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How One Medical Delivers Culturally Competent Chronic Disease Management

A team-based chronic disease management problem helps One Medical home in on the unique needs and preferences of patients, delivering on culturally competent care.

When Cy Villaflores heard she was at high risk for developing diabetes, a signal from her family health history, she wasn’t quite sure what she should do next. Sure, her doctors all advised weight loss, but there wasn’t any kind of tactile and culturally competent chronic disease management to help her actually do it.

“The advice has always been simple, like, ‘you need to lose weight or eat less sugar because I see your A1C is like this,’ or, ‘your family history is saying you are going to be like this one day,’ and it's like drinking from a fire hose,” Villaflores said in an interview. “Where do I start? I'm not educated in this.”

That’s because Villaflores has been trapped inside a reactive healthcare system her whole life. As a childhood cancer patient, she remembers mostly getting healthcare because she was sick.

As she aged into adulthood, that trend continued, gaining a mindset that healthcare was a treatment when something bad was happening. When doctors would notice a family history of diabetes and see numbers indicating pre-diabetes, they would issue advice to treat her lab tests in that moment in time, not information that would guide a life of wellness.

“A lot of the advice felt fear-based,” Villaflores recalled. “Like, ‘if you don't do this, surely your future will be scary.’ I wouldn't know how to apply that because I'm already nervous. Or it'd be general advice such as, ‘lose weight, you'll feel better. Eat healthier.’”

“But I had no real concept of food,” she added. “I would be like, as long as I eat under a thousand calories, I'll be in this downturn. But nobody tells you outright that it's not sustainable forever just to follow that.”

This is a familiar paradigm for a lot of healthcare providers who are constrained by traditional fee-for-service healthcare models. Stymied by short appointment times and demand to see as many patients as possible, providers don’t have the luxury of truly getting to know a patient and giving out meaningful and contextualized patient education.

Instead, chronic disease prevention and management becomes a prescription, which, according to Hemalee Patel, DO, the senior medical director for chronic care at One Medical, doesn’t make for a good patient or provider experience.

“In a traditional healthcare system, a lot of providers don't have the capacity to actually empower the member or the patient,” Patel told PatientEngagementHIT in a Zoom call. “They're usually coming in and just starting medications, and that, as a physician, is super dissatisfying.”

During those more traditional care interactions, a lot of important information slips through the cracks. While clinicians are almost always on top of patient health metrics and the quantitative data necessary for delivering high-quality care, it’s that qualitative data that’s missing, Patel said. Knowing a person’s background and culture is critical to creating a feasible care management plan.

Most clinicians know that. They want to get to know their patients on this level, but they are resource-limited. A 2022 report from The Physicians Foundation showed that nearly every surveyed doctor sees the utility of understanding patient social determinants of health, but workforce shortages and limited time keep them from digging deeply with patients.

And patients are directly feeling the consequences of those limitations. Villaflores particularly felt limited when getting diet advice from clinicians who were only really equipped to home in on Western cultures and diets; they simply didn’t have the time to learn about Villaflores’ Filipino culture and assess how it could influence her lifestyle needs.

“My family's centered around food. I'm Filipino, so we have Filipino parties with this kind of food, and I always thought it would be a big sacrifice because Filipino food and salads are much different,” she recalled.

Without that cultural guidance, Villaflores was left to Dr. Google. She employed crash diets, relying on unsustainable calorie deficits that, in the long run, did not set her up for a lifestyle change. That impacted her relationship with well-being, thinking she is healed when she succeeded in losing weight and feeling shame when she did not.

That mindset started to shift when Villaflores got a new job in a new city and was looking for a doctor at her company’s benefits fair. At the One Medical booth, where she learned more about the different care models available in the membership-based primary care system now owned by Amazon, she was able to peruse provider profiles.

She said she believed Patel, who’d eventually become her physician, would see her as a whole person and help her on a lifelong journey toward health and well-being.

“When people find a doctor, they want to be taken into account wholly,” Villaflores said. “One thing Dr. Patel did that I loved was she really homed in on me being Filipino, and she tailored my care to it so much, and I just never had that cultural lens. That, to me, was worth a million bucks.”

Beginning a chronic disease prevention program

Because Patel was able to tailor care to Villaflores, it created a strong patient-provider relationship that would ultimately make Villaflores feel comfortable entering the Impact program.

This team-based chronic disease prevention and management program, which started first with patients with diabetes or who are at risk for diabetes, allows for frequent follow-up and wraparound care that helps facilitate an overall lifestyle change. This isn’t the reactive care of Villaflores’ childhood; it’s a system that made patient education and care management accessible enough that she was able to build new habits.

Patel said the program hinges on patient trust, and that begins by understanding how an individual’s illness factors into the rest of their life.

“Chronic disease management is an area that most everybody suffers from, and it traverses anything,” she explained. “As the world is becoming more diverse, having more access and understanding how one approaches health from a literacy standpoint or from an access standpoint via socioeconomic status, it's really important for us to get that right from the get-go when we're looking at a patient, talking to a patient, and understanding really how we're going to address a disease state.”

That culturally competent lens can apply to any part of the care management plan. Take goal-setting. While standard-of-care might be advising 10,000 steps a day, Patel said it’s important to be realistic about patient goals and set them in the context of a patient’s daily life. Maybe 5,000 steps is a better goal for that patient; small change is better than no change, Patel suggested, and it’ll pay dividends when patients see their outcomes improve.

“Just starting somewhere small, but then them seeing that actually even 5,000 steps is going to lower their blood pressure or adding a cup of broccoli is going to lower their blood glucose,” she said.

That new approach—what is good for them, the individual patient—might not have been what got Villaflores to sign up for the Impact program, but it’s what got her to stay.

“I had a personal motivation to stay on the right side of those numbers, but the tools in the program, they were also different too,” she said.

For Villaflores, the mindset shift about diet was unprecedented. She wasn’t being told that she couldn’t eat the food that was important to her culture or that she couldn’t share meals with her family.

Instead, her nutritionist was helping her understand how different food choices impact her health and how she feels.

“They have a nutritionist, Lori, who, gosh, the way she talked about food, it was so different,” Villaflores recalled. “It was not really about calories, but understanding what you're eating, how it affects you.”

Getting that information empowered Villaflores to make her own decisions about food, and, in turn, she’s able to design a diet and lifestyle that she can carry on throughout her entire life.

“I'm taking the guidance and noticing it's working, and as it's working, it's encouraging me more,” she added.

“The trust extends to the team”

Villaflores’ relationship with her nutritionist, and not just her doctor, is another highlight of the program, Patel said. Indeed, patient trust in their provider is essential, but Patel is realistic that patients will connect with non-physician providers, too, and that can open the door for valuable patient insights that allow the entire team to improve care.

“Patients may only be seeing me as their provider,” Patel explained. “They might not want to share too many personal details, but with a health coach, they might be talking about something that stressed them out over the week that's actually significant for me to know as a provider, but they wouldn't want to necessarily tell me.”

Patel noted that having these multiple relationships has been important for getting some patients a mental healthcare referral and has also exposed preventive screening gaps.

“You might unearth that there's a family history of something that wouldn't have normally been told because constantly when a patient is coming in, you're just focusing on their diabetes,” she stated.

Team-based care also serves another key purpose: frequent follow-up. High-touch healthcare is important, especially in a chronic disease population, but it’s often missing in medicine’s fee-for-service models.

When providers have the ability to follow up with the same patient over time, they can uncover different aspects of an individual’s life that ultimately impact care, Patel said. And from the patient’s perspective, it opens an opportunity to fine-tune different care management plans and reevaluate whether a certain approach actually works. It’s about a path to wellness, not an intervention.

Of course, there are some power hierarchies at play. Patel said the physician quarterbacks the team, but having a shared sense of mission helps each member of the care team learn from each other. For example, each care team huddle is led by a different team member each time.

“The trust extends to the team,” she said, “and through the shared joy of taking care of these patients, you end up really leaning on each other in a really nice way.”

Playing the long game toward health and well-being

Villaflores said her healthcare is not a one-and-done deal, and that she still isn’t done working toward better outcomes. She has other conditions she’s keeping an eye on, and she plans to keep working with her provider team to make sure she says on a path toward well-being.

“As I'm aging, I'm asking more questions, and I think that feeling comfortable and trusting your doctor helps you do that in the future,” she explained. “I'm planning with a team that knows my history, and so I feel more confident.”

“I learned that weight management and health is a long game, and that's a huge perspective that changed for me,” Villaflores concluded. “I used to see things as immediate, and so I'm always going to be working on it, but the difference is, it doesn't feel like work. I'm trying to make it my life, not seeing it as maybe a task list that every day I'm looking at.”

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