How Teams Work-Or Don't-In Primary Care: A Field Study On Internal Medicine Practices
American Board of Internal Medicine, Philadelphia, PA, USA. Health Affairs
(Impact Factor: 4.97).
05/2010; 29(5):874-9. DOI: 10.1377/hlthaff.2009.1093
We conducted a field study in three primary care practices representing different practice types: a solo practice; a certified patient-centered medical home; and a multiphysician, multispecialty practice connected to a local university. All three practices shared a common culture in the way that practice members related to each other. In each instance, the practice team operated in separate social "silos," isolating physicians from each other and from the rest of the practice staff. We concluded that current practice structures are primarily focused on supporting physicians' hectic routines and have trouble accommodating the diversity of patients' needs. For practices to succeed in managing diverse patients and in helping them understand and manage their own health, it will be critical to break down the silos and organize teams with shared roles and responsibilities.
Available from: annfammed.org
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ABSTRACT: We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life's vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.
Available from: Roderick S Hooker
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ABSTRACT: We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006-2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.
Available from: Stephanie Tache
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ABSTRACT: Introduction: Nonlicensed allied health workers are becoming increasingly important in collaborative team care, yet we know little about their experiences while filling these roles. To explore their perceptions of working as health coaches in a chronic-disease collaborative team, the teamlet model, we conducted a qualitative study to understand the nature and dynamics of this emerging role.Methods: During semistructured interviews, 11 health coaches reflected on their yearlong experience in the teamlet model at an urban underserved primary care clinic. Investigators conducted a thematic analysis of transcriptions of the interviews using a grounded theory process.Results: Four themes emerged: 1) health-coach roles and responsibilities included acting as a patient liaison between visits, providing patient education and cultural brokering during medical visits, and helping patients navigate the health care system; 2) communication and relationships in the teamlet model of care were defined by a triad of the patient, health coach, and resident physician; 3) interest in the teamlet model was influenced by allied health workers' prior education and health care roles; and 4) factors influencing the effectiveness of the model were related to clinical and administrative time pressures and competing demands of other work responsibilities.Conclusion: Nonlicensed allied health workers participating in collaborative teams have an important role in liaising between patients and their primary care physicians, advocating for patients through cultural brokering, and helping patients navigate the health care system. To maximize their job satisfaction, their selection should involve strong consideration of motivation to participate in these expanded roles, and protected time must be provided for them to carry out their responsibilities and optimize their effectiveness.
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