1. Making Teamwork Work in the Residency­Based Patient­ Centered Medical Home Tziporah Rosenberg, PhD Stephen Schultz, MD Colleen Fogarty, MD University of Rochester School of Medicine and Dentistry Family Medicine Residency Program

2. Objectives 1. Identify the “key ingredients”/roles/personnel of the PCMH team in a residency training program. 2. Enumerate the barriers to creating an effective team as well as strategies to overcome them. 3. Generate methods of measuring team effectiveness in a residency program. 4. Appreciate the difference between the process skills and content expertise requisite to run an effective team in a residency training program.

3. What does the National Demonstration Project (NDP) tell us about teamwork? 36 practices around USA Followed for 2 years Half facilitated, half not Quantitative & qualitative analysis For teamwork: Practice Environment Checklist (PEC) Qualitative analysis of interactions with practices -from Evaluation of the AAFP Patient-Centered Medical Home National Demonstration Project ( Annals of Family Medicine Vol. 8, Supplement 1, 2010)

4. “Practices often had trouble implementing team-based care. Many took initial steps by creating stable physician-medical assistant teams and locating physicians and MAs in same work area; however, these actions were viewed only as important intermediate steps and did not constitute team care.” Nutting PA, et al. Effect of facilitation on practice outcomes in the NDP model of the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):s33-44

5. Practice-based Care Teams The components of this domain: Provider leadership Shared mission and vision Effective communication Task designation by skill set

6. What Helps Form Functional Teams? 1.Developing shared visions of how care teams affect the patient experience 2.Frequent front-back office meetings and retreats 3.Reconfiguring office work flow and patient flow across front-back functions 4.SUBSTANTIAL effort in cross-training, systematically having ongoing training

7. What Helps Form Functional Teams? 5.Establishing standing orders for routine lab ordering, and refilling prescriptions 6.Daily team huddles (NOT to be confused with MD- MA dyad!) 7.“Transformation required substantial shifts in individual roles and personal identities.”

8. The State of the Team in Primary Care The IOM’s call for change in our healthcare delivery system clearly identifies the need for creating practices (and training) built around interdisciplinary teams. Little offered (or published since!) regarding how to apply models that work to the outpatient setting (especially ones in which residents are trained).

9. The State of the Team in Primary Care Grunbach & Bodenheimer authored a 2004 manuscript in JAMA describing the phenomenon of primary care teams, including focus on membership and how each members sees their role and responsibilities identifying key elements of team building: clear goals with measurable outcomes clinical and administrative systems that support teams division of labor training continuous communication.

10. The State of the Team in Primary Care Not too big, not too small, but JUST right. Team cohesiveness appears to correlate with effectiveness, though “effectiveness” is not the same as productivity. So what about outcomes? Not much to say for outpatient care teams Improved learning opportunities, quality of teaching, job satisfaction, staff attitudes toward residents reported by Wayne State’s Markova, Mateo, and Roth (2012; JABFM).

11. Our Context p4 residency program focused on team based care, quality improvement, and merging education and clinical practice Thursday afternoon (weekly) team/teaching time Team Collaboratives (monthly) Interdisciplinary teams (staff, residents, faculty, behaviorists) Additional methods we’ve used to develop teams (retreats, relationship-building, Difficult/Crucial Conversations) Team meetings (incl roles, agenda, structure)

12. What Makes Teams So Danged Hard? Small group process Reflect for a moment individually on your own programs and what barriers have gotten in the way Work with your group to prioritize the top 3-4 barriers in terms of importance, desire for feedback, or general PITA factor Try on a strategy we’ve used with much success

13. Breaking Down Barriers Some strategies we’ve tried have worked! Examples: red dot/green dot, meeting roles, huddles Some haven’t. Or can’t. Examples: multiple sites, staff turnover, meeting roles And how do we know? Issues related to measurement of teamness and effectiveness Relevance in the day to day clinical setting vs “Research”

14. Resources for Change Core functions Adaptive reserve – a practice’s capacity for organizational learning and development 3 components to adaptive reserve: relationship infrastructure facilitated leadership aligned management model “Teamwork…arises when adaptive reserve features are present and operating well.”

15. How Can You Transform Teams in your Program? What We’ve Learned May Help Change ain’t easy. Really, it isn’t. Evolution is key to surviving, and thriving. Change is impossible without investment of time and heart.