Yale Bulletin and Calendar

May 24, 2002Volume 30, Number 30Two-Week Issue

Clinical receptionist Mary McGovern assists a visitor at the Yale University Health Services Center's information desk. The information desk is among the new offerings at the center.

IN FOCUS: Yale University Health Services Center

New patient-focused initiatives are already bringing results

It's a time-honored practice: When people have medical problems, they contact their health care provider and make an appointment.

But the Yale University Health Services Center is now turning that dynamic on its head by having its staff contact at-risk patients and invite them in for appointments before they develop serious health problems.

This new relationship between the health care facility and its patients is part of a re-thinking of the center's programs and services being spearheaded by Dr. Paul Genecin, who was recently appointed to his second five-year term as director of Yale University Health Services (YUHS).

In addition to providing medical care to the University's graduate and undergraduate students, YUHS serves faculty and staff through the Yale Health Plan (YHP).

"We have a mission to keep members of the Yale community healthy and to provide them with excellent care," says Genecin.

To achieve this, he notes, YUHS caregivers first need to know who their patients are and identify their special needs.

"We have individual people who need individual health care. We also have populations within our patient population," he says. "People have needs, and they don't necessarily address their own needs. Sometimes, they are reliant on their health care facility to lead them in the direction of optimal health care or lifestyle.

"For example, diabetics have special needs," he adds. "If you look at the national statistics on the care of adult diabetics, it's really lamentable how few get foot exams and eye exams, how few have well-controlled sugar, how few of them are getting screened and treated appropriately to prevent kidney failure." The same is true for other patients with chronic conditions, such as asthma, as well as groups with specific health concerns, such as women, seniors and students, notes Genecin.

The key to keeping those patient populations healthy is to reach out to them and urge them to get needed care, he says. "It's different from the traditional medical mindset, which is: 'I sit in my office and I wait to see patients who have thought to make an appointment with me.'

"Now you are being proactive. You are saying: 'I am going to reach out to people because they belong to a group of people who have special needs, special vulnerabilities, special risks. I am going to invite them in.'" This approach increases the odds patients will "live to old age in healthy condition," says Genecin.

There is already evidence that this approach works, he notes. YHP recently sent a letter to its members over age 60, suggesting they be inoculated against pneumococcal pneumonia, a serious health risk for seniors. As a result, "We have increased the rate of immunization of our older members by four-fold -- to four times the national average -- within months," says Genecin.

Yale has attended to the medical needs of its students since the 1900s through various departments and at various facilities. YUHS, which was formally established in 1971, widened that circle of care to students, faculty and staff and their dependents, and created a central facility at 17 Hillhouse Ave. with its own team of medical professionals.

"There's both an advantage and a disadvantage to being an old health plan -- 31 years is extremely old," says Genecin. "It gives the advantage of stability and gives us the advantage of being part of the Yale culture. But there are also a lot of habits of work ingrained which, if you were creating a health plan in 2002, wouldn't be part of it."

For example, says Genecin, "you'd be thinking what the needs of people are, schedule-wise." Some people can't take time off from their 9-to-5 jobs for routine medical procedures, and parents want to know early in the morning whether they need to take the day off to care for a sick child, he notes. "Many Yale students don't use health care resources in the morning. It's just part of the culture of being a college student. Students are up at three in the morning, and that means they don't want to come in for a nine o'clock appointment. It doesn't matter if they're sick or not."

To accommodate these needs, many YUHS departments have changed or extended their hours. For example, the Pediatrics Department now opens at 7:30 a.m., while the Student Medicine Department is open until 6:30 p.m. Monday-Thursday during the academic year. Other departments are offering off-hours clinics. "The idea is to push the hours out, and I think over the next year we'll see a lot more of it," says Genecin.

Other patient-oriented improvements introduced in recent years include a larger parking lot with an attendant who directs motorists to open spaces, and an information desk in the lobby with a greeter who helps new members navigate the facility. "A lot of improvements are very mundane, but they make all the difference in the world," says Genecin.

Another major initiative launched this year is Yale Health Online, which allows members to communicate directly and securely with YUHS staff via the Internet at www.yalehealthonline.yale.edu. Patients can use the service to schedule appointments, renew prescriptions and even pose health-related questions. Like online banking, Yale Health Online uses encrypted e-mail to ensure confidentiality. Patients' messages are directed to a "listening post" in the appropriate department, where they are monitored and "triaged," explains Genecin. The service is already up and running in several departments and will be system-wide by the end of the year, he says.

Yale Health Online is "part of a trend that we have been pushing forward -- to increasingly automate what can be automated," says Genecin. During his first term as director, the center introduced "a significant information system" for scheduling appointments, processing claims and bills, and identifying patient populations.

"The next step after that is electronic medical records," he says. When this is in place, clinicians will be able to access a patient's history, laboratory data and list of medications simply by calling up an on-screen "dash board," notes Genecin. "The goal is to get all this as integrated as possible, so there are not these pieces of information about people floating around that are inaccessible or inaccurate."

As he looks ahead to his second term as YUHS director, Genecin sees several challenges on the horizon.

The first is in the area of student health, "which is so central to our mission," he notes. While there are longstanding health concerns affecting students -- such as tobacco and alcohol abuse, eating disorders and issues related to sexuality -- "the amount of attention we have to pay to students from the standpoint of stress is now much higher," he notes. "It's a huge concern. It requires constant reflection and a willingness to try different things, because what works for one college doesn't work for another, and what works one year doesn't seem to work the next year."

Furthermore, the increasing number of international students on campus adds "a wonderful diversity to the University, but they have a diversity of health-care assumptions, cultural experiences and problems that either have or have not been attended to," says Genecin. "It's a big challenge."

Like most other health care facilities today, YUHS is grappling with the question of how to cope with escalating medical costs.

"We are in an era in which there is -- not a creep -- but a very, very steep trajectory of increase in medical costs," says Genecin. "It becomes a very big challenge to live within finite resources, to do great things for people and ever-better things for people, on the one hand, and, on the other hand, deal with huge escalations in costs."

The issue is especially complicated because expensive new technologies and treatments don't necessarily bring proportionate benefits, he says. "Very often you don't see the increase in health outcomes that you'd wish as compared with the increase in costs of diagnostic tests, for example. The same can be said of new medications. You don't necessarily see the advantage when a new and expensive drug comes out over an old and cheap drug."

The goal is to strike the right balance between costs and benefits, he says. "A kid with leukemia or lymphoma can get a bone marrow transplant and be cured. That's an extremely expensive procedure, but I can't think of anything better to spend money on."

Equally problematic is meeting the space needs of the growing number of departments, services and patients at the three-decades-old facility. The center now serves over 30,000 students, staff, faculty and their dependents, and its membership has increased about 8% over the past five to seven years, notes Genecin. "That represents a big growth because we were already at our maximum in terms of accommodating people and space." He and other campus administrators are currently considering their options, including the possibility of building a new facility.

Still another challenge on the horizon is largely self-imposed. Because of its status as an employer-owned health plan, YHP is not required by law to be accredited by the Joint Commission on Accreditation of Health-Care Organizations. Under Genecin's leadership, however, YHP has begun a "massive overhaul of how we do business on every level" and will seek accreditation in 2004.

"There are a lot of quality-improvement measures imbedded in the philosophy of accreditation," says Genecin. "The whole purpose is to say: 'Our mission is this: to provide excellent, accessible care to our members.' Every type of thing you do in accreditation has to support that."

A specialist in liver disease who served on the YUHS medical staff for eight years before becoming director, Genecin describes the center as "a great place to be at a very interesting and challenging time in health care. ...

"People often ask me: 'Don't you miss being a people's doctor?'" he says. "In a way I do, but I also have to say there is nothing I do that isn't clinical, because there's no decision in a health plan of this size and scale that doesn't affect individual people. It's still being a doctor. It's just thinking of it at a system level.

"This is the best job at Yale," he says, "We never have a dull day."

-- By LuAnn Bishop


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IN FOCUS: Yale University Health Services Center

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