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1The presentation will begin shortly. Welcome to Team-Based Primary Care Presented by Thomas Bodenheimer, MD, MPHThe 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).
2The components of high-performing teams in primary care Tom Bodenheimer MDAmireh Ghorob MPHRachel Willard MPHCenter for Excellence in Primary CareUCSF Department of Family and Community Medicine
8Teams are difficultThe larger the team the more time and energy it takes to communicateOne person who is uncooperative can ruin a teamEasiest team? Team of 1
9So, why do we need teams?How many of you have achieved same day access for all your patients?Good access requires that demand = capacityDemand: number of appointments patients in your panel wantCapacity: number of appointment slots you offer to patients in your panelIn your organizationDemand = capacity?Capacity > demand?Demand > capacity?Most US primary care practices,Demand >> capacityWe need teams to add capacity
10How do we increase capacity? More doctors?More nurse practitioners (NPs)?More physician assistants (PAs)?
11Colwill et al., Health Affairs, 2008:w232-241 Adult Care: Projected Generalist Supplyvs. Population Growth/AgingShortage of 40,000 by 2020Demand: adult pop.growth/aging, ACA, diabetes/obesitySupply: family med, general internal medColwill et al., Health Affairs, 2008:w
12NP/PAs to the rescue? New graduates each year Nurse practitioners: 8000Physician assistants: 4500% going into primary careNurse 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.
13How do we increase capacity? More clinicians?Doctors?Nurse practitioners?Physician assistants?It won’t happenWe need to think differentlyWe need to increase capacity by empowering other team members to care for patientsShare the care13
14Colwill et al., Health Affairs, 2008:w232-241 Adult Care: Projected Generalist Supplyvs. Population Growth/AgingShortage of 40,000 by 2020Demand: adult pop.growth/agingSupply: family med, general internal medColwill et al., Health Affairs, 2008:w
15Adult primary care: capacity vs. demand It’s not about doctorsShare the careDemand for care=Capacity to provide careThinking differently
16Teams can add capacity without adding clinicians High-performing primary care practices have done itThese practices have same-day or same-week access with large panel sizesRNs, pharmacists, medical assistants (MAs) share in the responsibility to care for the patients of these practicesIf they can do it, so can we
1723 High-Performing Practices Martin’s Point- Evergreen WoodsGroup Health OlympiaFairview Rosemont ClinicHarvard Vanguard MedfordBrigham and Women’s and MGH Ambulatory Practice of the FutureMultnomah County Health DeptAllinaThedaCareMayo Red CenterNorth Shore Physicians GroupMedical Associates ClinicCleveland Clinic- StonebridgeClinic OleClinica Family Health ServicesSebastopol Community HealthMercy ClinicsUniv of Utah- RedstoneNewport News Family PracticeQuincy, Office of the FutureLa Clinica de la RazaWest Los Angeles- VASouth Central Foundation17
18Data-driven improvement Patient-team partnership Population management 10 Building BlocksEngaged leadershipData-driven improvementEmpanelmentTeam-based care12345Patient-team partnershipPopulation managementContinuity of carePrompt access to careCoordination of careTemplate of the future678910Willard and BodenheimerCalifornia HealthCare Foundation April 2012
19Team-based care Culture shift: Share the Care Stable teamlets Co-locationStanding orders/protocolsDefined workflows and roles – workflow mappingTraining, skills checks, and cross trainingGround rulesCommunication – huddles, team meetings, and constant interaction19
20Team-based care: culture shift Instead of: “what can I do to maximize the care of the 30 patients on my schedule today?”MondayPatients8:00AMMs. Ngo8:15AMMr. Barnes8:30AMMs. Reilly8:45AMMr. PadillaThe future: “what can we do to maximize the care of the 1500 patients in our panel?”202020
21Team-based care: stable teamlets PatientpanelPatientpanelPatientpanelClinician + MAteamletClinician + MAteamletClinician + MAteamletRN, behavioral health professional, social worker, pharmacist, complex care manager1 team, 3 teamlets21
22Clinician 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
23Homework: teams in our clinics now Make a chart of the team structure in your clinicDo 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?
24Homework: future teams in our clinics Make a chart of a team structure in your clinic for the futureTeams should be stable (same people working together every day or almost every day)Each team should be responsible for a defined panel of patientsHow many teams?Who is on which team?
25Share the Care What does it mean? Non-clinicians assuming responsibility for care that does not require a MD/NP/PA level of trainingA great way to start sharing the care is population managementPanel managementHealth coachingIs your clinic sharing the care?
27Population-based care: stratifying the panel Panel Management: Ensuring that ALL of the patients in our panel get recommended preventive and chronic careNot dependent on whether they come in for the purpose of preventive care… or even if they come in at all.2727
28Sharing 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 performedPreventive care: immunizations, cancer screening (cervical, breast, colorectal)Chronic care: e.g. diabetes, making sure all lab tests done on timeStanding orders needed to empower medical assistantsQuality 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
29Preventive services: old way Mammogram for 55-year-old healthy womanOld way:Clinician gets reminder that mammo is dueAt next visit, clinician (maybe) orders mammoClinician gets result, (sometimes) notifies patient29
30Preventive services: new way MA (as panel manager) checks registry every monthIf due for mammo, MA sends mammo order to patientResult comes to MA, if normal, MA notifies patientIf abnormal, MA notifies clinician and app’t madeFor most patients, clinician not involvedFor women who want or need mammogram, clinician is involved for discussionSimilar for colon cancer screeningRequires standing orders30
31Stratifying the panelHealth Coaching: Helping patients with chronic conditions to improve their self- management. MA health coaches, RNs, health educators, peer coaches31
32Non-clinician personnel: share the care Health coachingMedical 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
33Chronic care: hypertension: old way Clinician sees today’s blood pressureClinician refills meds or changes meds (maybe)Clinician makes f/u appointmentNo one addresses med adherenceOften blood pressures are not adequately controlled33
34Chronic care: hypertension: new way MA (panel manager) checks registry every monthPatients with abnormal BP contacted for pharmacist, RN, or health coach visitHealth coach does education, med adherence, lifestyle changePatient taught home BP monitoringIf BP elevated and patient med adherent, RN/pharmacist intensifies meds by standing ordersIf questions, quick clinician consultHealth coach f/u by phone orClinician barely involvedBlood pressure control improved with this innovation(Margolius et al, Annals of Family Medicine 2012;10:199)34
35Share the Care: preserving the relationship Share the Care means that the personal clinician (MD, NP, PA) does not provide all the careTo preserve patients’ relationship with the personal clinician, sharing the care should take place in the teamletThe relationship changes from patient-clinician to patient-teamlet81% 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)
36Team-based care: stable teamlets PatientpanelPatientpanelPatientpanelClinician + MAteamletClinician + MAteamletClinician + MAteamletRN, behavioral health professional, social worker, pharmacist, complex care manager1 team, 3 teamlets3636
39Physician confidence in MA doing panel management
40Take-home points Share the care means: Non-clinicians assuming responsibility for carePanel managementHealth coachingIt is challenging without payment reformSharing the care adds capacity without needing more clinicians
42Data-driven improvement Patient-team partnership Population management Engaged leadershipData-driven improvementEmpanelmentTeam-based care12345Patient-team partnershipPopulation managementContinuity of carePrompt access to careCoordination of careTemplate of the future678910Share the Care10 Building Blocks ofHigh- Performing Primary CareWillard and Bodenheimer California HealthCare Foundation, April 2012 ,www.chcf.org