Building a team-based medical practice

Primary care practices are being urged to adopt “patient-centric” practice models, such as the Patient-Centered Medical Home (PCMH) or accountable care organization, as a way of improving the quality of care they provide. But implementing these models requires a team-based approach to patient care. And although most practices would say they operate as a team now, they quickly find that the term means something quite different in the context of patient-centric care delivery. 

So what is a team-based primary care practice? And how does a practice owner or administrator go about building one?

Team-based versus ‘hero’ model of care delivery

To answer those questions, it helps to understand how the team concept differs from the way most primary care practices now operate. Although somewhat oversimplified, the current paradigm is largely episodic and reactive, while a team-based approach is characterized as ongoing and proactive. Under the current model, patient care comes almost exclusively from the physician, whereas in a team-based practice virtually everyone has responsibility for some aspect of patient care.

“I call what we have now the ‘hero’ model, where the physician is the only source of knowledge, education, and decision-making, and everyone else is basically there to support the physician,” says Bruce Bagley, MD, interim president and chief executive officer of TransforMed, a branch of the American Academy of Family Physicians that seeks to help practices transition to the PCMH model

By contrast, under a team model “we look at all the resources we have available, in particular the human resources, and determine who are the best people to help monitor or manage different parts of the patient’s care based on those individuals’ qualifications, rather than on the initials after their name,” says Mark Greenawald, MD, FAAFP, associate professor and vice chair of family and community medicine at the Virginia Tech Carilion School of Medicine. Greenawald also sees patients part-time in a Carilion facility.

“Part of the attraction of the PCMH and other new models of care is that they allow providers to practice closer to the level of their license,” Greenawald adds. “They provide the opportunity for professionals to be stretched and challenges at whatever level they operate. For us, it meant defining staff roles in ways that really looked at training and skill levels and ask are we really using them that way?”

Using staff to full extent of their training

Charles Cutler, MD, FACP, an internist in Norristown, Pennsylvania and chair of the American College of Physician’s Board of Regents, notes that under the current system he would be called on to perform tasks that don’t require his level of training, such as filling out a school physical, or for which others have better training, such as providing dietary instruction.

But a patient-centered, team-based system, “uses a variety of different medical professionals to the full extent of their training. Maybe a nurse practitioner is the best person to fill out a school form. Maybe a trained dietician is the best person for the specifics of dietary care. But if you’re experiencing symptoms of pneumonia, you should be seeing me,” he says.

The expansion of roles under a team-based model isn’t limited to providers. Greenawald cites the changing role of a front-office staff person in his practice. Five years ago, he says, the person’s responsibilities were to answer the phone, take messages, and make appointments. “It could have been a secretarial position anywhere. There was nothing unique to medicine about it,” he says.

“Today, the person in that position is much more tuned in to their role in the practice and how it matters. So if the patient’s chart says they are due for a mammography the receptionist will say, ‘as long as I’ve got you on the phone let’s find a time you can come in for a mammogram.’ That’s a huge paradigm shift.”

Fostering a greater sense of ownership

Moreover, as staff members and providers other than the physician expand their roles, they begin to feel a greater sense of ownership and responsibility for patients’ well-being. “They start to see how what they do make a real difference to a patient, even on the back end of a visit, so they feel a real sense of ownership in ensuring the follow-up visit,” Greenawald notes.

“In the past, if a patient didn’t show for an appointment the response was ‘maybe they’ll make another appointment,’” he says. Now it’s really following up with the patient, saying ‘we see you missed your appointment. Is something wrong, can we get you re-scheduled’”?

Bertha Safford, MD, is part of a multi-location family practice in northwestern Washington State that started to make the transition to team-based care in the late 1990’s, after she and some colleagues attended a seminar on treating patients with diabetes. While there they were introduced to the chronic care model developed by Edward Wagner, MD, which emphasizes the importance of proactive team care.

“At that point we started engaging our whole team in the care of our diabetes patients, and then we slowly expanded into other areas,” she says. The practice established standing orders and protocols for midlevels and medical assistants so that immunizations have been administered if indicated, mammograms have been scheduled, and medications have been reconciled before the patient sees the doctor.

The role of the EHR

A comprehensive electronic health record (EHR) system is virtually a must for team-based care to function effectively, experts say. That’s because the team approach relies heavily on being proactive in patient care, which in turn means being able to identify specific patient populations, such as those with diabetes, so that team members can schedule needed appointments and monitor patients’ progress.

“I can go into my EHR and in 2 minutes pull up a list of patients with, say, hemoglobin A1C levels greater than eight,” says Greenawald. “Then we can start asking the people on that list to come see us because their diabetes isn’t under control.”

Carilion uses its EHR system to identify “high-risk, high-utilizer” patients, Greenawald says, based on factors such the number of emergency department visits and the number of chronic diseases a patient has. “We decided these are patients we really want to go after, both because they’re at risk for having something bad happen to them, and from a cost perspective.”

“An EHR is basically a platform that allows us to build better care processes,” says Bagley. “For example, if a patient calls and gets transferred to the population health manager, then that person can get the patient’s information in front of them immediately and begin addressing the patient’s needs.”

Persuading employees to buy in

As with any significant organizational change, getting buy-in from employees is key. Practices who have made the transition say they rely on training, and the promise of a more rewarding work environment to persuade employees to go along. “I think we appealed to their (staff members) hearts, by saying this is how we’re going to be able to provide better care,” says Safford. “And then training is a key piece. You can’t change your practice to a team approach where everyone has a role unless you specifically train them to those roles.”

New physicians and clinical assistants undergo a series of training sessions in the practice’s methods, and the physician’s charts are reviewed to ensure they are adhering to them. “Otherwise you couldn’t sustain a model like this,” Safford says.

Overcoming patient resistance

Of course, staff members and physicians aren’t the only ones who need to be persuaded of the benefits of team-based care. Long-time patients accustomed to seeing only the  physician may balk at the idea of receiving even routine or follow-up care from a midlevel or medical assistant.

A key to easing that transition is the “handoff” of the patient from the physician to another team member, says Paul Grundy, MD, MPH, president of the Patient-Centered Medical Home Collaborative, and global director of healthcare transformation at IBM.  He recalls seeing a medical assistant in a practice call a patient about following up on some test results.

“The assistant started out by saying ‘I’m calling on behalf of Dr. Gonzales because she cares about you, and she wants you to know that.’ Then the MA provided the details about what needed to be done, and finished by saying, ‘Any time you want to get in touch with Dr. Gonzales she’s available to you.’  And the patient was fine with that.

“If this (handoff) is done right, no matter when or how it occurs, the patient knows the doctor cares about them, and that is crucial,’ Grundy says.

Does the team-based approach work? Evidence so far is sketchy, but promising, at least in terms of provider satisfaction. A 2011 study published in the Annals of Family Medicine looked at how 23 “high-performing” family practices had reduced physician burnout and brought joy to the practice of medicine.

 Much of what researchers found in these practices mirrored the characteristics of team-based medicine, including “proactive planned care, with pre-visit planning and laboratory tests, sharing clinical practice among a team, with expanded rooming protocols, standing orders, and panel management, and improving team functioning through co-location, team meetings, and work flow mapping.”

Improved quality outcomes

Safford says her practice has seen results in terms of better quality outcomes. Among patients with diabetes for example, blood sugar levels, blood pressure, and several other American Diabetes Association recommended guidelines have been stable for 6 years.

Among other benefits, improved quality data has enabled the practice to negotiate higher reimbursement rates from insurance companies. The practice consistently ranks highly in third-party payer surveys of patient satisfaction, and employee turnover is down. “I think our desirability as a place to work has been helped by the fact that we try to use everyone to their maximum ability,” Safford says.