Advanced team-based care: How we made it work

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Applied Evidence

Advanced team-based care: How we made it work

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

By

James Jerzak, MD

Gina Siddiqui, MD

Christine A. Sinsky, MD

Our move away from a traditional practice model has improved quality metrics and enhanced our financial sustainability.

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PRACTICE RECOMMENDATIONS

› Up-train staff to provide enhanced support for physicians during the office visit, such as handling most electronic health record work, including documentation. C

› Take a team approach to between-visit work, leveraging principles of team-based care (such as co-location) to optimize efficiency. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

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.

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

Leaders in health care and practicing physicians recognize the need for changes in how health care is delivered.^1-3 Despite this awareness, though, barriers to meaningful change persist and the current practice environment wherein physicians must routinely spend 2 hours on electronic health records (EHRs) and desk work for every hour of direct face time with patients⁴ is driving trainees away from ambulatory specialties and is contributing to physicians’ decisions to reduce their practices to part-time, retire early, or leave medicine altogether.^5,6 Those who persevere in this environment with heavy administrative burdens run the increasing risk of burnout.⁷

Some physicians and practices are responding by taking creative measures to reform the way patient care is delivered. Bellin Health—a 160-provider, multispecialty health system in northeast Wisconsin where one of the authors (JJ) works—introduced an advanced team-based care (aTBC) model between November 2014 and November 2018, starting with our primary care providers. The development and introduction of this new model arose from an iterative, multidisciplinary process driven by the desire to transform the Triple Aim—enhancing patient experience, improving population health, and reducing costs—into a Quadruple Aim⁸ by additionally focusing on improving the work life of health care providers, which, in turn, will help achieve the first 3 goals. In introducing an aTBC model, Bellin Health focused on 3 elements: office visit redesign, in-basket management redesign, and the use of extended care team members and system and community resources to assist in the care of complex and high-risk patients.

We trained certified medical assistants and licensed practical nurses to become care team coordinators and optimized the direct clinical support ratio for busier physicians.

Herein we describe the 3 components of our aTBC model,^1,9 identify the barriers that existed in the minds of multiple stakeholders (from patients to clinicians and Bellin executives), and describe the strategies that enabled us to overcome these barriers.

The impetus behind our move to aTBC

Bellin Health considered a move to an aTBC model to be critical in light of factors in the health care environment, in general, and at Bellin, in particular. The factors included

an industry-wide shift to value-based payments, which requires new models for long-term financial viability.
recognition that physician and medical staff burnout leads to lower productivity and, in some cases, workforce losses.^5,6 Replacing a physician in a practice can be difficult and expensive, with cost estimates of $500,000 to more than $1 million per physician.^10,11
a belief that aTBC could help the Bellin Health leadership team meet its organizational goals of improved patient satisfaction, achieve gains in quality measures, enhance engagement and loyalty among patients and employees, and lower recruitment costs.

A 3-part aTBC initiative

■ Part 1: Redesign the office visit

We redesigned staffing and workflow for office visits to maximize the core skills of physicians, which required distributing ancillary tasks among support staff. We up-trained certified medical assistants (CMAs) and licensed practical nurses (LPNs) to take on the new role of care team coordinator (CTC) and optimized the direct clinical support ratio for busier physicians. For physicians who were seeing 15 to 19 patients a day, a ratio of 3 CTCs to 2 physicians was implemented; for those seeing 20 or more patients a day, we used a support ratio of 2:1.

The role of CTC was designed so that he or she would accompany a patient throughout the entire appointment. Responsibilities were broken out as follows:

Pre-visit. Before the physician enters the room, the CTC would now perform expanded rooming functions including pending orders, refill management, care gap closure using standing orders, agenda setting, and preliminary documentation.¹²

Visit. The CTC would now hand off the patient to the physician and stay in the room to document details of the visit and record new orders for consults, x-ray films, referrals, or prescriptions.¹³ This intensive EHR support was established to ensure that the physician could focus directly on the patient without the distraction of the computer.

Continue to: Post-visit