1. Paige Hatcher, MD - Diplomate, ABFM - Preventive Medicine Resident, OHSU - MPH Candidate, PSU - Health Policy Fellow, OHA

2.  Average panel size as the population ages is estimated to increase to 2300 per PCP 1.  This would require 7.4 hours a day to provide all their needed preventive care 2 and 10.6 hours a day to manage their chronic conditions 3.  15 minute FFS model

3.  Thomas Bodenhemier, UCSF and California HealthCare Foundation  Based on model for caregiver support  Shift from lone doctor with helpers  Physician has responsibility to make all the decisions and delegates tasks  Delegating tasks from doctor to team implies less work for doctor and more work for others  “We” paradigm means relocating responsibility. The panel is cared for by the team. Ghoroh, A., & Bodenheimer, T. (2012). Share the Care: Building Teams in Primary Care Practices. Journal of the American Board of Family Medicine, 25 (2), 143-145.

4.  Co-location  Team Goals  Mapping Team Workflow  Team Training, Meetings, and Expectations  Standing Orders

5.  Defined Goals and specific, measurable operational objectives  Clinical and Administrative systems  Division of labor  Training and Cross-training  Communication Structures and Processes Grumbach, K. (2004). Can Health Care Teams Improve Primary Care Practice? JAMA: The Journal of the American Medical Association, 291 (10), 1246- 1251. doi: 10.1001/jama.291.10.1246

6.  Optimal size 6-12 members to prevent increasing complexity and number of handoffs  Protected time required for all team members  Redefinition of existing roles, or creation of new ones, is critical  Stability of membership important  Culture Changes/hierarchy

7. Low-Hanging Fruit Procedures for providing prescription refills Escobedo, J. (2002). Rethinking Refills. Family Practice Management, 9 (9), 55-56.

8. Low-Hanging Fruit Pre-visit scrub for preventive care

9. Low-Hanging Fruit Visual Measures The Power of a Green Dot!

10. General Rules Meet prior to each session in a central location Limit the time to several minutes Cover the same agenda every time Stewart, E. E., & Johnson, B. C. (2007). Huddles: Improve Office Efficiency in Mere Minutes. Family Practice Management, 14 (6), 27-29.

11.  What is needed for the day? Equipment, staff, extra time, etc.  Are there any obvious changes that need to be made to the schedule? (errors, rooming particular patients early or late, etc.)  Schedule issues for the day (meetings, breaks, other providers)  Records or lab results that are needed  Identify schedule “bottlenecks”

12.  Procedures for informing patients of laboratory results  Team meetings led by non-physicians  Conflict Resolution Training

13.  Cost per visit hasn’t decreased so far, but satisfaction and turnover have improved tremendously.  Physicians estimate that 50% of their time is spent on activities that could be performed by caregivers with far less training  Services provided outside the visit, and by non- physicians are harder to bill.  May increase volume and access and decrease costs to system at-large. Bodenheimer, T. (2007, July). Building Teams in Primary Care: Lessons Learned (Rep. No. ISBN 1-933795-30-1).

14.  Previsit  Huddle  Agenda Setting  Medication Reconciliation  Ordering Routing Services  History Taking  Visit  Postvisit  Soliciting Patient Concerns  Closing the Loop  Goal Setting  Navigating the System Bodenheimer, T., & Laing, B. Y. (2007). The Teamlet Model of Primary Care. The Annals of Family Medicine, 5 (5), 457-461. doi: 10.1370/afm.731

15. 1. Alexander, G.C., J. Kurlander, M.K. Wynia. “Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics.” Journal of General Internal Medicine 2005; 20:1079–83. 2. Yarnall, K.S., K.I. Pollak, T. Ostbye, K.M. Krause, J.L. Michener. “Primary care: is there enough time for prevention?” American Journal of Public Health 2003; 93:635–41. 3. Ostbye, T., K.S. Yarnal, K.M. Krause, K.I. Pollak, M. Gradison, J.L. Michener. “Is there time for management of patients with chronic diseases in primary care?” Annals of Family Medicine 2005; 3:209–14.