FAMILY MEDICINE AND THE HEALTH CARE SYSTEM
Delegating Responsibility from Clinicians to
Nonprofessional Personnel: The Example of
David Margolius, MD, Jennifer Wong, BA, Matthew L. Goldman, MS,
James Rouse-Iniguez, MA, and Thomas Bodenheimer, MD, MPH
Background: 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
Methods: 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 clini-
cians who practice family medicine in a safety net clinic. Transcripts were analyzed using thematic con-
Results: 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 coach-
ing to continue on a permanent basis.
Conclusion: 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. (J Am Board Fam Med 2012;25:
Keywords: Health Care Team, Hypertension, Primary Health Care
Adult primary care faces a dilemma. On the one
hand, the worsening shortage of adult primary care
physicians imperils access to care for millions of
Americans.1On the other hand, panel sizes are too
large for adult primary care physicians to handle. It
would take almost 18 hours to provide high-quality
preventive and chronic care to a panel of 2300
patients, which is the average primary care physi-
cian panel size.2The dilemma arises in the need to
increase panel size to make up for the adult primary
care physician shortage but the impossibility of
doing so because of the amount of time it takes to
care for larger panels.
One solution lies in delegating less complex ac-
tivities from physicians to other members of the
primary care team so that the team, not solely the
physician, becomes responsible for the health of a
large panel of patients.3Such delegation would
This article was externally peer reviewed.
Submitted 21 November 2010; revised 27 February 2011;
accepted 2 March 2011.
From the Department of Family and Community Medi-
cine, University of California, San Francisco (DM, JW, JR-I,
TB); the Warren Alpert Medical School of Brown Univer-
sity, Providence, Rhode Island (DM); and the University of
California Berkeley–University of California San Francisco
Joint Medical Program, Berkeley, CA (MG).
Funding: This research was funded by the Kaiser Perma-
nente Community Benefits Program Northern California
Region (grant reference number 20602348).
Conflict of interest: none declared.
Corresponding author: Thomas Bodenheimer, Department
of Family and Community Medicine, University of Califor-
nia, San Francisco, Bldg 80–83, San Francisco General
Hospital, 995 Potrero Ave, San Francisco, CA 94110
doi: 10.3122/jabfm.2012.02.100279Delegating Responsibility to Nonprofessionals209
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