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The Patient Advisory Council Concept Milton H. Seifert, Jr. The Patient Advisory Council (PAC) has been in operation for 8 years in the private, fee-for-service medical practice of Milton H. Seifert, Jr., M.D. Members pay $5 per family per year, and the practice contributes some support for medical activities such as the Annual Health Education Forum. Other than this, there has been no external funding for the council. The purpose of the PAC is to achieve health care delivery that is competent, caring, and appropriate to community needs. It functions to establish a good working relationship between the practice staff and the patient group. Membership is open to all members of the practice, which number 4,000 people. There are four meetings annually of the full council, but working committees meet more frequently, and all meetings are open to anyone in the practice. The areas of council and practice cooperation are detailed in Table 1. This Patient Advisory Council is a major factor in determining the con- duct of the medical practice. Through a cooperative effort of the practice staff and the patient group, the services offered are better able to meet the goals of community oriented primary care as iterated by Drs. Kark and Abrarnson. This is discussed on an itemized basis below. A Defined Population: The practice has counted its patients and deter- mined who are regular patients and who are not. In this study, 75 percent of the total patients were found to be regular patients. This practice has served the same area for 52 years. Availability and Accessibility: The practice provides 24-hour availability through an arrangement with two other practices in the building, as well 239

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240 PART II: PRACTICAL APPLICATIONS TABLE 1 Areas of Council and Practice Cooperation Council Practice Staff A. Organization 1. Membership 2. Treasury 3. Meeting arrangement 4. Recording secretary B. Accountability 1. Policy development and assessment ~ r' . . a. services Improvement 3. Support service C. Patient services 1. Talent bank registry 2. Health education fomm 3. Patient education D. Liaison E. Research Assistance of staff secretary Assistance of staff secretary Assistance of physician and whatever staff is appropriate, e.g., bookkeeper, nurse, . . service coorc lnator Assistance of appropriate staff to acquire practice version of a patient complaint Physician, accountant, practice manager, bookkeeper, and services coordinator at- tend all meetings of this committee Referrals provided by staff Staff assist in program development Staff assist in developing groups and edu- cational formats, usually physicians and nursing staff Assistance of staff secretary Staff assistance in refining a research ques- tion and to aid in issues of human subject use as a 24-hour answering service. Council members provide increased acces- sibility by transporting patients to and from the office. Economic availability is provided by a self-discount program, a Family Therapy Fund, and an Annual Forgiveness Day. These programs are under the supervision of the Support Services Committee of the council. Epidemiology: Diagnostic data are collected on every patient and have been since 1974. Various samplings of these data have been done over the years. The data from these samplings have been compared with published data from other primary care practices, with the Physician Oriented Disease Surveillance Program of the Minnesota State Board of Health and also with the National Ambulatory Medical Care Survey. Our practice compares favorably to other primary care practices, except in the categories of mental health and living disorders, where it has a diagnostic rate of 16 percent, as compared to the usually recorded 3 to 5 percent. These data have been derived without the aid of a computer.

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The Patient Advisory Council Concept 241 Programs to Deal With Health Problems: The practice has several programs to deal with the identified health problems of its patients. These include: the Well Child Care Program, Marriage Health Education, Parenting, Body Weight Management Program, Alcohol Education, Social Drinking, Inten- sive and Maintenance Chemical Dependency Treatment, and Education for Life Management Skills. Community Involvement: Decision making is shared in all areas with mem- bers of the PAC. The practice is accountable to the community through its Policy Development and Assessment Committee, the Services Improve- ment Committee (grievances), and the Support Services Committee (fees, salaries, and practice management). There is also community involvement through health education and patient-to-patient services. Clinical Skills: Patient services are delivered by a full-time family phy- sician, a part-time adjunct physician, a health educator, a living problem counselor, and the usual supporting practice staff members. This provides a broad range of clinical skills, which is broadened even further by estab- lished relationships with various specialists and health resources within the community. Laboratory and x-ray facilities are available on site. Comprehensive Care: Comprehensive care in our practice begins with the study of the diagnostic data. It has been enhanced by adding additional members to the provider staff, especially in the areas of health education and counseling. All problems are considered health problems whether they are physical, mental, emotional, or social. Team Function: The practice staff has monthly meetings, and one per- manent agenda item is "Interdependent Functioning." In addition, the prac- tice staff has developed an Interdependence Protocol. Members of the practice staff meet with the Support Services Committee of the PAC to explore problems and share decision making regarding practice management matters. Outreach: The practice and the council cooperate in an Annual Health Education Forum. A prominent speaker or two are invited, and the audience participates. The council has a Talent Bank Registry, which collects and collates the skills of various people who are willing to share them with other patients. The Talent Bank Registry provides patient-to-patient ser- vices such as babysitting, homemaking, transportation, or physical therapy. The Liaison Committee of the council provides information about the coun- cil to interested consumers or providers. Finally, the practice attempts to identify those patients who are at greater health risk and has procedures to encourage follow-up on health problems that have already been iden- tif~ed. Carative and Rehabilitation Services: There is an integration of the curative and rehabilitation services, especially through the Talent Bank Registry of

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242 PART II: PRACTICAL APPLICATIONS the Patient Advisory Council. Members are available to provide support for persons with grief reaction, epilepsy, mental illness, chemical depen- dency, and others. Our program of continuity is designed to provide main- tenance health services after the acute episode has been treated. Health maintenance and preventive medicine are stressed at the time of annual health examinations. The Patient Advisory Council has played a significant role in this practice. At their suggestion the medical building was refinanced, which led to a 33 percent decrease in rent. With the help of council members, a new book- keeping and billing system was installed. This and the development of improved methods of collecting past due accounts reduced the accounts, receivable of the practice by 30 percent. The council has also helped to improve inventory control and practice staff salaries. The Services Improvement Committee (Grievances) has helped us to better understand the needs of people. It no doubt reduces the risk of committing malpractice, and this has been recognized by our professional liability insurance carrier, who has reduced our malpractice premium by 10 percent because of the participation of the Patient Advisory Council. There are a number of experiences that could be described to illustrate the usefulness of the patient-to-patient services. Suffice to say that these people are providing services that are not available in any other way. In general, the outcome of the health care system is made up of all the individual outcomes of each provider/patient relationship. The delivery of health care services for an individual originates in a single relationship. The better the relationship of provider and patient, the better will be the di- agnostic effort and the better the diagnostic effort, the better the therapeutic effort. Thus, the better the relationship, the better the outcome. The Patient Advisory Council is simply an extension of that relationship at the com- munity level. There is always some relationship between a practice staff and the patient group, but in our case that relationship has been formalized. The Patient Advisory Council is a concept that provides local account- ability and therefore local control of the health system. Since this is the level close to the actual services and their outcomes, the controls should remain appropriate. A local system under the influence of a Patient Advisory Council would be more responsive, more practical, more accountable, and more cost-effective. If the whole system were comprised of local systems such as this, the attributes mentioned would then accrue tO the system as a whole.