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Welcome to Team-Based Primary Care Presented by Thomas Bodenheimer, MD, MPH The presentation will begin shortly. This webinar will be recorded and used.

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Presentation on theme: "Welcome to Team-Based Primary Care Presented by Thomas Bodenheimer, MD, MPH The presentation will begin shortly. This webinar will be recorded and used."— Presentation transcript:

1 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

6

7 Is this a 5-person team?

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

9 So, why do we need teams? How many of you have achieved same day access for all your patients? How many of you have achieved same day access for all your patients? Good access requires that demand = capacity 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 In your organization – Demand = capacity? – Capacity > demand? – Demand > capacity? Most US primary care practices, Most US primary care practices,  Demand >> capacity We need teams to add capacity We need teams to add capacity

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

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

12 NP/PAs to the rescue? New graduates each year New graduates each year – Nurse practitioners: 8000 – Physician assistants: 4500 % going into primary care % 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 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 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?More clinicians? –Doctors? –Nurse practitioners? –Physician assistants? It won’t happenIt won’t happen We need to think differentlyWe need to think differently We need to increase capacity by empowering other team members to care for patientsWe need to increase capacity by empowering other team members to care for patients Share the careShare the care

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

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

16 Teams can add capacity without adding clinicians High-performing primary care practices have done it High-performing primary care practices have done it These practices have same-day or same- week access with large panel sizes 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 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 If they can do it, so can we

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

18 Engaged leadership Data-driven improvement Empanelment Team-based care Patient-team partnership Population management Continuity of care Prompt access to care Coordination of care Template of the future Willard and Bodenheimer California HealthCare Foundation April Building Blocks

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

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

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

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)

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

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

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 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 Standing orders needed to empower medical assistants Quality of preventive services improves (Chen and Bodenheimer, Arch Intern Med 2011;171:1558) 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) 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 Capacity is increased

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

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

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

32 Non-clinician personnel: share the care Health coaching 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 Capacity is increased

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

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

35 Share the Care: preserving the relationship Share the Care means that the personal clinician (MD, NP, PA) does not provide all the care 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 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 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 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 1 team, 3 teamlets Clinician + MA teamlet Patient panel Clinician + MA teamlet Patient panel Clinician + MA teamlet RN, behavioral health professional, social worker, pharmacist, complex care manager

37 Teamlets

38 Health coaching in the teamlet model

39 Physician confidence in MA doing panel management (n= )

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

41 Share the care: who should do it?

42 Engaged leadership Data-driven improvement Empanelment Team-based care Patient-team partnership Population management Continuity of care Prompt access to care Coordination of care Template of the future Share the Care  10 Building Blocks of High- Performing Primary Care Willard and Bodenheimer California HealthCare Foundation, April 2012,www.chcf.org


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