Applied Evidence

Advanced team-based care: How we made it work

J Fam Pract. 2019 September;68(7):E1-E8

References

1. Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.

2. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.

3. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.

4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.

5. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91:422-431.

6. Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92:1625-1635.

7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.

8. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.

9. Sinsky CA, Sinsky TA, Althaus D, et al. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29:966-968.

10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.

11. Association for Advancing Physician and Provider Recruitment. Schutte L. What you don’t know can cost you: building a business case for recruitment and retention best practices. 2012. https://member.aappr.org/general/custom.asp?page=696. Accessed June 20, 2019.

12. American Medical Association. AMA STEPS Forward. Expanded rooming and discharge protocols. https://edhub.ama-assn.org/steps-forward/module/2702600. Accessed June 20, 2019.

13. American Medical Association. AMA STEPS Forward. Team documentation. https://edhub.ama-assn.org/steps-forward/module/2702598?resultClick=3&bypassSolrId=J_2702598. Accessed June 20, 2019.

14. American Medical Association. AMA STEPS Forward. EHR in-basket restructuring for improved efficiency. https://edhub.ama-assn.org/steps-forward/module/2702694?resultClick=3&bypassSolrId=J_2702694. Accessed June 20, 2019.

15. California Health Care Foundation. Bodenheimer T, Bauer L, Olayiwola JN. RN role reimagined: how empowering registered nurses can improve primary care. https://www.chcf.org/publication/rn-role-reimagined-how-empowering-registered-nurses-can-improve-primary-care/. Accessed June 20, 2019.

16. Chung S, Lesser LI, Lauderdale DS, et al. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate. Health Aff (Millwood). 2015;34:11-20.

17. American Medical Association. AMA Policy H-160.912. The structure and function of interprofessional health care teams. https://policysearch.ama-assn.org/policyfinder/detail/The%20Structure%20and%20Function%20of%20Interprofessional%20Health%20Care%20Teams?uri=%2FAMADoc%2FHOD.xml-0-727.xml. Accessed June 20, 2019.

18. Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med. 2015;128:337-343.

19. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31:1591-1594.

20. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100-e106.

21. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.

22. RAND Corporation. Friedberg MW, Chen PG, Ban Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. https://www.rand.org/pubs/research_reports/RR439.html. Accessed June 20, 2019.

23. Evaluation and Management (E/M) visit frequently asked questions (FAQs): physician fee schedule (PPS). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf. Accessed August 27, 2019.

24. Centers for Medicare & Medicaid Services. Scribe services signature requirements. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals-Items/R713PI.html. Accessed June 20, 2019.

25. American Association of Medical Assistants. State scope of practice laws. http://www.aama-ntl.org/employers/state-scope-of-practice-laws. Accessed June 20, 2019.

26. Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65:155-159.

27. Arya R, Salovich DM, Ohman-Strickland P, et al. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490-494.

28. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.

29. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15:35-40.

Use EHR tools to facilitate this work. Using standard templates and documentation tools helped CTCs develop the confidence needed to thrive in their new role. Knowing these tools were available helped CTCs become effective in helping the team manage the between-visit work.

In our aTBC model, the percentage of patients receiving age- appropriate screening is higher now in every domain we measure, and metrics have improved in most quality measures.

Monitor workload. As we developed more workflows and processes, we took care to monitor the amount of additional work for those in this role. We offloaded work whenever possible. For example, coordinated refill management at time of service, coupled with a back-up centralized refill system, can significantly decrease the number of refill requests made to CTCs. We continue to adjust staffing, where appropriate, to provide adequate support for those in this valuable role.

Be prepared for turnover. As CTCs became empowered in their new roles, some decided to advance their training into other roles. We developed a plan for replacing and training new staff. Higher pay can also be used to help attract and retain these staff members. Bellin uses LPNs in this role to ensure adequate staffing. Other health systems have developed a tier system for CMAs to improve retention.

Registered nurses

Before our move to an aTBC model, our office RNs primarily managed phone triage. Now the nurses were enlisted to play a more active role in patient care and team leadership. Although it was a dramatic departure from prior responsibilities, the majority of Bellin’s RNs have found increased satisfaction in taking on direct patient care.

Implementation strategies

Define new roles and provide training. In addition to participating in acute patient visits, consider ways that care team RNs can expand responsibilities as they pertain to disease counseling, population health management, and team leadership.¹⁵ At Bellin, the expanded role of the RN is evident in diabetes education and Medicare AWVs. Specifically, RNs now provide diabetes education to appropriate patients following a warm handoff from the physician at the time of the visit. RNs now also complete Medicare AWVs, which frees up physicians for other tasks and helps ensure sustainability for the new RN roles. Rates of completed AWVs at Bellin are now more than 70%, compared with reported national rates of less than 30%.¹⁶

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