All for One, One for All: Value of Small Teams in Residency Family Medicine Clinics Robert Kraft, MD and Alice Brown, RN Salina Family Healthcare Center, the Family Medicine Clinic for Smoky Hill Family Medicine Residency Program  Introduction  References  Team based care is an important aspect of the New Model of practice  The Future of Family Medicine and the American Academy of Family Physicians advocate team based care  There exists little advice on how to implement or evidence of its impact in an ambulatory practice  There is even less reported on team based care in the Family Medicine Clinics for Family Medicine Residency Programs 1.Roth LM, Markova T, Monsur JC, Severson RK. Effects of Implementation of a Team Model on Physician and Staff Perceptions of a Clinic’s Organizational and Learning Environments. Fam Med 2009; 41(6): Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004 Mar0Apr; 2 Suppl 1:S3-S32.  The way we WERE…  The way we ARE…  Self-Evaluation  Informal discussions and formal evaluation process  Patient satisfaction surveys  Staff satisfaction and office culture surveys  Chart audits  Resident Practice Management rotation project  Who we are…  community based rural family medicine residency  Single site Family Medicine Clinic (FMC) is also a federally qualified community healthcare center  4 teaching faculty, 4 physician assistants (PAs), 12 residents  7790 active patients with 28,751 patient encounters in 2009  In-house laboratory and x-ray  2 years post “go-live” with ambulatory electronic medical record (McKesson Practice Partner, v 9.3.2)  Discussion  Bigger was not better – smaller teams allowed nurses and providers to better know their patients and each other  Improved Provider-Nurse, Provider-MA and Nurse-Patient continuity seems important in improving care in a clinic of part- time providers, like a residency FMC  EMR allowed for decreased direct patient interaction by nurses -- this was not necessarily good patient care  Results, Formal Evaluation 2  Acknowledgements Thank you to Robert Freelove, MD, CEO of Salina Family Healthcare Center and Program Director of Smoky Hill Family Medicine Residency Program for leadership and encouragement and to TransforMED SM for assistance in office cultural assessment.  Results, First Impressions Logo                                                                                            Findings  Patients dissatisfied with ability to get appointment with their provider, telephone wait times and refill turnaround time  Nurses dissatisfied with lack of direct patient contact  MAs wanted more direction, supervision and interaction with Nurses  Providers unhappy about floating/rotating MAs not knowing how they like things to be done and the large volume of patients who were not “their patient” 1.Two large pods – 12 exam rooms each pod 2.10 providers per pod (2 faculty, 6 residents, 2 PAs) 3.Some providers floating across pods patients for the clinic 5.No nurses on the floor - Phone nurse, message nurse, overflow nurse and immunization/coumadin clinic nurse in separate areas of clinic (Purple Team) 6.1 Nurse and 6 Medical Assistants (MAs) floated across the 2 pods - rooming patients 7.Traditional scheduling: all appointments booked on a first call, first filled basis, limited emphasis on scheduling with primary provider 1.Four smaller, well-defined teams (2 teams/pod) 2.5 providers per team (1 faculty, 3 residents, 1 PA) 3.No providers floating across pods 4.Average 1950 per team 5.One “Team” nurse: on the floor, answers all team patient care phone calls, answers team providers messages, supervises team MA; kept immunization/coumadin nurse 6.One “Team” MA per team and one MA shared between two teams – rooming patients 7.Advanced access schedule: keeps open slots for a provider’s patients. Patients scheduled with provider first, then team provider, then any provider  Nurse Supervisor assessment: “The very day we put the nurses back on the floor, there was peace, calm and laughter.”  Results, Formal Evaluation  Improved patient satisfaction with ability to set appointment with provider and rate of phone call turnaround in 24 hours  Patient-Provider continuity increased from 63% to 86% of appointments  88% of all staff (RNs, LPNs, MAs, faculty, residents, PAs) prefer new system and would not return to the old way Red Team Green Team