Practice Facilitators, Care Managers Can Improve Patient Care in FP Offices

Many family physicians in practice today feel overworked and overwhelmed by an influx of patients with complex health care needs. Some physicians might long for more hours in the day or a larger staff to help carry the load.

Team-based care -- and, in particular, practice facilitators and care managers -- could be part of the solution, say authors of an article in the current issue of Annals of Family Medicine.

In the article "Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers," the authors write that team-based care at its best should offer a better patient experience, improved patient health and reduced health care costs. And they point out that America's small and medium-sized primary care practices are less inclined to use care managers and practice facilitators in their practices.

Corresponding author Erin Fries Taylor, Ph.D., a researcher at Washington-based Mathematica Policy Research, says the team-based care concept should be top-of-mind for every family physician.

"In recent years, the job description for family physicians has expanded well beyond providing excellent clinical care during the patient visit," says Taylor. "Physicians now are asked to manage the health of their entire patient panel, track and improve quality of care over time, coordinate care across the fragmented health care system, and help link patients to scarce community resources.

"Given this expanding job description, coupled with increasing use of new payment models to promote better quality and improved health at reduced costs, family physicians simply can't meet expectations without drafting other members to join the practice team."

According to the article's authors, practice facilitators work with practice staff to change workflows and processes. They help "build capacity for QI (quality improvement) activities and help the practice reach incremental and transformative improvement goals."

Facilitators are not involved in direct patient care and often are external to a practice, which allows them to offer honest and objective assessments of practice operations. Facilitators often serve multiple practices and, therefore, provide a rich source of what the authors call "cross-pollination of best practices."

Care managers play an entirely different role on the team. Generally, this team member is part of the in-house staff and coordinates services for patients "across clinicians, settings and conditions/diseases." Care managers help patients "access and navigate the system" and can be a considerable asset to patients with chronic conditions and multiple health care needs, say the authors.

Diane Cardwell, A.R.N.P., P.A., M.P.A., has spent the past five years working alongside primary care physicians in their practices to help them achieve practice transformation. As the vice president of health care solutions at TransforMED, the AAFP's not-for-profit subsidiary, Cardwell knows all too well the frantic pace that is synonymous with a busy family medicine practice.

"If family physicians are not engaged in practice transformation or are tuned out to training the primary care team, it's because too often, they are paralyzed in their own daily process," says Cardwell. "Many times, they don't know where to start or how to use resources that already are out there and available."

But a good experience with team-based care can change minds fast.

"What family physicians tell me over and over again when I'm in the field is that utilizing the primary care team improves the value of their time with their patients," says Cardwell. "If physicians effectively delegate to the team and use team members to the top of their licenses and abilities, it allows physicians to truly focus, at the time of the patient interaction, on things that bring value to the patient."

Cardwell also suggests that care management and care coordination shouldn't stop at high-risk patients with chronic conditions. "High risk is a starting point, but the management and coordination processes ultimately should apply to the entire patient population," she says. "The care manager can serve as a catalyst for change in this area, and then teach all the clinical staff members that these same processes apply to all patients."

Authors of the Annals article concede that although there is a growing awareness of the value of practice facilitators and care managers, cost is an issue. "Establishing and sustaining funding for these positions can be challenging," they note.

The authors explain that facilitation services often are paid for through federally funded and state-run regional extension centers and other state initiatives, as well as with funds from nonprofit organizations, such as the Robert Wood Johnson Foundation's Improving Performance in Practice program.

Health plans and health systems also have a vested interest in fronting the funds for practice facilitation that most likely will improve patient outcomes. "These funding sources position facilitators as a shared community resource whose services are available to many practices," write the authors.

On rare occasions, a practice may find a facilitator's services so valuable that the practice is willing to pay out-of-pocket.

On the other hand, care managers most often are paid as practice employees. The authors note that in some areas, small and rural practices have begun to use the same shared resource approach, where a single care manager serves multiple practices within a community.

Regardless of how these positions are funded, the complementary roles of care managers and practice facilitators "aim to help primary care practices deliver coordinated, accessible, comprehensive and patient-centered care," conclude the authors.