Delegating Responsibility from Clinicians to Nonprofessional Personnel: The Example of Hypertension Control

Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA 94110, USA.
The Journal of the American Board of Family Medicine (Impact Factor: 1.98). 03/2012; 25(2):209-15. DOI: 10.3122/jabfm.2012.02.100279
Source: PubMed


Involving nonclinician personnel in the treatment of hypertension may provide a solution to improve blood pressure control; however, this team-based approach cannot be implemented without first determining clinicians' willingness to delegate patient care to nonclinician team members. This study explores clinicians' perspectives on working with nonclinicians trained as "health coaches" to address medication adherence and lack of medication intensification among low-income patients with uncontrolled hypertension.
We used a qualitative research approach to determine clinicians' opinions on the Treat-to-Target study, an intervention to improve blood pressure control. We conducted focus groups with clinicians who practice family medicine in a safety net clinic. Transcripts were analyzed using thematic content analysis.
Seven overarching themes emerged: (1) Clinicians support the delegation of functions to health coaches; (2) clinicians like the high frequency of coach-patient interactions; (3) clinicians feel that health coaching assists medication adherence; (4) clinicians have varying views on home titration; (5) coach-clinician communication is necessary for successful delegation; (6) coaching helps clinicians understand their patients' barriers to hypertension control; and (7) clinicians would like health coaching to continue on a permanent basis.
Clinicians appreciate the presence of nonclinicians on the primary care team. In the coming era of primary care clinician shortage, clinicians can be supportive of nonprofessional team members assisting with the care of patients with hypertension.

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    • "Research indicates that the initial step in implementing a team-based approach in PHC involves a shift from physician-centred practices to “goal-oriented” practices defined by a physician-led team [2]. The PHC team then evolves as its structure progressively integrates different health professionals [13] to work with the physician, then professionals in health-related fields [10] and finally various laypersons [14]. Studies demonstrate that health care processes and outcomes improve when non-physician team members provide important components of care [2,15-17]. "
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    ABSTRACT: A team approach in primary care has proven benefits in achieving better outcomes, reducing health care costs, satisfying patient needs, ensuring continuity of care, increasing job satisfaction among health providers and using human health care resources more efficiently. However, some research indicates constraints in collaboration within primary health care (PHC) teams in Lithuania. The aim of this study was to gain a better understanding of the phenomenon of teamwork in Lithuania by exploring the experiences of teamwork by general practitioners (GPs) and community nurses (CNs) involved in PHC. Six focus groups were formed with 29 GPs and 27 CNs from the Kaunas Region of Lithuania. Discussions were recorded and transcribed verbatim. A thematic analysis of these data was then performed. The analysis of focus group data identified six thematic categories related to teamwork in PHC: the structure of a PHC team, synergy among PHC team members, descriptions of roles and responsibilities of team members, competencies of PHC team members, communications between PHC team members and the organisational background for teamwork. These findings provide the basis for a discussion of a thematic model of teamwork that embraces formal, individual and organisational factors. The need for effective teamwork in PHC is an issue receiving broad consensus; however, the process of teambuilding is often taken for granted in the PHC sector in Lithuania. This study suggests that both formal and individual behavioural factors should be targeted when aiming to strengthen PHC teams. Furthermore, this study underscores the need to provide explicit formal descriptions of the roles and responsibilities of PHC team members in Lithuania, which would include establishing clear professional boundaries. The training of team members is an essential component of the teambuilding process, but not sufficient by itself.
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  • No preview · Article · Mar 2012 · The Journal of the American Board of Family Medicine
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    ABSTRACT: Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population. We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months. Both the home-titration arm and the no-home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure. Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.
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