Patients are viewed as valued partners in the journey toward healthy outcomes.And when possible, they offer on-site pharmacy services so patients can walk out the door with the medications they need. Instead, they arrange safe rides to and from the clinic when they know patients struggle with reliable transportation. They don’t recommend virtual visits when they know the patient doesn’t have home internet service. They don’t prescribe an expensive medication or treatment if they know the patient can’t afford it.

Physicians recognize and solve for the social determinants of health patients are facing.They don’t simply tell a patient with diabetes, “Make sure you don’t eat bread, pasta, or potatoes.” Instead, they ask the patient where they do their grocery shopping, provide a list of alternative foods to target, and explain how those foods help control their blood sugar. Physicians take as much time as necessary during and between visits to ensure their patients understand their care plan and why each step matters.The physician assumes the role of coach, helping to inspire and influence patients toward making better health choices. It happens between visits, with the patient adhering to the care plan they’ve created alongside their physician. Physicians understand that most of the work of improving health doesn’t happen inside the clinic.We need to adopt a total health care approach that addresses not only patients’ medical conditions but also the personal and socioeconomic challenges that fuel them. To help these patients live longer, healthier, and happier lives, physicians need to do more than write prescriptions and issue instructions.

And many of them harbor a healthy distrust of the health system because they’ve been neglected by it for decades. They come from long-underserved communities that lack resources like reliable transportation or broadband internet access. Most are retired and living on low, fixed incomes. Many of our patients are in their 70s and 80s, living with multiple chronic conditions such as advanced kidney disease, congestive heart failure, and COPD. In our ChenMed centers across the country, we serve patients with some of the most complicated challenges you’ll find in American medicine.

Total system care full