1. Communication, Relationship and Efficiency: Building individual mastery through teamwork Larry Mauksch, M.Ed Senior Lecturer Department of Family Medicine University of Washington Cici Bean Asplund, MD Wenatchee Valley Clinic Wenatchee, Washington

2. Outline From burnout to flame on Cici Challenge of primary care Team work Training Larry

3. Seattle Wenatchee V V V V

5. Increase Patient Satisfaction Identify and Treat Depression Recognize Domestic Violence & Elder Abuse Increase Quality of Chronic Illness Care PharmacoVigilance! Don’t Miss the Diagnosis! (...A.C.S. to Zebra...) Evidence-Based Principles!

6. How does it feel, as a Primary Care Provider? --Sisyphus was a PCP?

7. “Listening Well” at WVMC  2007 to present  “Hearing more than just the lyrics”

8. Institutional Endorsement is Powerful Makes values tangible Helped me reconnect with original values for going into medicine I am supported in creating a place where healing can happen Teams feel encouraged to adopt core values

9. Observing and Being Observed Value of observing Creating the “observer self” Using a common language to describe skills The value of being observed Creating a partnership in problem solving Getting feedback

10. Agenda Setting Differentiated, flexible skill Quick results in practice Permission to manage time aids focus

11. Teaching Creates Reflection Time must be protected in order to teach Reflection improves language Reflection reinforces mindfulness

12. Teamwork is a Hopeful Experience We need the help Sharing hope creates cohesiveness Varied talents support adaptability

13. This is important to us. A place where healing happens Caring for our patients A core value for our team

14. Primary Care The challenge

15. US Prevalence (2001) of Multiple Risk Factors in Adults ≥ 18 Am J Prev Med 2004 27(2S) 18-24 Risk Factors: Alcohol abuse, overweight, sedentary life style, smoking Estimated US percent 010 133 241 314 43 Mean1.7 per person

16. Primary Care Realities Primary Care patients average 3-6 problems per visit Indigent primary care populations have a greater illness burden Half of adults have two or more chronic illnesses

17. Stages of Activation Hibbard et al Health Services Research 2007, 42(4) 1443-63 Level of activation (age 45 or older, 2.9 chronic conditions) diabetes, HTN, lung, cholesterol, arthritis, heart Percent (cumulative) May be overwhelmed and unprepared to play an active role in their own health 12 May lack knowledge and confidence about self management 29 (41) Taking action but may lack confidence and skill to support self management 37 (78) Mastered self management but may not maintain behaviors at times of stress 22 (100)

18. Mental Disorders in Primary Care J of Fam Practice 200150(1), 41-47

19. Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214. 2500 patients Conservative time estimates Ten most common Chronic illnesses Well controlled 3.5 hrs/day Poorly controlled 10.5 hrs/day Preventive care Level A and B recommendations 7.4 Hours per day

20. Patient Centered Medical Home: Two interdependent components Rogers, PCMH Movement: Promise and peril for family medicine. JABFP, 2008 21(5) Infrastructure Care Info tracking between HC settings E-Planning, E-Rx EHR Open access

21. Teamwork The solution

22. Why Are High Functioning Teams Essential To Primary Care Too much work for one person Collaboration produces better outcomes Effective teams help sustain healthy behaviors in their members and in patients Less likely that important issues will be missed and more likely that problems will be solved creatively

23. Role versus Function Toward transdisciplinary teamwork

24. Continuum of Role Integration Multi-disciplinary Clinical separation Minimal sharing of information or responsibility or coordination of care Interdisciplinary Team effort for cooperation, cohesiveness, shared information, responsibility. Professional status and protectionism are barriers optimal function Transdisciplinary Complexity of the patient or population informs team membership and process “Role release” – overlapping function across disciplinary boundaries, collaborative power sharing.

25. A set of functions associated with training, credentials and license Role An action or activity Many can be mastered by multiple disciplines Starfield: Supplementary --foot check Complementary --behavior change Substitute --diagnosis Function Role and Functions in Health Care

26. Transdisciplinary Functions in Primary Care Role Function PCPNurseMedical Assistant PharmBehaviora l health Care Manage r Relationship Agenda setting and assess activation Self management- simple Self management- complex Primary care counseling Plan confirmation and care integration Proactive follow-up and stepped care Psychotherapy Intensityalwaysoftenperiodicsupportreinforceconnect

27. Agenda Setting and Activation Organize the visit and manage time Help patients get their needs voiced Assess activation level Check on goal progress Identify cues about fears or questions

28. Self Management-Complex (Integration of Motivational Interviewing and Patient Activation Models) Examples Multiple biomedical and mental illnesses Unexplored illness beliefs Distrust in health care Financial strain Low confidence in self management Health Behavior Counseling Educatio n Addressing ambivalence Problem solving Building confidence Relapse prevention

29. Training Skill differentiation precedes skill integration Follow the patient

30. Barriers Lack of faculty training Limited vocabulary for teaching Intangible skills Fear of loss of control of time Limited faculty time for direct observation Limited team focus on health behavior Stigma and hidden curriculum

31. Educational Strategies Use team training to reinforce skill use Team members follow the patient through a full visit Make skills tangible: common and better video Improve trainee vision and vocabulary using observation forms Increase direct observation and feedback Observe peers to increase self awareness Have trainees dissect their own skills using video Online form training

32. Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective 3. Co-creating a plan

33. Medical School Training Faculty report increase self awareness and improvement in clinical activity Students demonstrate skill mastery on video and report increased confidence using communication skills and managing time Students report being less anxious about time use, more able to learn medicine and form partnerships 3 rd yr Family Medicine Clerkship and 4 th yr elective: Paired Observation and Video Editing

34. Residency Training Residents report increased awareness of interview skills, health behavior change skills and communication while using the EHR Faculty report the same! Collaborative observation by a behavioral science and physician faculty team-all three years Learn vocabulary and skills through structured peer observation, observation by faculty and video review –all three years

35. Examples from Five Large Multispecialty Groups Improved patient and provider satisfaction, enhanced team cohesiveness, improved agenda setting (RCT). Coaching by experts and and in house trained trainers Video interviews of “high satisfaction providers and teams” Team members follow patients through the visit using forms and discuss experience Interaction skill training for all team members

36. Bibliography 1. Arnold RW, Losh DP, Mauksch LB, et al. Lexicon creation to promote faculty development in medical communication. Patient Educ Couns 2009;74:179-83. 2.Cameron J, Mauksch L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health 2002;20:343-63. 3.Egnew TR, Mauksch LB, Greer T, Farber SJ. Integrating communication training into a required family medicine clerkship. Acad Med 2004;79:737-43. 4.Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns? Fam Pract Manag 2008;15:35-40. 5.Kim S, Spielberg F, Mauksch L, et al. Comparing narrative and multiple- choice formats in online communication skill assessment. Med Educ 2009;43:533-41. 6.Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical students: an innovative strategy. Acad Med 2005;80:118-24.

37. Bibliography Continued 7. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model From a Literature Review. Arch Intern Med 2008;168:1387-95. 8.Mauksch LB, Hillenburg L, Robins L. The established focus protocol: training for collaborative agenda setting and time management in the medical interview. Families, Systems and Health 2001;19:147-57. 9.Mauksch LB, Reitz R, Tucker S, Hurd S, Russo J, Katon WJ. Improving quality of care for mental illness in an uninsured, low-income primary care population. Gen Hosp Psychiatry 2007;29:302-9. 10.Mauksch LB, Tucker SM, Katon WJ, et al. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001;50:41-7. 11.Schirmer JM, Mauksch L, Lang F, et al. Assessing communication competence: a review of current tools. Fam Med 2005;37:184-92.

38. Five Questions for the Team I s the patient confident in being able to carry out the plan? Is the patient invested in the plan? Do we understand the patient’s view on today’s health concerns? Have we confirmed what is most important to this patient today ? A nd to us? Have we made a connection with this patient?

39. The Patient’s Path MA/ Nurse BH Warm greeting, elicits agenda, activates patient, may provide HBC MD ARNP PA Makes connection, confirms, elicits, and negotiates agenda, provides care, promotes self management MA/ Nurse BH Elicits questions, Makes connections, Provides education, Resources, F/U Support, beh change Tx, counseling Patient uses e-planning Front Office Greets patient and introduces form and acknowledges e-plan receipt

40. The complexity of the health care system has to match the complexity of the patient in the context of family, community and culture