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).

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

No conflicts of interest to disclose.

Why do we need teams?

Why do we need teams?

Why do we need teams?

Is this a 5-person team?

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

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

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

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:w232-241

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.

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

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:w232-241

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

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

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

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 2012 www.chcf.org

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

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

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

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

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?

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?

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?

Share the care: who does it now?

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

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

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

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 40-50 who want or need mammogram, clinician is involved for discussion Similar for colon cancer screening Requires standing orders 30

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

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

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

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 e-mail Clinician barely involved Blood pressure control improved with this innovation (Margolius et al, Annals of Family Medicine 2012;10:199) 34

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)

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

Teamlets

Health coaching in the teamlet model 38

Physician confidence in MA doing panel management

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

Share the care: who should do it?

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 ,www.chcf.org