Welcome to Team-Based Primary Care Presented by Thomas Bodenheimer , MD, MPH. The presentation will begin shortly. This webinar will be recorded and used for future presentations. - PowerPoint PPT Presentation
Welcome to Welcome to Team-Based Primary Care Team-Based Primary Care Presented by Thomas Bodenheimer, Presented by Thomas Bodenheimer, MD, MPH MD, MPH The presentation will begin shortly. This webinar will be recorded and used for future presentations. Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative. This webinar is being offered by the San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California Primary Care Office (PCO).
Transcript
Welcome to Welcome to Team-Based Primary CareTeam-Based Primary Care
Presented by Thomas Bodenheimer, MD, MPHPresented by Thomas Bodenheimer, MD, MPHThe presentation will begin shortly.
This webinar will be recorded and used for future presentations.
Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act
(ARRA) funding for the Retention and Evaluation Activities (REA) Initiative .
This webinar is being offered by the San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California
Primary Care Office (PCO).
The components of high-performing teams The components of high-performing teams in primary carein primary care
Tom Bodenheimer MDTom Bodenheimer MD
Amireh Ghorob MPHAmireh Ghorob MPH
Rachel Willard MPHRachel Willard MPHCenter for Excellence in Primary CareCenter for Excellence in Primary Care
UCSF Department of Family and Community MedicineUCSF Department of Family and Community Medicine
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We should use the dame tittle being that it was advertised that way, and use this ttitle as a sub tittle.
No conflicts of interest to disclose.
Why do we need teams?Why do we need teams?
Why do we need teams?Why do we need teams?
Why do we need teams?Why do we need teams?
Is this a 5-person team?Is this a 5-person team?
Teams are difficultTeams are difficult
• The larger the The larger the team the more team the more time and energy time and energy it takes to it takes to communicatecommunicate
• One person One person who is who is uncooperative uncooperative can ruin a teamcan ruin a team
• Easiest team? Easiest team? Team of 1Team of 1
So, why do we need teams?So, why do we need teams?• How many of you have achieved same day access for all your How many of you have achieved same day access for all your
patients? patients? • Good access requires that demand = capacityGood access requires that demand = capacity
– Demand: number of appointments patients in your panel wantDemand: number of appointments patients in your panel want– Capacity: number of appointment slots you offer to patients in Capacity: number of appointment slots you offer to patients in
your panelyour panel• In your organizationIn your organization
Supply: family Supply: family med, general med, general internal medinternal med
Shortage of 40,000 by 2020
NP/PAs to the rescue?NP/PAs to the rescue?
• New graduates each yearNew graduates each year– Nurse practitioners: Nurse practitioners: 80008000– Physician assistants: Physician assistants: 45004500
• % going into primary care% going into primary care– Nurse practitioners: Nurse practitioners: 65%65%– Physician assistants: Physician assistants: 32%32%
• Adding new GIM, FamMed, NPs, and PAs entering Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care clinician to primary care each year, the primary care clinician to population ratio will fall by population ratio will fall by 9%9% from from 2005 to 2020.2005 to 2020.
Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64. Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.
How do we increase capacity?How do we increase capacity?• More clinicians?More clinicians?
• It won’t happenIt won’t happen• We need to think differentlyWe need to think differently• We need to increase capacity by We need to increase capacity by
empowering other team members to care empowering other team members to care for patientsfor patients
• Share the careShare the care
Colwill et al., Health Affairs, 2008:w232-241Colwill et al., Health Affairs, 2008:w232-241
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Adult Care: Projected Generalist Supply Adult Care: Projected Generalist Supply vs. Population Growth/Agingvs. Population Growth/Aging
Supply: family Supply: family med, general med, general internal medinternal med
Shortage of 40,000 by 2020
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Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand
Demand for careDemand for care
==Capacity to Capacity to provide careprovide care
Thinking differently Thinking differently
It’s not about doctorsIt’s not about doctors
Share the careShare the care
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Add reference here using same format as others.
Teams can add capacity without Teams can add capacity without adding cliniciansadding clinicians
• High-performing primary care practices have High-performing primary care practices have done itdone it
• These practices have same-day or same-These practices have same-day or same-week access with large panel sizesweek access with large panel sizes
• RNs, pharmacists, medical assistants (MAs) RNs, pharmacists, medical assistants (MAs) share in the responsibility to care for the share in the responsibility to care for the patients of these practicespatients of these practices
• If they can do it, so can weIf they can do it, so can we
Willard and BodenheimerWillard and BodenheimerCalifornia HealthCare Foundation April 2012 www.chcf.orgCalifornia HealthCare Foundation April 2012 www.chcf.org
10 Building Blocks
Team-based care• Culture shift: Share the Care• Stable teamlets• Co-location• Standing orders/protocols• Defined workflows and roles – workflow
mapping• Training, skills checks, and cross training• Ground rules• Communication – huddles, team meetings,
• Instead of: “what can Instead of: “what can II do to do to maximize the care of the 30 patients maximize the care of the 30 patients on my schedule today?”on my schedule today?”
Monday Patients
8:00AM Ms. Ngo
8:15AM Mr. Barnes
8:30AM Ms. Reilly
8:45AM Mr. Padilla
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• The future: “what can The future: “what can wewe do to maximize the do to maximize the care of the 1500 care of the 1500 patients in our panel?”patients in our panel?”
Team-based care: stable teamlets
Patientpanel
1 team, 3 teamlets
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
RN, behavioral health professional, social worker, pharmacist, complex care manager
Clinician Satisfaction with Teamsn=135
Teamlet (work with same Teamlet (work with same MA) (n=27)MA) (n=27)
Team (work with group of Team (work with group of MAs) (n=90)MAs) (n=90)
No teams (work with No teams (work with different MAs) (n=18)different MAs) (n=18)
Homework: teams in our clinics nowHomework: teams in our clinics now
• Make a chart of the team structure in your clinicMake a chart of the team structure in your clinic• Do you have stable teams (same people Do you have stable teams (same people
working together every day or almost every working together every day or almost every day)?day)?
• How many teams?How many teams?• Who is on which team?Who is on which team?• Is each team responsible for a defined panel of Is each team responsible for a defined panel of
patients?patients?
Homework: future teams in our clinics Homework: future teams in our clinics
• Make a chart of a team structure in your clinic Make a chart of a team structure in your clinic for the future for the future
• Teams should be stable (same people working Teams should be stable (same people working together every day or almost every day)together every day or almost every day)
• Each team should be responsible for a defined Each team should be responsible for a defined panel of patientspanel of patients
• How many teams?How many teams?• Who is on which team?Who is on which team?
Share the CareShare the Care What does it mean? What does it mean?
• Non-clinicians assuming responsibility for care that Non-clinicians assuming responsibility for care that does not require a MD/NP/PA level of trainingdoes not require a MD/NP/PA level of training
• A great way to start sharing the care is A great way to start sharing the care is population population managementmanagement• Panel management Panel management • Health coachingHealth coaching
• Is your clinic sharing the care?Is your clinic sharing the care?
Share the care: who does it now?Share the care: who does it now?
Tasks PCP RN LVN Medical assistant
Pharmacist
Orders mammograms for healthy women between 50
and 75 years old
Refills high blood pressure medications for patients
with well-controlled hypertension
Performs diabetes foot exams
Reviews lab tests to separate normals from
abnormals
Cares for patients with uncomplicated urinary
tract infections
Finds patients who are overdue for LDL and
orders lipid panel
Prescribes statins for patients with elevated LDL
Does medication reconciliat ion
Screens patients for depression using PHQ 2
and PHQ 9
Follows up by phone with patients treated for
depression
Totals
Population-based care:Population-based care:stratifying the panelstratifying the panel
Panel Management: Ensuring that ALL of the patients in our panel get recommended preventive and chronic care
Sharing the care through Sharing the care through panel managementpanel management
• Medical assistants use preventive care and chronic disease Medical assistants use preventive care and chronic disease registries to identify patients overdue for routine services and registries to identify patients overdue for routine services and arrange for those services to be performedarrange for those services to be performed– Preventive care: immunizations, cancer screening (cervical, Preventive care: immunizations, cancer screening (cervical,
breast, colorectal)breast, colorectal)– Chronic care: e.g. diabetes, making sure all lab tests done on Chronic care: e.g. diabetes, making sure all lab tests done on
time time • Standing ordersStanding orders needed to empower medical assistants needed to empower medical assistants• Quality of preventive services improves Quality of preventive services improves
(Chen and Bodenheimer, Arch Intern Med 2011;171:1558)(Chen and Bodenheimer, Arch Intern Med 2011;171:1558)
• An estimated 50% of all preventive care activities could be shared An estimated 50% of all preventive care activities could be shared with medical assistants with medical assistants (Altschuler et al, Annals of Family Medicine 2012;10:396)(Altschuler et al, Annals of Family Medicine 2012;10:396)
• Capacity is increasedCapacity is increased
Preventive services: old wayPreventive services: old way
• Mammogram for 55-year-old healthy womanMammogram for 55-year-old healthy woman• Old way: Old way:
– Clinician gets reminder that mammo is due Clinician gets reminder that mammo is due – At next visit, clinician (maybe) orders mammoAt next visit, clinician (maybe) orders mammo– Clinician gets result, (sometimes) notifies Clinician gets result, (sometimes) notifies
patientpatient
Preventive services: new wayPreventive services: new way
• MA (as panel manager) checks registry every monthMA (as panel manager) checks registry every month• If due for mammo, MA sends mammo order to patientIf due for mammo, MA sends mammo order to patient• Result comes to MA, if normal, MA notifies patient Result comes to MA, if normal, MA notifies patient • If abnormal, MA notifies clinician and app’t madeIf abnormal, MA notifies clinician and app’t made• For most patients, clinician not involvedFor most patients, clinician not involved• For women 40-50 who want or need mammogram, For women 40-50 who want or need mammogram,
clinician is involved for discussionclinician is involved for discussion• Similar for colon cancer screeningSimilar for colon cancer screening• Requires standing ordersRequires standing orders
Stratifying the panelStratifying the panel
Health Coaching: Helping
patients with chronic conditions to improve their self-management. MA health coaches, RNs, health educators, peer coaches
Non-clinician personnel:Non-clinician personnel:share the careshare the care
• Health coaching Health coaching – Medical assistants trained as health coaches can assist Medical assistants trained as health coaches can assist
patients with chronic conditions to learn about their patients with chronic conditions to learn about their disease, engage in healthier behaviors, and increase their disease, engage in healthier behaviors, and increase their medication adherence medication adherence (Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, (Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369)Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369)
– An estimated 25-30% of all chronic care activities could be An estimated 25-30% of all chronic care activities could be shared with medical assistants shared with medical assistants (Altschuler et al, Annals of Family Medicine (Altschuler et al, Annals of Family Medicine 2012;10:396)2012;10:396)
• Capacity is increasedCapacity is increased
Chronic care: hypertension: old wayChronic care: hypertension: old way
• Clinician sees today’s blood pressureClinician sees today’s blood pressure• Clinician refills meds or changes meds (maybe)Clinician refills meds or changes meds (maybe)• Clinician makes f/u appointmentClinician makes f/u appointment• No one addresses med adherenceNo one addresses med adherence• Often blood pressures are not adequately Often blood pressures are not adequately
controlledcontrolled
Chronic care: hypertension: new wayChronic care: hypertension: new way
• MA (panel manager) checks registry every monthMA (panel manager) checks registry every month• Patients with abnormal BP contacted for pharmacist, RN, or health Patients with abnormal BP contacted for pharmacist, RN, or health
coach visitcoach visit• Health coach does education, med adherence, lifestyle changeHealth coach does education, med adherence, lifestyle change• Patient taught home BP monitoringPatient taught home BP monitoring• If BP elevated and patient med adherent, RN/pharmacist intensifies If BP elevated and patient med adherent, RN/pharmacist intensifies
meds by standing orders meds by standing orders • If questions, quick clinician consultIf questions, quick clinician consult• Health coach f/u by phone or e-mailHealth coach f/u by phone or e-mail• Clinician barely involvedClinician barely involved• Blood pressure control improved with this innovationBlood pressure control improved with this innovation
(Margolius et al, Annals of Family Medicine 2012;10:199)(Margolius et al, Annals of Family Medicine 2012;10:199)
Share the Care:Share the Care:preserving the relationshippreserving the relationship
• Share the Care means that the personal clinician (MD, Share the Care means that the personal clinician (MD, NP, PA) does not provide all the careNP, PA) does not provide all the care
• To preserve patients’ relationship with the personal To preserve patients’ relationship with the personal clinician, sharing the care should take place in the clinician, sharing the care should take place in the teamletteamlet
• The relationship changes from patient-clinician to The relationship changes from patient-clinician to patient-teamletpatient-teamlet
• 81% of California patients surveyed said they would be 81% of California patients surveyed said they would be willing to be seen by a team even if they see the doctor willing to be seen by a team even if they see the doctor less often less often
(Blue Shield of California Foundation, June 2012)(Blue Shield of California Foundation, June 2012)
Team-based care: stable teamlets
Patientpanel
1 team, 3 teamlets
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
Patientpanel
Clinician + MAteamlet
RN, behavioral health professional, social worker, pharmacist, complex care manager
TeamletsTeamlets
Health coaching in the teamlet modelHealth coaching in the teamlet model
Physician confidence in MA doing Physician confidence in MA doing panel management panel management
(n=129-133)(n=129-133)
Take-home pointsTake-home points
• Share the care means: Share the care means: • Non-clinicians assuming responsibility for Non-clinicians assuming responsibility for
carecare• Panel managementPanel management• Health coachingHealth coaching
• It is challenging without payment reformIt is challenging without payment reform
• Sharing the care adds capacity Sharing the care adds capacity without needing more clinicianswithout needing more clinicians
Share the care: who should do it?Share the care: who should do it?
Tasks PCP RN LVN Medical assistant
Pharmacist
Orders mammograms for healthy women between 50
and 75 years old
Refills high blood pressure medications for patients
with well-controlled hypertension
Performs diabetes foot exams
Reviews lab tests to separate normals from
abnormals
Cares for patients with uncomplicated urinary
tract infections
Finds patients who are overdue for LDL and
orders lipid panel
Prescribes statins for patients with elevated LDL
Does medication reconciliat ion
Screens patients for depression using PHQ 2
and PHQ 9
Follows up by phone with patients treated for
depression
Totals
Engaged leadership Data-driven improvement
Empanelment Team-based care
1 2 3 4
5
Patient-team partnership
Population management
Continuity of care
Prompt access to care
Coordination of care
Template of the future
6 7
8 9
10
Share the Care
10 Building Blocks of High- Performing Primary Care
Willard and Bodenheimer California HealthCare Foundation, April 2012 ,www.chcf.orgWillard and Bodenheimer California HealthCare Foundation, April 2012 ,www.chcf.org
