1. How to Create and Maintain High Functioning Primary Care Teams
The experience of Union Square Family Health Center, Cambridge Health Alliance
Gladys Angel, MA
Kirsten Meisinger MD

2. Disclosures
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

3. Cambridge Health Alliance
An academic public health safety net system outside of Boston
12 medium-sized community health centers, 3 school-based clinics, 2 hospitals, specialty clinics
Largely public payer mix – 82%,almost all Medicaid
>50% patients speak language other than English
600,000 outpatient visits/year
160,000 primary care visits for 92,000 patients

4. Union Square Family Health Center4

5. Who are we? Founded 1998 Full spectrum Family Medicine Care
9 MDs, 3 Pas
25,000 patient visits/yr
80 percent with public or no insurance
Onsite Services also include Nutrition, Adult and Child Psychiatry and therapy, Social Work, Family Planning, Lab, Complex Care Management, Referral Coordinator and Pharmacist services
Team care since 2005 5

6. Where we are 40% Brazilian
20% Spanish speakers from most of Latin America
8% Haitian Creole
Sizable Hindi, Gujarati, Punjabi and Nepali populations

7. Why teams?
Places patient at the center – MD not the center of staff attention
Entire staff know and own the care of the patient
Work is distributed according to level of staff training (e.g. RNs free to do RN level tasks)
Improves quality and efficiency of care
Makes primary care possible and ENJOYABLE!

8. COMMUNITY MR MA Patient = “Captain” Primary Care Provider Registered
Nurse
Complex
Care Manager
Patient =
“Captain” MR MA

9. The Basics of What You Need
Create good Will – things aren’t so great now, much less boring with the team model, so folks have to be willing to try something different
Data – important to have accurate information about the work (lists!)
Time – need to schedule time to do the work (time = value) DM

10. So who is our team? Front Desk Staff added soon after
USFH: Initial teams of MA, MD; RNs “on the team” but not really integrated into clinic flow
Main focus was the MA/MD Dyad
Front Desk Staff added soon after
The complex social relationships between our patients are key to both successful outreach and engaging a population
“Aha” moment: all of our primary care work—not just our quality goal work—could be conceptualized as work done by teams
Diabetic patient for flu shot example

11. Team Photo – Communicating this way of working to the patients

12. Union Square Business Cards

13. How Teams Structure The Work- It Evolves as Members are Added
The work of the team is organized around four processes: pre-visit, visit, post-visit and between visits
All MA-MD pairs Huddle before visits
MD-MA-RN/pharmacist electronic huddle before visits to coordinate RN visits on high risk patients
Warm hand offs with Pharmacy, SW, psych etc.
Meet regularly as a whole team to manage “between visit” work – weekly meetings of whole team
Celebrate successes , discuss patients who are struggling, review quality goals, plan outreach, assign tasks

14. Role Clarification
Important to divide labor and define roles and responsibilities of team members
-MA and MR do prevention screening outreach calls and appointments
Best achieved in a collaborative non-hierarchical manner
-Classified or arranged so that a group or person has the same authority as everyone else; not hierarchical.
Communication and flexibility are essential
-Communicate through huddles, handoffs, page system

15. The Specific Roles Medical Receptionist
Patient Advocate who understand the social context of the patient’s life
Keeper of Access and continuity – not trivial!
Outreach for screening (eg. PAPs) and prevention visits (eg. Well Child visits)
Team based knowledge lets them offer to make multiple appointments when a single family member calls
Schedule specialty appointments, manage forms and letters
Responsible for managing the flow of the MD schedule at the front end

16. Voice of the Team
Starting the visit: Medical Receptionists Elisangela Barbosa and Silvia Hamilton

17. MA
The “Boss” on the floor during patient care sessions – manage the flow In reach and outreach for screening and prevention (eg. Paps, Diabetes, Well Child visits) Attends team meetings and participates in the 5-10 minute huddle Proactive in patient care during the visit, after the visit and between visits Team work between MAs on the floor and cross training allows us to cover check in and phones Patient story: new pt with diabetes, back pain, frequent visits

18. RNs
Ideally, the clinical leader of the team, practically getting them on the floor has been a challenge
Help patients manage disease states rather than focusing on screenings, able to connect with patients on a deeper level now that they have education visits and longitudinal relationships
Outreach to complex patients (depression, diabetics not at goal, those with abnormal cancer screens)
Manages transitions of care- follow-up on inpatient discharges and post ER visit calls to avoid overuse and readmissions

19. Voice of the Team
Monica Tague, RN

20. I.T. is your friend!

22. Planned Care: the focus is on quality
Patient lists to guide your work
Stratify based on chronic disease and/or high risk status
Outreach for prevention (Pap, mammography, colon screening, well child visits and prenatal patients)
There is lots of work at the outset getting accurate lists then it is just maintenance

23. Frequency of Team Meetings- A learning process
Early in our development this was left up to each team to self schedule-not very effective
“A-ha” moment when we realized that patient care team work was more effective during those weeks when we met
Ideal schedule is weekly meetings of the entire team with a rotating set of topics to insure that all areas get “touched” monthly

24. Planned Care Team Meetings/Prevention Groups
Clinic: Union Square Family Health
Date/Time of Monthly ALL STAFF meeting: 4th Wednesday of Every Month
Planned Care Coordinator (PCC) Name: Aline Pause
Senior Care Options – Agnes Opari, RN
Group Visits: Wheeler DM (2nd Wed – Monthly 4:15-6:30pm); Demasi 6 weeks Tues eves
Paula Coutinho SW, HR manager
Pharmacist: Monica Akus, PharmD
Care Team Name
Date/Time of Team Meetings
Mtg Place
Provider
RN(s)
MA(s)
Front Desk Staff PA
Thackrey
Friday 1:00-1:30pm
USFH
Dr. Michael Thackrey
Monica Tague
Veronica Miranda
Judith Roc
Juliane
Cohen
Tuesday 1:30-2
Dr. Bonnie Cohen
Susan Gesing
Janice
Demasi
Thursday PM
Dr. Monica Demasi
Autumn Roy
Patricia Alves
Eli Barbosa
Amy

25. Cycle of Team Meetings Week 1: Well Child Outreach/Pediatric Asthma
Week 2: Diabetes/Depression
Week 3:MA/FD:Normal PAP/Mammography Outreach
RN/MD/pharmacy/SW: High Risk patient case review
Week 4: Abnormal Cancer Screening Follow up

26. IT is your friend
Screen shot of HM on pt lists 26

27. How Teams Find Time for This Work
Ongoing- during down time in sessions or at front desk – there is more of this time than you think!
Medical assistants and Front end staff have some reserved time to work on planned care
We needed to restructure provider and staff time to make this model effective
Cross-training is one key to efficiency
-MA’s are trained to do front desk

28. What a Difference! A mammogram for a cold
A celebration of our work in a new patient with early stage breast cancer
Patients know their team members by name…and ask for them specifically.
Staff began to see themselves as givers of care, not as “just staff” —and began innovating themselves.
Health Proxy Form story
-Staff build a close relationship with patients
patient story

29. Engaging and Empowering Team Members
Orientation
Every new staff member spends time shadowing different team meetings/members
Concept of patient care teams and their expected role is a focal point of new staff orientation
Education and training
Ongoing training occurs at staff meetings, individual team meetings, and during our all-clinic retreats
Best practice 29

30. Engaging and Empowering Team Members and Patients
Everyone involved in making workflow decisions
Performance Improvement Team
Leaders have to do this too!
Leadership alignment and modeling is important
Leadership works as a TEAM

31. Diabetes “Perfect Care”

32. Lessons Learned
Reward for the work is shared (money, celebration, job satisfaction)
Share the success and failures publicly
Give the work value by setting aside time to meet and time to do the work
It’s a lot of work at first but it gets better
Create opportunity for and expect innovation

33. Works in Progress
Integrating Education into every aspect of teams so teaching and learning is natural in all of our interactions with patients
Getting patient advisors involved in more of our work
Accountability – it is not a perfect world!
Dissemination of Best Practices

34. Things to Watch Out For Important for people to own the work
Important to preserve a sense of teamwork across care teams-vacations, sick days, etc
Personality management
Redesigning workflows is difficult and requires strong leadership
Trying to do it all….in the first month!

35. This is a…..

36. How this relates to a residency practice
All providers part time at USFH
MA and team as central to patients, not just the MD model
Residents learn from multiple team members as part of their training
“Teamness” is natural

37. Team Care Video for Cambridge Health Alliance
Medical Director – can me to get a hold of Veronica (Angel Gladys Miranda)