In 2003, Peter Anderson, M.D., a member of the Riverside Medical Group at Hilton Family Practice in Newport News, Va., had all but given up. Two to three pay cuts during a four-year period and the possible resignation of nurses he had worked with for 20 years because they could make more money elsewhere were dragging him and his practice down. Anderson knew he had to do something. That's when he made the decision to implement a practice-based care team model.
The model that Anderson developed is based on an understanding that routine patient visits can be divided into four parts:
- data gathering,
- data analysis and physical exam,
- decision-making and care plan development, and
- plan implementation and patient education.
The team care aspect is key to making the model work, because nurse assistants complete parts one and four in the process, and the doctor focuses on parts two and three.
Anderson worked with his nurse assistants and developed a series of symptom-related questions they could ask patients, such as questions about chest pain, cough and abdominal pain, among others. In 12 months, Anderson had written a book for nurses that shows them how to gather the information a physician uses. His nurse assistants use the book as a guide to take a competent patient history before he ever enters the exam room.
Anderson found the practice-based care team model so successful that he has become an active proponent of the patient-centered medical home, or PCMH, which includes a practice-based care team as one of its basic tenets. In addition, he recently applied for PCMH recognition from the National Committee for Quality Assurance, or NCQA. His application is pending, but he is hoping for Level 3 recognition -- the highest given.
Anderson sat down with AAFP News Now to talk about team-based care; how it works within the PCMH; the importance of electronic health records, or EHRs; and the NCQA process.
Q: What was it about the PCMH model that interested you?
A: Well, I found that it was better for patients and that we were already doing most of it. In 1998, I heard about an internist in Kentucky who was using the team care model. He saw 50 patients a day, and he was the best doctor in town. He had two nurses who would take the patient history. Then he'd come in, and the nurse would present the history. He would do the pertinent physical exam, write the prescription, hand it to the nurse, and go on to the next room. When I heard that, I was utterly astonished. This wasn't cutting corners; it just was efficient. He wasn't wasting his time doing what someone else could do.
In 2003, I decided that I would have to implement that kind of team care or my practice would die. I had patients who had been coming to me for 20 years, and I couldn't see them when they needed to be seen. I had new patients who wanted to see me, but I couldn't see them, either, and yet, I couldn't pay the bills. What kind of business can survive if it can't expand to meet the need? So, we went to the team care model, and I trained the nurses how to take a competent history.
Q: What kind of reaction did you get from staff members?
A: The nurses love it. Their involvement and sense of responsibility for the final outcome was very evident. They experienced a large increase in professional satisfaction.
This is not just a nurse sitting in front of the computer and running patients through the system. It is a team-building effort that results from an education program the doctor and nurses must go through together. The physician and nurses invest time and effort as they go through the program. Trust and respect increase between the doctor and nurses, and this foundation of trust creates a genuine team atmosphere. The patients then see the doctor/nurse as a team, so when they talk to the nurse on a phone call or in the exam room, they know they're talking to me. Now that we're one entity, talking to the nurse is just as helpful to them as talking to me.
In addition, patients are accustomed having nurses involved in their medical care. I thought that having a nurse in the room for the entire visit would be a hurdle, but it wasn't. Patient satisfaction started rising because patients saw how confident and organized we were. They saw the amount of information we had to deal with, and they saw that there's a real method to all this -- it wasn't random.
Q: What do your patients think about the team care model?
A: Ninety-six percent of our patients say they would recommend us to others. We survey our patient satisfaction every quarter, and it's been very high. My parent group, Riverside Medical Group, is very pleased with those results.
We never turn anyone away. We see all of our acute patients the day of service. I walk into every day with 15 acute slots open on the schedule.
I can relate to the difficulty patients experience trying to get medical care and having to go to urgent care centers or specialists and not having anybody to help them make decisions. It's easy for any FP to see that the PCMH is going to fix a lot of issues that we've just come to live with. The question is, how do you pay for it? That's where team care makes the difference. I can see 35-40 patients a day and produce the finances to have the staff and pay for the technology required in a PCMH.
When I walk into a patient exam room, my goal is to never sit down at the EHR. The nurse stays in the room and keys in all the information from the visit. The nurse does all the documentation. I'm focused on the patient for that 10-15 minutes in the room. I'm not focused on anything but the patient, the patient's chart and seeing what needs to be done, and that's a wonderful experience for me.
Although I had moved to this model entirely for financial reasons, after a year of doing it, I went home and told my wife that I had never given better care in my life. The quality I have now is what I've always dreamed about but had never been able to produce because of the lack of time.
Q: Team care is one element of the PCMH, but are there other elements you are incorporating?
A: In TransforMED's PCMH model(transformed.com) there are eight different components, and team-based care is just one of the eight. But it starts with the needs of the patient. The patient needs availability, they need communication, they need education, and they need safety. So they need a lot more involvement from the physician than they are getting right now, and the PCMH offers that. It's asking physicians to give more of what the patient needs than we're presently giving.
But primary care has gotten so financially strapped that we can't give patients all the services they need. In the present managed care environment, how can you go from a model that is much smaller to something, such as the PCMH, that is much bigger without coming up with a way to pay for the larger model?
That's where team care comes in for me. With the increased number of staff members who can take a history, I went from seeing 22-23 patients a day to seeing 35-40. With the financial improvement that followed, we were able to upgrade our equipment, bring on more staff, and give staff bonuses. So practice-based team care is not the whole picture, but without it, I don't know how you pay for the PCMH -- unless the major carriers really start paying, which is the hope and expectation. But that's going to be years away.
Q: There are pilots out there that actually are paying for implementing the PCMH. Are you one of those practices?
A: No, the only principle we're using is free market. You can see more and you produce more, so you make more income. I don't have to ask the government or insurers to give me any money to do what we're doing.
I love telling people, "You don't have to wait." I was probably $70,000 to $80,000 in the red in 2003. When I transferred to this system, we were in the black in two years. We were paying all of our bills, all of our overhead, and we still had money left over. Our net collections went up about $180,000.
Q: How big a role did the EHR play in this transition?
A: I think it's important, but it's not essential. When I first got it, the EHR just about broke my back. I went from seeing 28-30 patients a day to seeing 22 patients a day with the extra expense of the EHR on top of that. So I went from a fairly sound practice to a very vulnerable practice because of the EHR.
The EHR is like buying a tank for the Army. If they purchased this $10 million tank and all they use is the machine gun, they've wasted $10 million. But if you combine that tank with someone who knows how to use the cannon, then all of the sudden that tank is worth $10 million.
If you can combine the EHR with practice-based team care and the doctor never has to sit down at the EHR, its true ability is getting unleashed because it facilitates good record-keeping and it facilitates communication.
If you've got an EHR, you may be crazy not to do team care because team care will make your EHR into a very profitable, beneficial investment and not just an excellent charting system. Doctors using paper charts also can do team care easily, but the communication and the clarity of the EHR gives it an advantage. I think the team care really brings out the true ability of the EHR, because if the doctor is the one doing all the keying in, he's wasting his time.
Q: How difficult was it to go through the NCQA recognition process?
A: I'd say we spent easily 55-60 hours of effort, and we have an EHR that captured a lot of the data. If it wasn't for that, this process would have been overwhelming.
Q: Why did you decide to try for NCQA recognition?
A: I've gotten enough skepticism about team care that I've done anything I could to prove this isn't a crazy idea. I think its time has come. And I'd like to help other physicians enjoy what we've experienced. The workload has decreased, quality has improved dramatically, the finances have increased, patient satisfaction is high, and I enjoy what I'm doing. I hated sitting down at the EHR and spending half the patient visit keying in information. I dreaded going to work. Now, I don't mind going to work, and I feel like I'm doing what I was trained to do.
It's very fortuitous for me that I happened to develop this practice-based team care at a time when the PCMH was coming down the track. I was telling physicians that they needed to change because team care is a better model, but why would they pay attention to me?
Now, however, PCMH advocates are telling physicians, "You need to consider change because patients need it, you produce better quality, patient satisfaction is up, and you save money." Physicians are starting to realize we really do have to change the model we've got. You can't blow the PCMH off very easily, so I knew it would be good for me if I could get the NCQA recognition for the PCMH.