Teamwork Is Crucial to New Model of Care

Teamwork. It can mean different things to different clinicians. You'd expect, for example, to find plenty of differences between teams in a community health center and in a solo family medicine practice. But what may surprise you is that there are similarities in how teamwork figures into both settings -- at least in the case of one good-sized community health center on the west side of Rochester, N.Y., and a tiny, two-room family medicine practice in Rochester's Brighton area.

FP Report visited both Westside Health Services' Woodward Health Center and the private practice of family physician L. Gordon Moore, M.D., for this final story in the series on the new model of care proposed in the Future of Family Medicine report. You can access the report at http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.

The FFM report frames the teamwork concept in the context of this new model of care: "Patient care in the New Model will be provided through a multidisciplinary team approach and grounded in a thorough understanding of the population served by the practice. In addition to nurses and clerical personnel, staffing will often include physician assistants and nurse practitioners, as well as nutritionists, health educators, behavioral scientists, and other professional and lay partners."

That description fits the Woodward Health Center to a tee. Part of a federally funded community health program, the center sits within a primary care health professional shortage area. The Woodward center, which has 10 family physicians on staff, provides the full range of primary health care services described in the FFM report.

As director of clinical operations at the Woodward center, Michele Hannagan, F.N.P., spearheaded the introduction of clinical teams last year. One of the first steps, Hannagan recalls, was asking the center's health professional staff some basic questions.

"I asked them, 'What would be the advantages? Why would we move to something like this?' -- because it's a big shift," she said. "The number one answer was continuity of care."

In family medicine, Hannagan says, "We cover everything -- peds, well-child visits, sick visits, chronically ill people, even (aspects of) OB. The idea was to come up with a system whereby the nurses on a given team would be working with a particular group of doctors and would really get to know that patient group.

"So for a smaller patient group of the bigger whole, the nurses would help the physicians and midlevel providers manage those patient groups more efficiently, to help continuity of care."

Granted, some of the gains may seem minor. Before the new system was implemented, for example, if a patient called in needing a medication refill, a member of the medical records staff pulled that patient's chart and placed it on the physician's desk. Now, a nurse intercedes.

"All refill calls actually first come through our pharmacy," said Hannagan. "But if it's something that needs to be rewritten, a nurse gets it first, so that he or she can essentially triage the stuff that's going to get dumped on the provider's desk. If the nurse can handle calling in a refill, getting a form filled out or making a phone call to a visiting nurses service to follow up on something, then the doctor's pile goes from being three feet high to being maybe a foot."

Hannagan admitted she got some initial pushback from the nurses, who saw their workload increasing. She countered by promising them, "You're going to get to manage this practice. You're going to get to know Mary Jones and know she oftentimes forgets to bring her prescriptions in for her appointment. You can call her ahead of that appointment and ask her to bring that stuff in."

"The nurses are really taking ownership," agreed Louise Bennett, M.D., one of the clinic's full-time family physicians. "Their attitude now is, 'These are our patients; this is our practice.'

"All of the nurses now really have a sense of who the patients are and who their families are so they can see things from the patient's perspective. Now we have a staff that's really working as a team and takes on some of the jobs I used to do."

Along with that sense of ownership has come greater empathy and a renewed commitment to making sure patients receive comprehensive, high-quality care, said Bennett. A nutritionist, social worker, podiatrist and several OB-Gyns work part time at the Woodward center, and members of the primary care clinical teams frequently consult with these extended-team members, said Bennett. The center's family physicians oversee provision of prenatal or obstetric services they don't themselves offer and follow patients admitted to nearby hospitals.

Over her years in practice, Bennett said she's built a stable of subspecialists to whom she refers patients with more complex medical or surgical needs. All members of the primary care team participate in facilitating these referrals and in tracking patients referred for such care.

Bennett's referral begins with an introductory letter summarizing the patient's complaint and work-up to date. But across town, Moore's solo practice takes a more high-tech approach to engaging subspecialists as ad hoc team members.

When it comes to reducing overhead, L. Gordon Moore, M.D., is way ahead of the curve. His practice, Ideal Health of Brighton, an area of Rochester, takes up only two rooms in a modest one-story building that's primarily home to an eye care clinic. In one room, Moore sees patients. In the other, he and nurse Judy Zettek, R.N., literally work side by side as a team, monitoring and recording preventive, diagnostic, treatment and follow-up services for the practice's 100-some patients and tracking virtually all business aspects of the practice.

Full integration of electronic health records and other health information technologies allows Moore to practice what he calls "world-class" medicine. By utilizing computerized patient registries, Moore can ensure his patients receive all the recommended preventive services. After all, he said, "The goal of primary care is to stop throwing stents around like rice at a wedding and prevent the need for stents in the first place."

When a patient requires referral for a specific problem, however, Moore smooths that transition for the patient through what he calls "facilitated communication." Using widely accepted clinical decision support tools, he can determine which patients require immediate referral and which can be handled less urgently.

The process starts while Moore's still in the exam room with the patient. He can make the phone call to set up an appointment and then send test results or other relevant findings directly from his computer to the subspecialist's fax machine.

"It increases my confidence that I can take care of it right here and now," he said. "If I can say 'Based on the JNC 7 guidelines, I think I have someone you need to see,' I've done my best to give them someone with high probability, and they'll get them in right away."

The flow of information back to Moore has improved, too. Written shared-care agreements outlining respective expectations and responsibilities help cement the collaborative relationship with specialists outside the practice.

Moore's approach has made a big difference to patient Mary Lou Lunt. "The patient is the center of the team," said Lunt. "It's helped me take more responsibility. You feel like you're working with a team and you're part of it."