Building Your Primary Care Team To Improve Patient Care and Outcomes: Learning from Effective Ambulatory Practices MacColl Center for Healthcare Innovation Group Health Research Institute Michael Parchman, Director Brian Austin, Associate Director June 22, 2016 This project is supported by grant number R18HS023908 from the Agency for Healthcare Research & Quality

How Can Teams Improve ABCS Performance Measures?

The KP-Southern California HTN Program From 44% to 90% in 13 Years (2000 to 2013)

Teams in KPSC HTN Program “Multidisciplinary team effort…is the point of care where most of the ‘heavy lifting” in the KPSC hypertension program occurred.” MA training on BP measurement Drop-in MA only visits for BP rechecks Delegated RN (& pharmacist) authority for medication adjustments via protocol 2-4 week phone calls by M.A.s to encourage medication adherence

The Medical Assistant Visit No appointment Visit Activities included: BP measurement Review of BP meds Discussed medication adherence Alerted nurse and physician if uncontrolled

Delegated HTN Treatment Protocol

Treatment Algorithm & Visit Protocol

How Can Teams Improve ABCS Clinical Performance Measures? Set performance goals Define roles within the team Identify tasks to meet goals Build Tasks into workflows and match to assigned roles Measure and assess progress

“We depend on each other to get the work done around here” -Primary Care Medical Assistant

Why Primary Care Teams? Improved clinical outcomes Better patient access and experience Improved support for complex patients Reduced burnout

Teams Improve Outcomes

Teamwork Improves Patient And Staff Experience Patients in U. Of Utah team model showed higher satisfaction with practice and with their provider. Day et al., Ann Fam Med 2013 “Working in a tight team structure and perceptions of a greater team culture were associated with less clinician exhaustion.” Willard-Grace et. al, J Am Board Fam Med 2014

Teams Can Expand Access Type of care Percent of physician’s time in traditional practice Estimated percent of physician’s work that can be reallocated to non clinicians Estimated percent of physician’s time saved Preventive 17 60 10 Chronic 37 25 9 Acute 46 5 Total 100 — 24 Thomas S. Bodenheimer and Mark D. Smith: Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians, Health Affairs, 32, no.11 (2013):1881-1886

PCT-LEAP Project Goals: Select 30 high quality, innovative primary care practices that can serve as models for improving primary care teams. Visit and study each practice for 3 1/2 days Summarize what we learn in a web-based Guide. Disseminate the Guide to practices involved in practice transformation, and evaluate.

30 LEAP Sites

Team Structure: Major Findings From Site Visits Providers and their panels supported by Core teams consisting of MAs, front desk, and others. All core teams supported by RN care managers, behavioral health specialists, pharmacists, etc. Medical assistants, receptionists, and lay-persons play key patient care roles . Roles are expanded. All staff work at the top of their license and skillsets.

Primary Care Team Core Team Extended Care Team Cent Receptionist Team RN Health Coach Panel Manager Core Team Provider-MA Teamlet Provider-MA Teamlet Provider-MA Teamlet RN Care Managers Lay Caregivers Pharmacists Behavioral Health Specialists Administrative Staff Extended Care Team

How Do Teams Enable Practices To Achieve The Quadruple Aim? By using their teams to effectively perform key primary care functions.

Key functions of primary care

How do effective practices create effective teams? Hire bright, energetic folks with good interpersonal skills. Define key roles and tasks and distribute them among the team members (everybody at top of their license). Train staff to perform tasks. Use protocols and standing orders to enable staff to operate independently. Establish job ladders. Give teams time to meet.

Care Team Basics Who is on the care team? How are they organized? Those folks needed to respond to all common problems for which patients seek care. How are they organized? Often, around a clinician and medical assistant/nurse dyad. Who is responsible? All have authority &responsibility for elements of care. Requires trust & transparency. What does each member do? The most they can in terms of patient-facing work. Training and role clarity matters. How big are care teams? Smallish, 5-7 team members, communication breaks down with increasing size. How do you know when you’re done? Ongoing efforts, training new staff.

Redesign Care Team Roles Where to start? Daily Huddles Weekly/biweekly QI meetings Start with Core team 1st, then expanded care team Meet together What’s the work? Address staff concerns Understand scope of practice Evaluate how things are going Patient input Plan for spread Redesign Care Team Roles Trust Training Titles Data needs Think hard about part-time providers Standing orders Co-location Facilitate teamwork Put up, take down, then go read the questions (Tram)

www.ImprovingPrimaryCare.org http:/vimeo.com/moogaloop.swf?clip_id=152518627

Coming Attractions July 27th Office Hour August 24th Webinar: Motivational Interviewing September 28th Office Hour And don’t forget, you can go to http://healthyheartsnw.org/events/ to catch up on what you have missed!