The complexity, diversity, and science of primary care teams (original) (raw)
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Mayo Clinic Proceedings, 2019
In this article, we describe the implementation of a team-based care model during the first 2 years (2016-2017) after Mayo Clinic designed and built a new primary care clinic in Rochester, Minnesota. The clinic was configured to accommodate a team-based care model that included complete colocation of clinical staff to foster collaboration, designation of a physician team manager to support a physician to advanced practice practitioner ratio of 1:2, expanded roles for registered nurses, and integration of clinical pharmacists, behavioral health specialists, and community specialists; this model was designed to accommodate the growth of nonvisit care. We describe the implementation of this team-based care model and the key metrics that were tracked to assess performance related to the quadruple aim of improving population health, improving patient experience, reducing cost, and supporting care team's work life.
Primary care multidisciplinary teams in practice: a qualitative study
BMC Family Practice
Background: Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. Methods: Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. Results: Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. Conclusions: Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.
Management Lessons for High-Functioning Primary Care Teams
Journal of Healthcare Management, 2016
Healthcare leaders and managers have only an emerging understanding of how to create high-functioning primary care teams. Management scholars have researched and debated the fundamentals of high-functioning teams over the past few decades in a variety of industries, and it is critical that the primary care providers adopt management teachings to deliver better interprofessional care. This semistructured literature review, grounded in the management and healthcare literature, summarizes and applies relevant team frameworks and best practices from the past 35 years to the current primary care landscape. Relevant management strategies for primary care teams include teaming, working with existing teams, and customer-based teams. The management literature presents a number of recommendations for building successful professional teams, such as re-envisioning goals, promoting shared decision making, communicating effectively and interprofessionally, clarifying roles, learning from failure, and using organizational structures to support multidisciplinary teams. Common barriers include systems-level obstacles to communication and efficiency, hierarchies, lack of time and financial incentives, information and interest asymmetry, and the complexity of working with people from diverse backgrounds. Early adopters of team-based care also offer recommendations. The strategies identified offer healthcare managers insights on common but important primary care topics, such as time-sensitive and interprofessional care, workforce shortages and constraints, and patient-centered care. In addition, this article offers healthcare managers key recommendations on building teams, deconstructing current practice hierarchy, promoting culture change, creating role clarity for healthcare managers and team members, and incentivizing team-based care.
Journal of the American Geriatrics Society, 2015
Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address patient, program, and system needs, we restructured a portion of our large, physician-led academic home-based primary care practice into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. Our Team Approach is an innovative way to improve interdisciplinary, team-based care though practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.
Impact of team configuration and team stability on primary care quality
Implementation Science, 2019
Background: The science of effective teams is well documented; far less is known, however, about how specific team configurations may impact primary care team effectiveness. Further, teams experiencing frequent personnel changes (perhaps as a consequence of poor implementation) may have difficulty delivering effective, continuous, well-coordinated care. This study aims to examine the extent to which primary care clinics in the Veterans Health Administration have implemented team configurations consistent with recommendations based on the Patient-Centered Medical Home model and the extent to which adherence to said recommendations, team stability, and role stability impact healthcare quality. Specifically, we expect to find better clinical outcomes in teams that adhere to recommended team configurations, teams whose membership and configuration are more stable over time, and teams whose clinical manager role is more stable over time. Methods/design: We will employ a combination of social network analysis and multilevel modeling to conduct a database review of variables extracted from the Veterans Health Administration's Team Assignments Report (TAR) (one of the largest, most diverse existing national samples of primary care teams (n teams > 7000)), as well as other employee and clinical data sources. To ensure the examination of appropriate clinical outcomes, we will enlist a team of subject matter experts to select a concise set of clear, prioritized primary care performance metrics. We will accomplish this using the Productivity Measurement and Enhancement System, an evidence-based methodology for developing and implementing performance measurement. Discussion: We are unaware of other studies of healthcare teams that consider team size, composition, and configuration longitudinally or with sample sizes of this magnitude. Results from this study can inform primary care team implementation policy and practice in both private-and public-sector clinics, such that teams are configured optimally, with adequate staffing, and the right mix of roles within the team. Trial registration: Not applicable-this study does not involve interventions on human participants.
Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study
Journal of General Internal Medicine, 2014
BACKGROUND: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. OBJECTIVE: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. APPROACH: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. PARTICIPANTS: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. KEY RESULTS: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). CONCLUSIONS: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.
Medical Care, 2007
Background: Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients' assessments of primary care, including access, integration, and clinician-patient interaction quality. Methods: From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n ϭ 14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. Results: Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and "on-team" visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only "off-team" visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P Ͻ 0.001). An exception was patients' assessments of teams, which were better when on-versus off-team visits occurred (P Ͻ 0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on-or offteam visits. Conclusions: The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on-or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.
Family health teams: can health professionals learn to work together?
Canadian Family Physician, 2007
To learn what educators across the health professions involved in primary health care think about the use and development of academic family health teams to provide, teach, and model interprofessional collaboration and about the introduction of interprofessional education (IPE) within structured academic primary care. Qualitative study using focus groups. Higher education institutions across Ontario. Purposeful sample of 36 participants from nursing, pharmacy, speech language pathology, occupational and physical therapy, social work, and family medicine. Participants were invited to join focus groups of 6 to 8 health professionals. Themes were derived from qualitative analysis of data gathered using a grounded-theory approach. Three major themes were identified: the lack of consensus on opportunities for future academic family health teams to teach IPE, the lack of formalized teaching of interprofessional collaboration and the fact that what little has been developed is primarily fo...
Background Interprofessional collaborative teams (teams) have been introduced across Canada to improve access to and quality of primary care. However, the quality and speed of team implementation has been challenging and has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care. Methods A narrative review that prioritized systematic reviews and evidence syntheseswas conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Charact...