1. 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 R18HS from the Agency for Healthcare Research & Quality

2. How Can Teams Improve ABCS Performance Measures?

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

4. 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

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

6. Delegated HTN Treatment Protocol

8. Treatment Algorithm & Visit Protocol

9. 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

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

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

12. Teams Improve Outcomes

13. 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

14. 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):

15. 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.

16. 30 LEAP Sites

17. 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.

18. 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

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

20. Key functions of primary care

21. 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.

22. 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.

23. 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)

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