of Iora to government and
clinical organizations?

Sara Schwanke Khilji Replied at 9:27 PM, 4 Mar 2014

Thanks for a highly interesting conversation so far. To expand on Thomas' question, I am curious about how the various practices interact with and respond to the needs of the communities they serve, as well as the larger (geographic and/or cultural) communities in which they're situated. Are there any principles for community engagement and/or specific examples?

Isabelle Celentano Replied at 11:11 AM, 5 Mar 2014

Many thanks to our Panelists for giving us a great understanding of Iora Health so far, and to our members for asking such great questions. In light of the recent discussion surrounding Iora Health’s payment model, which stands outside of the current fee-for-service service, I’d like to pose our third question: How can we best integrate care coordination models in the current fee-for-service payment system?

The MedPac article that I posted last week, (which can be found here: gives examples of pilot intervention programs focusing on care coordination in fee-for-service Medicare. Out of 29 different care coordination interventions tested, only one showed statistically significant reduction in regular Medicare expenditures when fees were included. In this model, physicians were still paid on a fee-for-service basis, but also worked closely with care managers (similar to Iora Health Coaches it seems) and were paid $150 per member per year to compensate for their time working with these care managers.

Laura - I know you mentioned that the success of adoption of the Iora Health model elsewhere depended upon the ability to break free from the fee-for-service system. Is that the only way the model can be adopted in other practices? Do others agree with this idea? To me, it seems as if breaking away from the FFS system is the best way to deliver innovative, coordinated care. However, this can be a long process. In the meantime, would it be practical to compensate physicians for their time with care managers/health coaches in this way (on top of the current fees)?

Attached resource:

Richard Waters Replied at 5:49 PM, 5 Mar 2014

Thanks everyone for such an interesting discussion!
A few thoughts with questions:
-- At least a subset of patients seem to be able to coordinate their own care well, often better than the health team can (since they know their needs and their schedules intimately), but need to be given the tools to do so (eg, recommendations regarding getting monitoring labs periodically, follow-up visits, or when to seek care for early harbingers of poor control of a chronic condition). Are there any tools that Iora Health employs for these purposes - to empower patients with their own "care plan" - that you feel are particularly useful?
-- To be able to drive to see a patient at work is amazingly wonderful example of great care! But also requires a certain amount of flexibility in the schedule of health care providers (if patients are waiting to be seen, leaving to see that patient at work might not be feasible). What is the day-to-day schedule of a clinician like, in addition to the huddles? How many patients are scheduled ahead of time, and how much time is left flexible for walk-ins or to allow the clinician to coordinate care for a patient who had an unexpected change? Does this flexibility reduce future "demand" by address needs in real-time, and do you have any measures of that?

thanks for your thoughts!

Marie Connelly Replied at 3:31 PM, 6 Mar 2014

Many thanks to our members and panelists for the rich discussion this week! Looking forward to reading your thoughts and questions on the role of health IT in care coordination today.

I hope everyone will also consider joining us for a live video chat with our panelists tomorrow, March 7th, at 3PM Eastern Time. We'll include the video here in this discussion, but you can also sign up to follow the conversation on Google+ at the link below. We look forward to hearing your questions for our panelists tomorrow!

Attached resource:

Jeannette Salabarria Replied at 7:08 PM, 6 Mar 2014

Every Iora clinic serves a different population. For the Las Vegas practice we have scheduled visits that are planned ahead of time. If the patients are sick that day we always accommodate same day visits. Patients without appointments that day can be challenging but it is important to see our patients. We try to keep a culture of "yes" with Iora. Health coaches are not always booked for the whole day, therefore we always find ways to block time out to go see a patient at the hospital or do a home visit.

We do a great job of keeping track of labs due, following up with patients and their specialist. We have a reminder task that we create so we can keep up with a good work flow. It can be a task (reminder) of labs in three months, a phone call to remind them to increase their insulin, ect.

It can be challenging at times with non-speaking spanish specialist. They will not see our patients if they do not have anyone to translate at their office. On occasion we meet them at the specialist to help translate. Basically, we do things outside the box that most primary care clinics would not do... the outcome of our quality time with our patients is well worth it. Health Coaches are not told to see our patients at the hospital or house visits, we get to know our patients at a deeper level, we take time to listen to them and when theses scenarios occur its only natural that we want to be there by their side at times of need.

We do try to empower our patients and we have to be very flexible, each patient is unique to where they are at. Yes, some patients don't require a lot from us.

A little more of our walk-in patients. We have had a large demand on how many walk-in patients come to our clinic, anywhere from 25-40 in one day! What is great to Iora that we are here to adjust to our patients not the other way around. We decided to try blocking two health coaches and one doctor daily on a rotation to just work on the walk-ins. This has been an amazing trial that worked out great, it helped us to be able to cut down wait time for our scheduled patients and not loose the quality time we have with them. The walk-ins are able to be seen just for that specific matter, for example, allergies, cough and cold ect. We make sure these patients still keep their scheduled visit with their care team. It has been a great success.

How do we keep doing the job we do with such great attitudes and wiling to help? We hire the right people, the passion to help. We are such a close team. Families and friends comment on how the heck we still hangout outside of working hours. I love to come spend time with my family at the clinic, they keep me motivated and up beat. We spend quality time being inspired by stories during huddle. We have inspiring Tuesdays (story telling on how we were excited about a patients success) transparent Thursday (we lay it out all on the table, what is bothering us, what can we do better). We have book clubs, we have weekend trips like Cabo San Lucas and Sedona Arizona. Yes, we love being around each other and it shows. It only keeps us at our best when we see our chronic patients.

I continue to be inspired of such an amazing willingness to fight for what is right for our patients. If he or she was your family member wouldn't you?

Tara McCoy Replied at 8:08 PM, 6 Mar 2014

Thanks everyone for all the thoughtful questions and insights so far!

In response to the first part of Richard's question:

A large segment of our freelancer population are very savvy, relatively healthy, have a high degree of health literacy and are theoretically able to coordinate their own care very well. We focus a lot of our energy on the basic reminders you discussed; reminding them to stay up to date with screenings, helping them weigh risk/benefits of various medical interventions and encouraging them to cultivate a healthy lifestyle. With this population, one of our most important interventions is coaches using basic motivational interviewing skills to draw out the patient's individual goals, create a game plan and then simply reaching out periodically to see how it's going. These coaching sessions can happen during medical visits or else patients meet one on one with coaches in-person, via Skype or over the phone. Just knowing that they're accountable to someone externally and knowing that we can course correct/brainstorm together if they come against barriers seems to make a lot of difference. With these check-ins already in place we can catch medical issues as they arise more easily as we're generally very high touch even before problems arise and have already established a strong relationship and rapport.

Jess Kadar Replied at 11:48 PM, 6 Mar 2014

Hi all, I'm Jess Kadar, Principal Product Manager for Iora Health's collaborative care platform (ICIS). I'm happy to share my thoughts on the role of IT in care coordination. I'm not sure I can predict the future for all IT, but I can speak to our own particular vision of Iora Health's IT future!

For Iora Health, IT is integrated into the practice model out of necessity. We determined early on through trial and error that traditional EMRs weren’t going to cut it for us for a few reasons. Quite simply: they are built around billing rather than care, focused on workflow of a single provider rather than a coordinated team, don’t do a lot of the stuff they say they do, and have high walls and limitations on what data can be shared downstream and with patients. Furthermore, we have no say in someone else’s product roadmap, no way of customizing another company’s software to make it bend to our model.

At Iora Health, we really strive to design a very open, transparent, and nimble system that can adapt with our teams. I think the main tenet of our design philosophy is to respect and protect the space where care happens: and that space is not between a clinician and a screen. It’s between human beings. No one affects change by pressing buttons on a computer screen. Change comes as a result of spending time with people and listening. I’m a technologist, but I believe in humanity first and foremost. I witness it firsthand in our practices, and I have seen no behavioral health iPhone app that is more effective than our health coaches.

That being said, computers are really great at doing unemotional automated stuff. Think Spock. (Mister, not Doctor.) We want to make computers do the administrative stuff and free up the humans to do the cognitive and human relationship work. We really want to create software that doesn’t make our staff “bow down to the data gods”— but rather supports our teams by providing the right information at the right time. Our design philosophy is focused on communication between team members and reducing administrative burden. Every checkbox, every click, every required field is questioned — is this a burden at the point of care? a barrier? Is it truly necessary to capture this data by requiring someone to input it? Can we capture it another way? Can we infer it from other data?

We also design for humanity rather than idealized expectations of compliance to protocols. Human error and variance are natural and will occur. There will be exceptions so expect them and design for them. For example, for any “rule” that exists in the application we must also provide a way for users to overwrite the rule.

We are constantly looking to iterate on the design of the patient facesheet to convey the whole person it represents. This also means that the patient is more than the data our team enters— the patient contributes to the chart and we continue to pull in data from other sources (hospitals, pharmacies, specialists, etc.) to paint a fuller portrait.

What does the future hold? I am really terrible at predicting the future in general, but I can speak to what we are working on at Iora Health: open, transparent full medical record collaboration between patient and care team, secure multi-channel communication, natural language processing, patients sharing quantified-self data with their care team, a widening of data channels between our teams and specialists and downstream care, and continued use of that data to trigger proactive outreach by the care team. For us, IT is all about care coordination.

Happy to follow up if anyone has specific questions about our tech platform and process!

Laura Duncan Replied at 7:49 AM, 7 Mar 2014

Many great questions have been posted. I hope to respond to several of them in this one posting. I will preface my response with the the a name and a paraphrase of the question.

Thomas Brothers - Does Iora engage in upstream/social determinants of health at the community level? I would say, "yes," but maybe not in the traditional sense in public health. Our engagement in the social determinents of health occur on multiple levels. At the individual level, the patient's eco-psychosocial status informs our assessment and plans. We try to meet each patient where they are, rather than expect our patients to meet our expectations. Our health coaches do home visits, we value the time it takes to practice motivational interviewing techniques, and we engage in shared decision making - all of which requires us to look at the whole patient as part of a larger community. Once we know what particular social determinants at are play for the individual, we focus on addressing those determinants, rather than just place all of the burden on the patient. Why a particular patient is sick at a particular time may be determined by factors outside of their specific control, but that are modifiable with our help. For example, we realize that social isolation (common in our rural setting) can lead to depression and anxiety that can exacerbate all sorts of medical issues from eczema to poor diabetic control. We have identified patients who present to us with health conditions and also report social isolation and have created a Deepening Social Connections group designed to address isolation as a determinant of health.

At the Employee/sponsor level - we work with the sponsor's wellness/benefits departments in an effort to provide health care benefits that are aligned with our values and support coverage of the services that we recommend for our patients. For example, at DHC, we are currently working with our sponsors at Dartmouth College, to improve access to mental health services. We are developing wellness workshops, mindfulness groups, deepending Community Connections groups, Eating support group, etc. We are hoping to influence the Dartmouth College community by building informed relationships with the leadership at the college that will hopefully affect upstream determinants of health.

At Iora, our core values are creativity, empathy, courage, humility, and passion. We are currently building out our population health management tools and processes which will no doubt lead to extended these core values in broad strokes in the community and affecting upstream social determinants of health. We are a young company overflowing with inspiration and mission-driven folks who see the world as connected and in need of multifaceted approach to healing.

Rebecca Weintraub, MD Replied at 1:55 PM, 7 Mar 2014

Having followed this discussion with great interest, it's inspiring to see how our colleagues at Iora Health are implementing care coordination in their practices around the country.

I wonder if the panelists might share some thoughts on how we could best adapt their approach to other types of delivery systems—academic medical centers, rural hospitals, etc. could all benefit from innovative care coordination as well. Do we have, in some sense, a charter school model here, where care coordination is used to support specific patient populations, or patients with particular needs?

Perhaps others in the community can offer examples of how they see care coordination in their practices? We look forward to hearing your thoughts...

Jeff Levin-Scherz Replied at 2:31 PM, 7 Mar 2014

It's heartening to read the passion to provide better care - and to center care around the patient's actual needs, rather than around preset algorithms or physician convenience.

Do you believe this is the right model of health care for all patients? Are there groups of patients who prefer more transactional care? Are there a group of patients for whom the risk of any type of any preventable illness in the next 20 years is so low that you would want to offer them a different (and lower cost) model of care? What is the role for self-care, and for self-service?

It's clear you could fund this out of cost savings if this type of intervention is focused on those who are highly likely to have high costs over the next few years. Aggregate health care costs could be higher if this model is used for the entire population. There might be other benefits (better health, decreased absenteeism and presenteeism), but the medical cost bucket itself could get larger.

Marie Connelly Replied at 2:34 PM, 7 Mar 2014

Just a reminder that we’ll be starting our live video chat with our Expert Panelists at 3PM Eastern Time—in just a few minutes!

To view the video chat, simply visit the discussion on GHDonline and hit play:

Please share your questions and comments for the panelists in the replies, or join us on Twitter with the hashtag #ghdexpertpanel. We look forward to hearing your thoughts!

Joaquin Blaya, PhD Replied at 2:46 PM, 7 Mar 2014

I would love to know more about the IT behind the Iora model.

My background is from the OpenMRS community, an open source electronic
medical record. On top of that implemented in over 50 countries. On top of
that we've created a chronic disease management system based on similar
patient centered principles as have been mentioned core to the Iora model.

Did you build your system from scratch? Have you published anything where
we could read more about it?

Jess Kadar Replied at 4:15 PM, 7 Mar 2014

Hi Joaquin,

Yes, we built our system from scratch. (It is a web-based system, Ruby on Rails, Postgres, Ember.js and Backbone.js)

We do have a tech blog which we update once in a while when we come up for air!


Laura Duncan Replied at 4:25 PM, 7 Mar 2014

Hello All,

I apologize for missing the google chat - I was called into urgent patient care.

Tara McCoy Replied at 5:50 PM, 7 Mar 2014

I also got called in with a patient, my apologies. Excited to view the replay. Thanks all!

Tara McCoy Replied at 6:19 PM, 7 Mar 2014


Great insight. I do think the quality of care and personalized attention that the Iora model emphasizes is something everyone deserves as an option but the cost question/applicability to certain low risk patients is a good one. The savings over time might play out in decreased chronic illness related costs over the long run but this is of course difficult to prove in the short term with healthy folks.

Our model is fairly adaptive to differences in preferred utilization styles, which allows us to focus a lot of our time/resources on those that really need us or buy into the "high engagement" version of the model (frequent health coach check ins, attending classes/groups etc). Some patients don't want as much interaction and want to treat the clinic in a more traditional way and with our use of technology/ flexibility due to lack of FFS, I think we're uniquely positioned to deliver a more transactional style of care as well (ie. doing phone consults rather than in-person visits, fielding refill requests over email, looking at rashes via emailed pics etc). I think this sort of mixed utilization is what makes the model work; allowing us to properly allocate our wide range of resources and flexibility around ways to engage in a way that best serves the population as a whole.

Marie Connelly Replied at 8:56 AM, 10 Mar 2014

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Marie Connelly Replied at 9:07 AM, 2 Jun 2014

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