1. The presentation will begin shortly.
Welcome to Team-Based Primary Care Presented by Thomas Bodenheimer, MD, MPH
The presentation will begin shortly.
This webinar will be recorded and used for future presentations.
Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative.
This webinar is being offered by the San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California Primary Care Office (PCO).

2. The components of high-performing teams in primary care
Tom Bodenheimer MD
Amireh Ghorob MPH
Rachel Willard MPH
Center for Excellence in Primary Care
UCSF Department of Family and Community Medicine

3. No conflicts of interest to disclose.

4. Why do we need teams?

5. Why do we need teams?

6. Why do we need teams?

7. Is this a 5-person team?

8. Teams are difficult
The larger the team the more time and energy it takes to communicate
One person who is uncooperative can ruin a team
Easiest team? Team of 1

9. So, why do we need teams?
How many of you have achieved same day access for all your patients?
Good access requires that demand = capacity
Demand: number of appointments patients in your panel want
Capacity: number of appointment slots you offer to patients in your panel
In your organization
Demand = capacity?
Capacity > demand?
Demand > capacity?
Most US primary care practices,
Demand >> capacity
We need teams to add capacity

10. How do we increase capacity?
More doctors?
More nurse practitioners (NPs)?
More physician assistants (PAs)?

11. Colwill et al., Health Affairs, 2008:w232-241
Adult Care: Projected Generalist Supply
vs. Population Growth/Aging
Shortage of 40,000 by 2020
Demand: adult pop.
growth/aging, ACA, diabetes/obesity
Supply: family med, general internal med
Colwill et al., Health Affairs, 2008:w

12. NP/PAs to the rescue? New graduates each year
Nurse practitioners: 8000
Physician assistants: 4500
% going into primary care
Nurse practitioners: 65%
Physician assistants: 32%
Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care clinician to population ratio will fall by 9% from 2005 to 2020.
Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.

13. How do we increase capacity?
More clinicians?
Doctors?
Nurse practitioners?
Physician assistants?
It won’t happen
We need to think differently
We need to increase capacity by empowering other team members to care for patients
Share the care 13

14. Colwill et al., Health Affairs, 2008:w232-241
Adult Care: Projected Generalist Supply
vs. Population Growth/Aging
Shortage of 40,000 by 2020
Demand: adult pop.
growth/aging
Supply: family med, general internal med
Colwill et al., Health Affairs, 2008:w

15. Adult primary care: capacity vs. demand
It’s not about doctors
Share the care
Demand for care =
Capacity to provide care
Thinking differently

16. Teams can add capacity without adding clinicians
High-performing primary care practices have done it
These practices have same-day or same-week access with large panel sizes
RNs, pharmacists, medical assistants (MAs) share in the responsibility to care for the patients of these practices
If they can do it, so can we

17. 23 High-Performing Practices
Martin’s Point- Evergreen Woods
Group Health Olympia
Fairview Rosemont Clinic
Harvard Vanguard Medford
Brigham and Women’s and MGH Ambulatory Practice of the Future
Multnomah County Health Dept
Allina
ThedaCare
Mayo Red Center
North Shore Physicians Group
Medical Associates Clinic
Cleveland Clinic- Stonebridge
Clinic Ole
Clinica Family Health Services
Sebastopol Community Health
Mercy Clinics
Univ of Utah- Redstone
Newport News Family Practice
Quincy, Office of the Future
La Clinica de la Raza
West Los Angeles- VA
South Central Foundation 17

18. Data-driven improvement Patient-team partnership Population management
10 Building Blocks
Engaged leadership
Data-driven improvement
Empanelment
Team-based care 1 2 3 4 5
Patient-team partnership
Population management
Continuity of care
Prompt access to care
Coordination of care
Template of the future 6 7 8 9 10
Willard and Bodenheimer
California HealthCare Foundation April

19. Team-based care Culture shift: Share the Care Stable teamlets
Co-location
Standing orders/protocols
Defined workflows and roles – workflow mapping
Training, skills checks, and cross training
Ground rules
Communication – huddles, team meetings, and constant interaction 19

20. Team-based care: culture shift
Instead of: “what can I do to maximize the care of the 30 patients on my schedule today?”
Monday
Patients
8:00AM
Ms. Ngo
8:15AM
Mr. Barnes
8:30AM
Ms. Reilly
8:45AM
Mr. Padilla
The future: “what can we do to maximize the care of the 1500 patients in our panel?” 20 20 20

21. Team-based care: stable teamlets
Patient
panel
Patient
panel
Patient
panel
Clinician + MA
teamlet
Clinician + MA
teamlet
Clinician + MA
teamlet
RN, behavioral health professional, social worker, pharmacist, complex care manager
1 team, 3 teamlets 21

22. Clinician Satisfaction with Teams n=135
Teamlet (work with same MA) (n=27)
Team (work with group of MAs) (n=90)
No teams (work with different MAs) (n=18) 22

23. Homework: teams in our clinics now
Make a chart of the team structure in your clinic
Do you have stable teams (same people working together every day or almost every day)?
How many teams?
Who is on which team?
Is each team responsible for a defined panel of patients?

24. Homework: future teams in our clinics
Make a chart of a team structure in your clinic for the future
Teams should be stable (same people working together every day or almost every day)
Each team should be responsible for a defined panel of patients
How many teams?
Who is on which team?

25. Share the Care What does it mean?
Non-clinicians assuming responsibility for care that does not require a MD/NP/PA level of training
A great way to start sharing the care is population management
Panel management
Health coaching
Is your clinic sharing the care?

26. Share the care: who does it now?

27. Population-based care: stratifying the panel
Panel Management: Ensuring that ALL of the patients in our panel get recommended preventive and chronic care
Not dependent on whether they come in for the purpose of preventive care… or even if they come in at all. 27 27

28. Sharing the care through panel management
Medical assistants use preventive care and chronic disease registries to identify patients overdue for routine services and arrange for those services to be performed
Preventive care: immunizations, cancer screening (cervical, breast, colorectal)
Chronic care: e.g. diabetes, making sure all lab tests done on time
Standing orders needed to empower medical assistants
Quality of preventive services improves (Chen and Bodenheimer, Arch Intern Med 2011;171:1558)
An estimated 50% of all preventive care activities could be shared with medical assistants (Altschuler et al, Annals of Family Medicine 2012;10:396)
Capacity is increased

29. Preventive services: old way
Mammogram for 55-year-old healthy woman
Old way:
Clinician gets reminder that mammo is due
At next visit, clinician (maybe) orders mammo
Clinician gets result, (sometimes) notifies patient 29

30. Preventive services: new way
MA (as panel manager) checks registry every month
If due for mammo, MA sends mammo order to patient
Result comes to MA, if normal, MA notifies patient
If abnormal, MA notifies clinician and app’t made
For most patients, clinician not involved
For women who want or need mammogram, clinician is involved for discussion
Similar for colon cancer screening
Requires standing orders 30

31. Stratifying the panel
Health Coaching: Helping patients with chronic conditions to improve their self- management. MA health coaches, RNs, health educators, peer coaches 31

32. Non-clinician personnel: share the care
Health coaching
Medical assistants trained as health coaches can assist patients with chronic conditions to learn about their disease, engage in healthier behaviors, and increase their medication adherence (Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369)
An estimated 25-30% of all chronic care activities could be shared with medical assistants (Altschuler et al, Annals of Family Medicine 2012;10:396)
Capacity is increased

33. Chronic care: hypertension: old way
Clinician sees today’s blood pressure
Clinician refills meds or changes meds (maybe)
Clinician makes f/u appointment
No one addresses med adherence
Often blood pressures are not adequately controlled 33

34. Chronic care: hypertension: new way
MA (panel manager) checks registry every month
Patients with abnormal BP contacted for pharmacist, RN, or health coach visit
Health coach does education, med adherence, lifestyle change
Patient taught home BP monitoring
If BP elevated and patient med adherent, RN/pharmacist intensifies meds by standing orders
If questions, quick clinician consult
Health coach f/u by phone or
Clinician barely involved
Blood pressure control improved with this innovation
(Margolius et al, Annals of Family Medicine 2012;10:199) 34

35. Share the Care: preserving the relationship
Share the Care means that the personal clinician (MD, NP, PA) does not provide all the care
To preserve patients’ relationship with the personal clinician, sharing the care should take place in the teamlet
The relationship changes from patient-clinician to patient-teamlet
81% of California patients surveyed said they would be willing to be seen by a team even if they see the doctor less often
(Blue Shield of California Foundation, June 2012)

36. Team-based care: stable teamlets
Patient
panel
Patient
panel
Patient
panel
Clinician + MA
teamlet
Clinician + MA
teamlet
Clinician + MA
teamlet
RN, behavioral health professional, social worker, pharmacist, complex care manager
1 team, 3 teamlets 36 36

37. Teamlets

38. Health coaching in the teamlet model38

39. Physician confidence in MA doing panel management

40. Take-home points Share the care means:
Non-clinicians assuming responsibility for care
Panel management
Health coaching
It is challenging without payment reform
Sharing the care adds capacity without needing more clinicians

41. Share the care: who should do it?

42. Data-driven improvement Patient-team partnership Population management
Engaged leadership
Data-driven improvement
Empanelment
Team-based care 1 2 3 4 5
Patient-team partnership
Population management
Continuity of care
Prompt access to care
Coordination of care
Template of the future 6 7 8 9 10
Share the Care
10 Building Blocks of
High- Performing Primary Care
Willard and Bodenheimer California HealthCare Foundation, April 2012 ,