APCC Care: All-Around, Personalized, Continuous, Coordinated Care

By providing "APCC Care", that is, All-around, Personalized, Continuing, and Coordinated Care, I had kept my patients healthier during the years I practiced: according to Medicare data for the 5 years 2010 to 2014, after adjusting for disease severity, my patients were admitted to the hospital 38% less than the national average.

APCC Care Generates Clinical Reasoning that Enables
Whole Person Longitudinal Complex Care

Generalist APCC Care generates a constantly updated and refined whole person clinical reasoning and treatment logic. This reasoning and logic is applied by the APCC Care doctor across time and care settings—office, hospital, nursing home. It is also communicated to the patient's other providers: specialists, PT, home health, hospital staff, nursing home staff, etc.—the whole care team. For complex patients, this is Whole Person Longitudinal Complex Care, and it is the missing piece to better outcomes and better costs for such patients.

The Four Components of APCC Care

1. All-Around Care

All-around care means the APCC Care generalist doctor, with broad training that cuts across all body parts and organ systems, can take in most any problem that the patient presents and devise a solution for it. The solution may be a prescription, a treatment, a piece of advice, a test, a procedure, hospitalization, a referral to a specialist doctor, or a referral to another provider like a physical therapist.

All-around care means that the patient is looked at, not just as a body part or an organ system, but as a whole individual, and all the problems, not just piecemeal, followed up. All-around care means attention to how all the patient's different medical and other conditions, as well as the lifestyle and activities, interact, plus how all that and the proposed treatment may interact. Also, because it is a generalist doctor, he/she can follow up several problems at one visit, thus enabling him/her to balance all the treatments and conditions, and to intervene in a more timely manner without waiting for another appointment with another provider for that organ or body system.

This kind of all-around and continuous approach is especially important in older, sicker, more complex patients with multiple ongoing chronic medical conditions. Not only do multiple conditions often interact with each other to give confusing signs and symptoms, but also they require multiple treatment regimens that often adversely interact with and even contradict each other. An all-around and continuous care approach is much better suited to efficiently following up on multiple conditions, figuring out the myraid signs and symptoms, fine-tuning the treatments, balancing or mitigating the contradictions that arise with the different treatment regimens for the various different problems, and thus optimizing the overall outcome. Further, the more efficient follow up of multiple conditions, all at one time, can often mean that problems that arise can be dealt with early, without waiting, when they are still mild and easy to solve, which is often of critical importance in older, sicker, more complex patients.

Also, the APCC Care generalist doctor, by dint of his broad, overall training, experience and outlook, which cut across all body parts and organ systems, is often the professional to go to for figuring out which body part or organ system a symptom or a problem comes from, especially when the disease is at an early stage. Sometimes the source of a symptom may not be obvious at all, such as the shoulder pain that is not an orthopedic problem of bone or tendon but actually a cardiac one of angina or a gastrointestinal one of gallbladder.

Again due to broad training, experience and outlook cutting across all body parts and organ systems, a generalist doctor is often the professional to go to for evaluating and managing vague, undifferentiated symptoms that come from diseases showing up at a very early or a very mild stage. At such stages of disease not only is it often difficult to decide which body part or organ system such symptoms come from, but also it is often difficult and sometimes impossible to distinguish them, even with very expensive and potentially harmful invasive testing, from minor, transient illness or illness with a strong psychological component. A generalist doctor who is used to evaluating, managing and following such symptoms can avoid testing up a number of long expensive blind alleys and the subsequent delays to timely diagnosis of potentially serious disease, or even abandonement of any attempt at diagnosis at all. Instead, skilled, close follow-up, along with appropriately timed and carefully chosen tests or therapeutic trials, can often lead to timely diagnosis and appropriate treatment.

The essence of all-around generalist care is not comprehensiveness, as in one doctor doing it all, which is only a remote area or horse-and-buggy-day scenario. The essence of all-around generalist care is first, a broad focus, on the overall patient, and second, training, experience and outlook that cut across all body parts and organ systems.

Even when it comes to referral to a specialist colleague, the generalist doctor provides value by first, ensuring an appropriate referral, to the appropriate specialist. Second, by giving the specialist colleague input when necessary about the overall picture of the patient, the generalist helps the specialist customize the patient's care. Third, the generalist can coordinate the care among different specialists. Finally, fourth, the generalist continues to follow up as the general physician on the patient overall even after a specialist is seeing the patient for a certain problem.

An APCC Care doctor definitely does not consider himself/herself to merely be a "gatekeeper".


2. Personalized Care

Personalized care is what many patients want nowadays, the kind that the family doctor provided back in the "good old days".

With all-around care, the ability to take in all problems enables the patient to come see the APCC Care doctor repeatedly for different matters, and thus he gets to know all the patient's problems, not just those of one organ system. Furthermore, he also gets to know the patient and his or her goals and preferences more personally. Thus, the doctor becomes an expert on the patient, and can personalize any care delivered. In turn, the patient comes to know, trust, and communicate well with the doctor and the staff.

Also with all-around care, the care can be personalized and tailored all-around, to all aspects of the patient, as a whole individual. The APCC Care doctor takes care to personalize management, to juggle and balance the often conflicting treatments, and to balance the burden of treatment with the patient's goals and preferences. This thoroughgoing personalized talored care, along with the trust and communication that gets built up, enables much better shared decision making by doctor and patient, much more timely and precise adjustment and fine-tuning of treatment, and therefore much better outcomes.

The APCC Care generalist has a personal team of staff (one doctor, one team) with a personal phone line, and deliberately keeps the team small, so that the staff get to know the patients and their needs on a more personalized level.


3. Continuous Care

Continuous care is to ensure that the all-around, tailored, personalized treatment logic continues, especially when the patient is at his or her sickest and most complicated, like when they are in hospital. Continuous care means that there is always management by the doctor who knows the patient overall and who knows the treatment overall.

Continuous care means the patient sees the same doctor over time, and this is very much more so with the all-around care that the APCC Care doctor provides, as he can see the patient for different problems, not just those of one body part or organ system.

To provide continuous care means that the APCC Care doctor sees his/her patients when they are hospitalized, since that's when they are the sickest and most in need of continuity of the all-around, tailored, personalized treatment logic. The APCC Care doctor will go to the hospital to be the attending physician in overall charge of his/her patients throughout their stay. When patients are admitted under a specialist colleague as attending physician for say, surgery or for testing, the APCC Care doctor will also go see them if requested, that is, to act as consulting physician, and work together with the specialist colleague to provide all-around care during the hospitalization.

Again to ensure continuity of all-around care, the APCC Care doctor sees his/her patients when they go into the nursing home.

Also, to help ensure continuity and timeliness of care, the APCC Care doctor has some extended hours. This is often important for family to be able to accompany complex, frail patients to their visits.

Finally, as part of continuity and timeliness of care, the APCC Care doctor is available to be reached by the patients for urgent matters after hours. In my 40 years of experience, patients do not abuse this privilege and I had often been quite thankful that they called—saved me a lot of work.


4. Coordinated Care

First, coordinated care means that all the care the patient gets from the APCC Care doctor plus from different providers like specialist doctors, physical therapists, pharmacists, home health and so forth, are customized and coordinated according to the patient's individual overall health and wishes and goals. This way the treatments from different providers complement each other and therefore are able to achieve the best effect for the patient. Also, this way the treatments from different providers don't conflict with each other. When needed the APCC Care doctor will also bring to the attention of the different specialities what he and other specilaties ae doing that may be relevant.

Second, coordinated care means that the APCC Care generalist, who has both an overall view of things and a medical understanding of what the specialties are doing, can explain, especially when a number of different specialties are involved, the different aspects of care to the patient and help him or her get an overall view and make sense of things.