Northern New England Systems Transformation for Primary Care
Helen Cornman, MSW, Elisabeth Wilson, MD, MPH, MS-HPEd, and
Amber Barnato, MD, MPH, MS
The Department of Community and Family Medicine at Dartmouth Health and The Dartmouth Institute at Geisel School of Medicine are launching the Northern New England Systems Transformation for Primary Care (NNEST-PC), a hub (or “nest”) for health care leaders who seek change at the practice, system and policy levels to advance equitable primary care and improve the health of rural communities.
Primary care is fundamental to building sustainable health systems and delivering equitable, whole person health care. In rural Northern New England, including New Hampshire, Vermont and Maine, primary care is facing a crisis. Barriers to delivering primary care services include long distances to services, inadequate transportation, inclement weather, insufficient connectivity, lack of affordable housing, low reimbursement rates, and severe workforce shortages.[1] Similar to other areas of the country, levels of burnout among clinicians in primary care practice are also at an all-time high. As highlighted by Rep. Larry Bucshon, M.D., R-Ind., at a recent Congressional Briefing on primary care investment, You don’t pay doctors enough, they don’t go to rural America and people can’t find their doctor.[2] Yet at the same time, the very nature of the problems and the solution space are shifting. Powerful market forces are disrupting the basic service delivery model from provider-centric, face-to-face visits to patient-centric, interdisciplinary team-based, virtual care.
Dartmouth Health and Geisel School of Medicine, based in New Hampshire, comprise one of the most rural integrated academic health systems in the United States. Over 37% of the population and 84% of the landmass in New Hampshire is considered rural, and our residents are older than the average U.S. population (20.2% vs. 17.3% 65 years and older).[3] In Northern New England, our older population is forecast to grow to 40% by 2030, with the fastest growth among those 85 and older. Rural residents are socially and economically marginalized. Intersections of rurality with other forms of marginalization, such as by racial and ethnic grouping, led to some of the worst racial disparities in COVID-19 rates in the country.[4]
All primary care strategic priorities must include a rural health equity lens. The goal of NNEST-PC is to ensure that whole-person and equitable primary care is implemented in our region. By growing a network of health care leaders in partnership with their individual communities, we join and advance the national conversation on implementing high-quality primary care. We achieve this goal by building on four foundational domains: clinical practice, education and training, research and technology, and health policy and advocacy.
Building on these domains, we seek change at three basic levels:
At the clinical practice level, we are engaging with primary care clinics through quality improvement initiatives, pilot redesign projects, practice-based research, and targeted education. We are partnering with clinicians, patients and communities in designing, monitoring and evaluating primary care innovation. We support a team-based approach, expanding the definition and scope of traditional care team models.
At the systems level, we believe that decision makers must be cultivated and empowered training tools to reflect the diverse communities they are meant to serve. We will work with organizational leaders to uplift the voice of primary care as foundational to our health care system.
At the policy level, we are collaborating with coalitions and associations to facilitate relationships with key government officials and agencies to prioritize equitable and whole health care. We plan to achieve this by advocating for increased investment in primary care and influencing legislative changes, particularly those focused on primary care investments such as AHEAD in Vermont and G2211 at the national level. We will also speak out against legislation that perpetuates rural health inequities and negatively impact the health of the communities we serve.
By building sustainable partnerships and ensuring a strong collaborative network, we will continue to champion and advocate for primary care as a common good. We seek to prioritize health equity, resilience and high-quality primary care at the practice, local, and national level to ensure that everyone has a fair and just opportunity to live in the best health possible.[5]
References
According to data released by Modern Health Care on October 16th, family medicine and internal medicine physicians accounted for more than 16,000 of the 71,309 doctors who left the workforce between 2021 and 2022.
https://www.aafp.org/news/government-medicine/furr-medicare-testimony.html
https://www.census.gov/library/visualizations/interactive/population-65-and-older-2021.html
Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.