While preparing this third series on Patient-Centered Medical Home, I reviewed the first two.    SETMA’s growing understanding of medical home and SETMA’s expanding deployment of new capabilities in the practice of medical home are reflected in the progression of these series.

In February, 2009, the first mention was made of The SETMA Foundation in relationship to Medical Home.  SETMA began discussing the formation of a charitable foundation in 2003.  The intent was to create a vehicle through which SETMA could help our patients obtain care when they could not otherwise afford it.  In the February 26, 2009 article, it was stated:

“(In) the Medical Home model, the provider has NOT done (his/her) job (by)… simply prescribing…care which meets national standards.  Doing the job of Medical Home requires the prescribing of the best care which is available to the patient…” (Emphasis added)

“…assisting patients in finding the resources to help (them get the care they need)… (is)…a part of medical home.  And, when those resources cannot be found, Medical Home will be ‘done’ by modifying the treatment plan so that what is prescribed can be obtained; the ordering of tests, treatments, and/or prescriptions which we know our patients cannot obtain is not healthcare, even if (that)…plan of care is up to national standards.”

In a Medical-Home article published June 3, 2010 article and which was quoted in series two on Medical Home, August 19, 2010, the Foundation was addressed again:

“The genius of PC-MH is to discover the true implications of SETMA’s motto which was adopted in August, 1995…: ‘Healthcare Where Your Health is the Only Care.’”  It is to put the patient and their needs first… SETMA…placed the patient…at the center of… (as) we developed The SETMA Foundation, through which we help provide funding for the care of our patients who cannot afford it.”

Medical Home and Healthcare Resources

There have been many heroes in SETMA’s Foundation experience.  Other, non-SETMA healthcare providers have contributed their skills and time to the care of our patients.  One of the first patients the Foundation helped had very bad teeth.  Beaumont dentist, Dr. Dave Carpenter, was consulted and he determined that repair of the patient’s teeth would cost $10,400.  The patient’s health could not be helped without resolving her dental issues.  It has long been known that dental care is a critical part of general health. In the case of patients with diabetes, dental care is so important; it has become one of the quality measures for SETMA’s care.

SETMA proposed to Dr. Carpenter that he make a $4,000 contribution to the Foundation and the Foundation would pay him $10,400 to do the dental work.  Without hesitation, he agreed.  The result is remarkable.  First of all the patient’s gratitude made the effort worth it, if there were no other benefit, but the real benefit is that the patient is off all medications and all health problems have resolved.  The patient’s life has been permanently changed and the patient’s future has been made bright.  That’s Medical Home and in that a non-SETMA healthcare provider was key to its success, it really is Medical Neighborhood.

Another patient, who had no insurance, was virtually crippled due to degenerative disease in the hip.  Surgery was not possible because there were no funds.  The Foundation negotiated a payment to a local hospital for the patient’s care.  That same day, I approached Dr. Carl Beaudry and said, “We have a patient that needs a hip replacement and we’d like for you to do the surgery.”  I then said, “There’s only one problem; we would like for you to do the surgery free.”  In the same breath, without asking any questions, Dr. Beaudry said, “OK!’  The surgery has changed this patient’s life.

Concerns about the Foundation

There have been concerns about the Foundation.  One of them is about “setting precedents.”  This really is a question about if you help one person and can’t help another, how will you deal with that.  In a recent discussion about this, I said:

“The fear of setting precedents is only valid if we become victims of our own beneficence.  The ability to say, ‘Yes,’ when appropriate must be balanced by the willingness to say, ‘No.’ when appropriate.  I enjoy saying, ‘Yes,’ but find it easy
to say, ‘No,’ even when it is not welcomed.  If we become shackled by those fears,  we will do…nothing.”

What about those we can’t help?  After we have done all that we can do, we’ll still try to help others.  When at last we can do no more; we can confidently say, “We did all we could.”

The Debt of Gratitude

Seven years ago, my School of Medicine asked me to write an article for the Alumni News; the following is part of that article:

“Tremulously, Private James Ryan, now in his seventies, approached the headstone of Captain John Miller who gave his life that Ryan might live. In perhaps the most poignant moment in a great film, tears stream down his face, as Ryan plaintively said to his wife, ‘Tell me that I have lived a good life; tell me that I have been a good man.’ The sacrifice of others, imposed upon Private Ryan a debt only a noble and honorable life could repay.

“Everyone owes such a debt to someone. The circumstances of that debt may not be as dramatic, but it is just as real. Years ago, a man asked me, ‘Aren't you proud of what you have accomplished?’…’Proud? Yes, but more grateful and humble than proud.’ And, ultimately, I am responsible for the gift and honor of being a physician.

“…there are few gifts as great as that of the opportunity to be a physician. The trust of caring for others has always been a sacred trust. It is a trust which should cause each person so honored to tremble with fear that he/she will not have lived worthily of that honor. It should cause us to examine our lives for evidence that we have been good stewards of the treasure of knowledge, skill, experience, and judgment which has been bequeathed to us by our university, by our professors and by the public which funded our education.

“What nobler calling could one have than the opportunity to collaborate with others in their quest for health and hope? The honor of trust and respect given by strangers, who share their deepest secrets, knowing they will be held sacrosanct, is a gift which exceeds any pecuniary advantage. The pursuit of excellence in the care of others is a passion which is self-motivating.

“Passion is the fuel which energizes any noble endeavor. It is what makes a person get up early in the morning, work hard all day, and go to bed late at night looking forward to the next day. It is a cause of great sadness that today's society is so devoid of true purpose-driven passion. Many only vicariously experience passion through the eyes and lives of athletes, movie stars, or musicians. Ultimately, passion and purpose are what make life worth living. Those of us, who have been allowed the privilege of being physicians, can and should know the passion of a noble purpose every day of our lives.”

The Nature of the Foundation

The SETMA Foundation is an extension of gratitude, honor and passion felt by each partner, provider and participant at SETMA.  In the same time period as these Medical Home series have been written – 2009, 2010, 2011 – the partners of SETMA have given $1,500,000 to the Foundation.  This was not done by coercion but by “cheerful giving.”  Universal American, the parent company for Texan Plus Medicare Advantage gave a $150,000 gift to the Foundation in honor of SETMA’s becoming a Diabetes Center of Excellence in 2010.  .

There are restrictions on how the funds of The Foundation can be spent.  One of them is that none of the money can profit or benefit SETMA.  None of the funds can benefit any provider or partner of SETMA.  The Foundation’s resources are relatively meager.  SETMAs partners will continue to fund the Foundation as long as we can.  There are no guarantees that it will last forever, but it is our hope that it will last for the length of all of our careers at least.

SETMA’s Medical Home and Foundation are great collaborators

Recently, one of SETMA’s nurse practitioner colleagues came to my office. She was beaming and exclaimed, “I have never enjoyed practicing medicine more than I do now.  I just had a patient who I can help but she couldn’t afford her medication.  I sent a referral to the Care Coordination Department and the lady now has her medications.  This is really fun.”  That story can be repeated by every member of SETMA’s team multiple times.

The Associated Press published an article about one of SETMA’s patients and our Medical Home. This patient has benefited extensively from personalized, compassion care through both the PC-MH and the Foundation.  Another patient who was seen initially in February, 2009, has been called SETMA’s Medical Home Poster Child as the patent’s needs and care perfectly illustrate the genius and dynamic of patient-centered medical home with support from The Foundation.

Medical Home Poster Child and the SETMA Foundation

In February, 2009, I saw a patient in the hospital for the first time.  He was angry, hostile, bitter and depressed.  It was impossible to coax him out of his mood. Nurses did not want to go into his room.  When he was ready to leave the hospital, I gave him an appointment to see me, even though he was not my patient.   In his follow-up visit, his affect had not changed.   In that visit, I discovered the patient was only taking four of nine medications because of expense.  He could not afford gas to get the education he needed about his condition. He was genuinely disabled and could not work.  He was losing his eyesight and could not afford to see an ophthalmologist.  He did not know how to apply for disability.  His diabetes had never been treated to goal.

When he left that visit, he had an appointment to SETMA’s American Diabetes Association-approved diabetes self management education program.  The fees for the education program were waived.  The patient also left with a gas card with which to pay for the fuel to get the education which is critical to his care.  SETMA’s staff negotiated a reduced cost with the patient’s pharmacy and made it possible for the pharmacy to bill The SETMA Foundation.  The patient’s care included our assisting him in his application for Social Security disability.  He had a visit that day with SETMA’s ophthalmologist who arranged a referral to an experimental eye-preservation program in Houston, which was free. 

Six weeks later, the patient returned for a follow-up visit.  He had something which I could not prescribe for him; he had hope.  He was smiling and happy.  Without anti-depressants, or sedatives, he was no longer depressed as he now believed there was life after being diagnosed with diabetes for ten years.  And, for the first time, his diabetes was treated to goal.

I continued to see him. Eighteen months later, he was in for a scheduled visit; he was sad. I asked him what the problem was and he said that he was afraid that we would get tired of helping him.  He had applied for and had received disability but he would not be eligible for Medicare for two years.  In two years. without care, he would be blind, in kidney failure, or dead.  He asked if we would stop helping him.  I said, “Yes, we will.  Absolutely, the day after we go bankrupt.”  Melodramatic, yes, but true.  He smiled and relaxed. He now has Medicare; his diabetes is still controlled, and he is doing well. 

Healthcare providers have always been warned about “transference,” which essentially is an emotional bond which a patient develops with a provider and which a provider can also develop with a patient.  While there is a caution to be heeded here, in patient-centered medical home, there is an appropriate bond which develops between patients and providers.  This bond is a caring compassion which has appropriate boundaries but is essential for trust and hope to power a medical home partially funded by a Foundation.