One of the biggest challenges we face as nurses in the traditional U.S. healthcare delivery model is that we're limited in the choices we have when serving patients. The fee-for-service model highlights the importance of reimbursement and incentivizes actions that may not meet the unique needs of a given patient. Conversely, in a value-based model, nurses deliver care in a way that's often challenging to implement. In holding a nursing leadership position with Iora Health, I've witnessed the merits of a value-based system.
How it works: Primary care case studies
The premise of Iora Health's model is that better healthcare starts with better primary care. This means we focus on personalized care that meets patients where they are and asks them what they want to get out of their primary care experience. To demonstrate how this model works, I'd like to introduce you to Gladys: a fun-spirited octogenarian who walks her dog every day and regularly travels out of state to visit her grandchildren. In Gladys' first visit with Iora, her BP was high: 204/100. In this initial visit, Gladys told her care team that her former provider recommended a BP medication prescription.
Gladys adamantly declared that while she understood the risks of myocardial infarction (MI), stroke, and death, she wouldn't take any medication for fear of worsened quality of life. At that time, she wasn't open to discussing it further. In a fee-for-service model, with limited time allotted to each appointment, Gladys' choice to end the conversation would be just that: an end to the conversation. But because Iora employees are provided discretion to increase time spent with patients, the team caring for Gladys was able to develop a plan to focus on deeper “interventions,” including building trust, understanding more of her concerns, and investing in a healing relationship with her. We knew that for our advice to matter, she needed to know we understood her and truly cared about her well-being.
Enter Rocky, the RN on Gladys' care team, who scheduled routine “nurse only” visits with her. Rocky took a more holistic view of her care, helping her think through ways she could reduce the risk of falls in her home and other quality-of-life issues. On the surface, these ways don't directly relate to the present issue of high BP, but with the long-term view of overall health in mind, they made sense for Gladys.
The turning point came when Rocky learned that Gladys was in need of regular foot care but was avoiding the $45 copay for each podiatrist visit. Rocky began to provide her with the foot care she needed during their one-on-one visits. This care, not typical in primary care, allowed for more conversation, which, in turn, offered another opportunity for us to earn her trust. During those sessions, Gladys started to reveal more about herself, sharing deeper insight into her thoughts—even painful experiences and memories from her childhood 70+ years ago. The healing relationship progressed further and, after a few visits with Rocky, Gladys indicated that if he still thought medication was important for her health, she would be willing to try it.
Today, Gladys takes her BP medication regularly and says she feels much better. At her most recent visit, her BP was at a safe geriatric reading of 148/81, showing that within just a few months, Rocky and the care team helped her drastically reduce her risk of MI and stroke.
We managed the same type of care for another patient named Laura: a socially and medically complex woman in her 30s with diabetes, who regularly had an HbA1C above 11. In her first visit, she revealed that she didn't like to think about herself as having a chronic disease, she didn't like physicians, and she'd often skip appointments. Laura's physician, nurse, and health coach recognized the fear Laura had toward healthcare and the subsequent disconnect that she felt toward managing her diabetes. Together, her care team brainstormed ways that they could make their encounters with Laura more comfortable.
Anna, the RN, played Laura's favorite music in the background during visits and, after her first foot care visit, painted her toenails. Although there isn't an ICD-10 code that requires nail polish for treatment, it's what ultimately engaged Laura in caring more for her feet and diabetes. The trust that the team began to build was powerful and the visits were much more relaxing for Laura. After a few months, Laura's HbA1C started dropping; for the last 4 years, her HbA1C has averaged around six. Overall, she's now motivated to manage her diabetes.
Many nurses I've worked with entered our profession to help heal. Many have told me how they'd love the opportunity to have the necessary time allotted in their schedule to build trust with patients the way that Rocky or Anna did. The ability to form meaningful bonds creates a positive, lasting impact on patients' health trajectories. The more we, as managers, can create this environment for our fellow nurses, the better we'll be in sustaining their longevity and job satisfaction.
Going in-depth: The Iora Health model
We've noticed that our model is working—the rise in value-based care and the shift of insurance plans moving away from fee-for-service is making headlines. The Iora model focuses on the granular aspects of primary care delivery that make for excellent patient care and exceptional customer service. Patients in a value-based care system have 24/7 access to an on-call physician, same- or next-day appointments for urgent needs, coordinated care with specialists, constant access to a collaborative care platform (Iora's is called “Chirp”), and free on-site exercise/health education classes, as well as numerous other services. What's particularly unique for nurses in a value-based model is the empowered role that we hold. Within this unique framework, we have “visits” over the phone or videoconference; there's no requirement to come into the practice to be seen when something can potentially be solved virtually. Thus, a nurse's knowledge and expertise in patient care is palpable both inside and outside of the four walls in which we work.
How you begin achieving positive results with patients can be attributed to building a solid team framework based on passion and innovation. Rushika Fernandopulle, MD, MPP, CEO and cofounder of Iora Health, notes five key abilities that every team member should have: 1) serve with humility, 2) bring creativity, 3) act with passion, 4) feel empathy, and 5) demonstrate courage. With a focus on these values, you may find that a highly empathetic individual tends to shine within the hiring process. These are traits that you can seek when hiring within your own system.
Team engagement and enthusiasm are fostered through many regular rhythms; for example, in the team's daily huddle, every member sits together first thing in the morning with the purpose of coordinating the care of patients of highest concern. During the huddle, we also check in with each other; personal conversations are encouraged to build camaraderie. Then, our focus shifts to the patients we're seeing that day, and those we aren't seeing but are concerned about. This is where the magic happens; because of this connectedness, the team's work becomes planned and highly coordinated. In contrast, the traditional healthcare system really only allows for time to respond to the day's patient schedule, many of whom aren't necessarily the most worrisome. We've found that a model enabling teams to have a population health mindset leads to a much more satisfying work environment and improved outcomes.
From a manager's perspective, seeing the positive impact of a value-based model on patient care has enabled team members to feel more competent in the work they're doing, more resilient in the face of hurdles, and more trusting in the reason they entered healthcare as a profession in the first place: to help people. At Iora, we call this the importance of “joy of practice” in our everyday clinical work.
Management culture: Fostering joy of practice
As with many mission-oriented start-ups, passion and drive have helped fuel the company's growth from its headquarters in Boston to practices all over the country. The measurement of Iora's joy of practice is both cultivated and tested in an annual “Happiness at Work” survey distributed countrywide to team members. This anonymous tool provides a comprehensive read on the culture to ensure that the company is providing a rewarding and fulfilling work environment. After results are released, there's great attention to addressing any concerns raised and creating a plan to improve overall team satisfaction. Just as the Hawthorne Effect suggests, the extra awareness surrounding the measurement of an item will naturally improve the behavior around that item.1 This annual assessment keeps happiness at work high on a manager's mind throughout the year and serves as a great point of reference to continually nurture.
Many Iora nurses hold leadership or managerial roles in which there are numerous opportunities to mentor health coaches, who aren't required to have a healthcare background when they're hired, by providing them with the basic clinical knowledge necessary to perform daily job tasks. RNs may also work directly with medical directors on defining and executing operational success. This partnership steers away from the dated view of physicians, alone, “steering the ship.” Overall, in any of Iora's nursing positions, there's a culture of heightened mutual respect that's unique to the nursing community.
This is what Dr. Damania discussed during his keynote address at the journal's annual conference. “As a doctor, realizing the vital role that nurses play in providing amazing patient care was eye-opening for me,” said Zubin Damania, MD (AKA ZDoggMD). “They make my job as a doctor more seamless, while not getting nearly enough credit. I love Iora's model because that vital role in care delivery is recognized and celebrated. Where else would I get to work one-on-one in leadership roles with a nurse to provide awesome care for patients? This model has it right.”
Excellent operational acumen is a must for any manager, but it's the cultural management that creates and fosters an engaged and happy team. Table 1 highlights “10 management principles to live by” that I've picked up from my time working at Iora Health. Although additional hurdles may be faced with a tight team schedule, you can implement these principles within a busy fee-for-service environment.
You might notice that the first four principles are often undervalued because they don't always feel “productive.” Intention and planning are required, particularly if you have a large number of direct reports. One-on-one meetings are sometimes the first thing to drop off a manager's radar, but they're one of the most important ways that managers serve their teams. The continued investment will pay off in the long run with the team's increased engagement. The temptation to close your office door to keep up with the piling work will always be present, but giving in to this urge risks you losing key insights and alienating the most important asset you have to expand your hard work: your team.
The fifth principle is where things can get ugly. It doesn't matter how beautiful or fast a boat is, if it has a hole it in, it will sink. Addressing toxic relationships within the workplace is one of the most taxing roles in management, but one universal truth is that ignoring the toxicity just makes it worse. The sixth, seventh, and eighth principles require a great deal of curiosity and effort outside of the normal rhythm of maintaining operations. They need a “roll up your sleeves” kind of mentality and an unwavering desire to improve the team's workflow and processes.
The ninth principle is easier said than done. Because nurses are some of the hardest working people out there, they're often put in management positions because of their ability to execute. However, in management, a different skillset is required to empower those around you to complete the work. A high functioning team's work will always surpass what one hardworking manager can do on his or her own.
The final (10th) management principle came as a piece of wisdom from one of Iora's first physicians, Andrew Schutzbank, MD. He noted that healthcare workers are particularly risk averse in the workplace (and for sometimes good reason), but unchecked, this mentality may curtail innovation. The spirit of courage is imperative when leading teams and developing a culture of sustainable change.
Overall, the similarity between each of these 10 managerial principles is that they require significant intention to continuously focus on relationship building to facilitate team engagement and satisfaction. Ultimately, my belief is that these principles and joy of practice bolster better patient care.
Every patient is deserving
With patients being at the heart of a value-based model, in addition to the annual assessment of team member happiness, it's important to keep a regular pulse on patient satisfaction. Iora collects this type of data through an anonymous survey called the Net Promoter Score (NPS), which includes an optional field for the patient to provide feedback directly to his or her care team. The team reviews the NPS on a weekly basis. Knowing that relationship building with patients takes time, this feedback not only serves as encouragement for team members to continue doing the work they do, but also allows teams to troubleshoot before small issues become systematic issues. Iora's average NPS nationwide for Medicare practices is 90, whereas the traditional primary care office is 4. Although a value-based model is simply doing what's right for patients, NPS allows us to monitor if the model is working and continue to innovate and improve because of it.
Knowing that this type of model is challenging to implement, it's important to start small. Gather input from colleagues about how workplace happiness and patient flow can be improved. The transactional nature of healthcare is what we've become accustomed to, and this may hinder reaching patients in a meaningful way. But small steps can start switching the conversation to a more empathetic model of care within an already established system.