One of the, I think, special features of your practice is the strong teamwork approach that you take. Did you invent that? >> [LAUGH] >> Did you borrow it from other places? Tell us more about your approach to working as a team. >> Well, I think, I don't want to say, we invented it, but let's just say we were very early adopters of what is a practice model that has now been come to known, as the patient-centered medical home. And the idea is that patients who have complex chronic illness are often lost in a myriad of subspecialists. And, and there's nobody who's actually looking at the whole patient and coordinating the care among the various subspecialists, and the physical therapists, and the mental health providers. And the, the visiting nurse, and the, you know, nobody who's, sort of, serving as the person who knows about everything that's going on. And so that model, I think, is really what we have built here and over the years. And actually our practice model qualifies with many of the third party payers as meeting the criteria for being designated a patient-centered medical home. We don't have the official designation but we certainly qualify. So, you know, as a provider, physician-provider, I can tell you it was absolutely essential. Because there is no way that I could adequately address all the needs that the patient has in the limited time frame that is available to me to see them. There's just no way. And really, when we try to look at distribution of resources, we should be utilizing the physician resource for the provision of the complex medical care. It's not a good use of the physician resource to be making phone calls to you know, to arrange for temporary housing or that type of thing. So this is another concept of, of, of the, this model of care provision, is that everybody is working, the term that's used is, at the top of their license. Meaning, you know, everybody is doing that for the patient that they are best qualified to do, and we're, we're utilizing those resources which are limited to the best advantage. >> As Margarite was running down the various resources that she tells people about in the first interview or the first meeting that you had with them. I was struck by your description of the peers who share their experiences with new patients, or with continuing patients, would you tell us a little more about that? >> Yes our peers, before we invite them to be part of this program, make sure that their providers agree they're doing well because, you cannot help someone take care of themselves if you're not taking care of yourself. So that's the one thing, that they are adherent to their medication, they come to the clinic on time you know, when they're supposed to. Then we put, we, they go through training where they learn about the different resources that are available. They learn about the disease process. We learn about benefits so that we don't expect them to solve the, the, the patient's problems or to be patient advocates. But we do want them to have an idea in case the patient bring a an issue to them they can call the advocates and say oh, the advocates can help you with this. And, once they've gone through the training, then we, they start working in clinic. And each of the navigators, we have them work with their particular doctors. Because they already have a rapport with the doctor so it's easier for them to, to work with the doctor. Because people tend sometimes to be intimated, intimidated by physician. But if it's someone you've worked with for years, so you're more comfortable working with them. >> Mm-hm. >> And they come to our, what we call our pre-clinic meeting that Dr. Brown mentioned earlier, where they get to hear the discussion that we have about each patient before clinic actually starts. >> Just to be concrete, could you give us one example of the, of a particular patient, of course not identifying them and a problem that the peer navigator helped with? >> I can remember once, it was myself and one of our navigators and fellows, this young lady came to clinic, she was newly diagnosed, just had a baby. She came to clinic, with her partner, they were living together, they weren't married, had not disclosed her status to him. So the doctor called me and said, okay, how are we going to do this because we need to encourage her to disclose to her partner so that he can get tested and that kind of thing. So we brought the peer in on the conversation, so all three of us, we sat down, we thought, how are we going to do this? Then we went to the patient and said, well, we really need to discuss this with your partner. Would you like us to help you with this? So she agreed. So the three of us decided who's going to say what when, and the lady was sitting on the, on the exam room, she had the baby in her hand. We brought the partner in, and once we started telling him, of course he wasn't happy, and he was starting to get a bit violent. So, we had to calm him down, grab the baby from her because he was ready to, you know, get it seems as if he were going to get physical. So then by the time we talk to him, the, the peer pulled him aside, talked to him, and I spoke to the patient because, of course, she was getting upset. And by the time we were done, I'm not saying that it was a beautiful happily, happy ending. But at least he was calmer, the partner was calmer, because the peer had, was able to explain to him, this is what is going on. This is what you can expect. And he convinced him to get tested, so we got him tested that same day. So at that time he didn't, his test was negative, actually he's still negative. Every time he comes, we make sure that we test him. So they're still together, still having issues because of course, there's some trust that's been broken, but they're working on that. And I feel, had we not had the peer's input in this, that it probably would not have gone as well. Because he wasn't able to speak to the partner, and the patient as well. >> It sounds like if that had happened at home without any help and support, it might well have been a disaster. >> [CROSSTALK] Not good. >> [CROSSTALK] Yeah. >> [CROSSTALK] Not good. >> For me, I've found that the value of the peer navigator also has been in helping me convince patients about the value of taking the anti-retroviral therapy. And so again, I can provide the information, the scientific you know, basis, the you know, how this. But having a person, particularly since the peer navigator that I work with, has had HIV for over 20 years and is healthy and, and, and doing well. That person has a credibility with the patient that I just don't have. I, I'm not saying that I don't have credibility. You, you know, I think, for most patients, I mean, the reason they're here is because they're seeking your expertise but I feel like the peer navigator gives credibility to what I'm saying, you know? A real face on the benefits that I'm telling them about and also can give the patient some practical advice about how they implemented, you know, their plan to maintain adherence with this long-term course of therapy. And this is actually again, a model that is not unique to HIV at all. It's being implemented in the management of many chronic diseases and for example, part of patient-centered medical home care and diabetes care involves what's called shared visits. Where you'll have one visit with five or six different individuals who are living with the same disease in which, they'll help each other talk about it. Now, we haven't implemented here, again because of the concerns about confidentiality around the disease we deal with. It would be a bigger challenge, but we can utilize the peer navigators, you know, in that same sort of capacity to just you know, talk about it from the perspective of someone who's lived it, and is continuing to live it. >> And here's a healthy person. >> Exactly. >> Mm-hm. >> Breathing and, and vibrant. >> Mm-hm. >> Because he or she is taking the medicine. >> It's still surprising to me despite the fact HIV is really switched to a chronic disease model, and I think it's, you know, should be widely know that there's effective treatment. Many new patients, newly diagnosed patients we see, still the first question they as is, am I going to die? >> Yeah. >> And so I, I think there's still a lot of lack of understanding that no, you can, actually, if you start treatment and maintain a normal immune system. You can anticipate that HIV will not shorten your lifespan, at least based on what we know currently. >> And that's what I always tell our patient, you come here, it's a partnership, our doctors are the best, and I'm not saying it because I work here, I believe they are the best, but, you have to do your work too. They do their part, your do that part. Your part is to stay on top of your medication if you're on medication. Come to your appointments. If you have a problem with the medication, don't stop, call us, let us know what you, what side effects your having, they tell you what to do. If you do this then, you shouldn't have any problem. >> Yeah and that's the same you know, model that I have to follow, I say it a hundred times. [LAUGH] I have the easy part, I send the prescription, you have the challenging part and that's taking the medicines every day and keeping up with the, so we have to work together. It's really, again like many chronic diseases, we now understand that self-management is key, key to successful treatment.
